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 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 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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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.

Related material: Insurance coverage

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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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:

Selling a Drug: History and ethics

Carl Elliot, M.D., professor in the Center for Bioethics at the University of Minnesota:

What does the FDA say?

The Food and Drug Administration approves drugs, such as antidepressants and specifically SSRIs, to treat specific health conditions that are recognized and diagnosed. However, many people who take antidepressants have never been diagnosed with depression–their main tested and approved use.

Media reports have estimated that 43 percent of people prescribed antidepressants have never been diagnosed with any psychiatric condition and have never had other mental health care.

And one study of Medicaid enrollees found that three-quarters of the people taking antidepressants were using the drugs for an “off-label” reason–one that is not approved by the FDA.

Related material: Risks and side effects

Prescribing antidepressants

According to the CDC, antidepressants are the most commonly prescribed drug in the U.S.–118 million prescriptions in 2005. About 11 percent of women and 5 percent of men currently use antidepressants.

Media have reported that for women in 2002, more than 1 in 3 doctor’s visits involved either a new antidepressant prescription or monitoring an existing one.

Where do they get them? Less than one-third of antidepressants are prescribed by psychiatrists–doctors who have been specially trained in the drugs’ prescription and use.

And psychiatrists, according to a Johns Hopkins University study, spend 71 percent of their time during office visits prescribing medications and only 29 percent on talk therapy (likely due to higher insurance reimbursement for the former).

Source: Medical Expenditure Panel Survey (2008), Agency for Healthcare Research and Quality

Though antidepressants have proven side-effects, some serious, the New York Times reported that only 1 in 5 people on the medications have any kind of follow-up appointment after prescription. More than 80 percent of adults do not see a doctor or therapist for mental health care in the first month after starting an antidepressant, according to research by Medco Health Solutions.

Diagnosing depression

According to the CDC, more than 1 in 20 Americans over age 11 had current depression in a 2005-2006 household survey, the highest rates being among the middle-aged, women and blacks. Among poor Americans, the number rose to 1 in 7.

Less than one-third of all people with depression–and nearly 40 percent of people with severe depression–sought help from a mental health professional in the past year.

And media reports have estimated that 40 percent of mental health complaints in the U.S. result in a depression diagnosis.

Life changes and depressive symptoms

A 2007 study from New York University found that 1 in 4 people diagnosed with and treated for depression is dealing with a major life change such as the loss of a job or end of a marriage.

Depression or depressive symptoms can also be common in young people who are going through transitions such as moving away from home or starting college. At the University of Minnesota in 2004, 1 in 5 female students and 1 in 10 male students reported being diagnosed with depression at some point in their lives. Nearly 8 percent of students were taking medication for depression, and 8 percent were seeing a mental health counselor or therapist.

The “official” depression diagnosis

What exactly constitutes depression? A valid question considering 40 percent of mental health complaints to health providers end in a depression diagnosis, according to the CDC.

Are most people being treating for depression technically depressed? And do the official diagnostic criteria encourage under- or over-diagnosis?

See what you think: View the official diagnostic criteria for depression from the Diagnostic and Statistical Manual of Mental Disorders, version four.

The Patient Health Questionnaire, or PHQ-9, is a depression scale based off of the DSM criteria that is also commonly used to diagnose patients with depression. See a sample.

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Have the Internet? Self-diagnose.

Though a true diagnosis of depression can be complex and serious, many institutions promote free self-screening tools to determine whether a person is–or may be–depressed and should seek professional evaluation and treatment.

The University of Minnesota’s counseling center recommends this online depression screening to students concerned about their mental health.

New York University created this depression screening test.

And Google “depression screening”–the first hit is a free test from Depression-Screening.org, who has clearly made its name in this “business.”

I took the test. “I” being a happy, healthy 20-something with no reason to suspect I might be depressed. But I am in my first semester of graduate school–a total lifestyle change. In the thick of midterms.

And, according to this test, my “screening results are consistent with moderately severe depression”: 

 

depression-screening.org

Related material: The “official” depression diagnosis