By Daniel G. Amen, MD Psychiatrist and Brain Imaging Expert Medical Director of Amen Clinics in Newport Beach, San Francisco, Seattle,Washington D.C., Atlanta and New York
Do you feel sad, blue, negative, worried, and unable to let go of thoughts that upset you? Do you have trouble sleeping, struggle with a low libido, and have you lost the zest and joy in your life?
These are all common symptoms of depression, and when you tell your family physician, internist or gynecologist about them, he or she often reaches for the prescription pad in hopes of giving you a quick fix. They only have a few minutes for you on their busy schedules, and antidepressant and anti-anxiety medications have been billed as offering fast, easy relief. But before you accept the prescription, you might want to give it a second, third, and even fourth thought and consider another way.
Let me be clear: I am not opposed to medication for anxiety and depression. I have been a psychiatrist for over 30 years and have helped many people overcome life-threatening mood disorders with these medications. But, unfortunately, I’ve also made people worse, especially before I started looking at the brain when I was metaphorically throwing medicated-tipped darts in the dark at my patients. Medications can be very effective when targeted properly after a thorough workup, but they can also be a disaster when not used appropriately.
While I am not opposed to medication for anxiety and depression, I am deeply opposed to the indiscriminate use of these medications and the way many physicians and other health-care professionals prescribe them, without a comprehensive workup and without clearly telling patients about the potential side effects, poor long-term outcome studies, and alternative treatment options.
The rampant use of these medications is hurting our society. It has been estimated that the use of antidepressants have gone up 400% in the last two decades and that nearly a quarter of all females (23%) between the ages of 40-59 are taking them.[i]
The overall effectiveness of antidepressants has come into serious question over the last decade with large-scale studies showing that when all depressed patients are started on the most popular antidepressants, selective serotonin reuptake inhibitors (SSRIs) such as Zoloft, Celexa, Lexapro or Prozac, they are no more effective than placebo (sugar pills), except for the most severely depressed patients. Dr. Thomas Insel, the Director of the National Institutes of Mental Health wrote in 2009, “The unfortunate reality is that current medications help too few people to get better and very few people to get well.”[ii]
Few physicians ever tell their patients that taking psychiatric medications can negatively affect their insurability and their ability to get health, life, long-term care or disability insurance. Insurance companies tend to view “psychiatric” patients as having more risk and often charge higher premiums or deny coverage. I have seen this happen repeatedly for patients I have treated over the years.
These medications are also not without their own side effects, especially in the area of sexual dysfunction, weight gain and relapse. Patients who start with antidepressant or anti-anxiety medications tend to have higher relapse rates than those who never start, or they use alternative forms of therapy such as exercise or talk therapy.
One of the main reasons why antidepressants are ineffective in large-scale studies is that most physicians have been taught that depression is a single or simple disorder: “Feel depressed, take an SRRI.” After I started looking at the brain 22 years ago, I came to realize that this form of thinking is just wrong. Giving the diagnosis of depression is exactly like giving someone the diagnosis of chest pain. Doctors don’t give people the diagnosis of chest pain because it has too many different causes and wildly different treatments. It can be caused by such diverse things as heart attack, an arrhythmia, pneumonia, an ulcer, anxiety, grief and gas. Giving everyone the same treatment for chest pain is crazy.
Yet depression is the same way. It can be caused by loss, grief, low thyroid, pancreatic cancer, brain trauma, toxins, obesity, diabetes, sleep apnea and more (untreated thyroid problems or sleep apnea are not helped with SSRIs). It is estimated that nearly 30% to 40% of all depressions have underlying medical causes. Without a thorough workup, it is impossible to know what.
At our clinics, we use a more natural approach whenever possible. Two of the underlying principles of our work is “First do no harm” and “Use the least toxic, most effective treatments.” The brain imaging work led us to use natural treatments, such as diet, exercise, and nutritional supplements, as many of the medications seemed to make the brain scans of our patients look worse. For example, benzodiazepines, such as alprazolam or diazepam, caused overall low blood flow states in the brain and caused the scans to look like many of our alcoholic patients. Recently, it was discovered that this class of medication has been associated with an increased the risk of dementia.[iii]
So, what is the “sane” way to treat anxiety and depression?
If you feel anxious or depressed and it lasts more than two weeks, make sure to get a thorough medical workup, including comprehensive blood work that includes a detailed look at your thyroid. Before trying medication, unless your condition is severe, try some simple interventions, such as:
- Exercise (walk like you are running late for 45 minutes a day)! In a study comparing exercise to antidepressants, they were equally effective at 12 weeks, and exercise was more effective at 10 months.
- A healthy, anti-inflammatory diet. Lose the processed foods and sugar, and foods that quickly turn to sugar. A Mediterranean Diet was shown to have antidepressant effects.
- Start taking fish oil to boost omega-3s, especially in the form of EPA. I usually recommend starting with 3,000 mg of fish oil a day.
- Work with a therapist to kill the ANTs (automatic negative thoughts) that fuel depression. Negative thinking patterns provide the gas for anxiety and depression.
- Investigate a new type of treatment called TMS (transcranial magnetic stimulation), which was recently FDA approved for depression with few side effects.
The typical way most physicians diagnose and treat depression looks like this:
Symptoms of depression = diagnosis of depression, leading to largely ineffective treatment and poor outcomes.
Amen Clinics Method
Symptoms of depression + brain SPECT imaging + specific laboratory studies = more targeted treatment and more successful outcomes.
In 1991, my team and I at Amen Clinics started looking at the brain using a study called SPECT imaging. SPECT is a nuclear medicine study that looks at blood flow and activity patterns in the brain. From the first year of doing scans, it became very clear that anxiety and depression were not single or simple disorders, and each patient needed individualized treatment plans. Giving everyone the same treatment was never going to work. SPECT helped us understand why certain people were made worse on antidepressants and why others improved.
At the end of six months, 75% of our complex patients were better across all measures, and 85% had an improved quality of life.[iv] As far as we know, these are the best outcome statistics in our field.
In a scientific study about to be published, using our method, we followed 500 consecutive patients who came to our clinics, using detailed assessment tools. On average, our patients were complicated; they averaged four diagnoses (such as depression, anxiety, ADD and addictions), failed to get better after seeing 3 different medical or mental-health specialists, and had no success with 6 medications. To learn more about our brain SPECT imaging work or other treatments, visit us at AmenClinics.com.
[ii] Insel, T. R. Disruptive insights in psychiatry: Transforming a clinical discipline. 2009. Journal of Clinical Investigation 119 (4): 700–05.
[iv] Amen, DG et al. Multisite, 6-Month Outcome Study of Complex Psychiatric Patients Evaluated with Addition of Brain SPECT Imaging, ADVANCES, SPRING 2013, VOL. 27, NO. 2.