Mood Disorders III (Chapter 7) March 12, 2014 PSYC 2340: Abnormal Psychology Brett Deacon, Ph.D.

1. Mood Disorders III(Chapter 7)March 12, 2014PSYC 2340: Abnormal PsychologyBrett Deacon, Ph.D.

2. Or, Everything You Ever Wanted to Know about Antidepressant Medications

3. Announcements • Exam #2 handed back • Midterm grades turned in

4. From Last Class • Genetic influences on depression • Chemical imbalance theory • Popularity • Accuracy • Effects on depressed individuals

5. Treatments for Depression • Cognitive therapy • Supported by large body of evidence • Directly targets errors in thinking • Teaches patients to: • 1. Identify thinking errors • 2. Dispute them • 3. Generate more accurate ways of thinking • 4. Generate practical solutions to problems

6. Treatments for Depression • Behavioral activation • Increases contact with reinforcing events • Equal to or more effective than cognitive therapy (Jacobson et al., 1996; Dimidjian et al., 2006) • Interpersonal psychotherapy • Addresses problematic relationship functioning associated with depression • Physical exercise • “Antidepressant” medications

7. Comparison of Four Depression Treatments • Dimidjian et al. (2006) • Compared Paxil, placebo, cognitive therapy, and behavioral activation during 8 weeks of treatment for 241 depressed patients • Examined low vs. high severity patients separately • Why?

8. Comparison of Four Depression Treatments • Dropout rates: • Cognitive therapy = 13.3% • Behavioral activation = 16.3% • Paxil = 44.4% • For “low severity” participants, Paxil was not significantly more effective than placebo pill • Placebo was 85.7% as effective as Paxil on self-reported depressive symptoms and 85.6% as effective on clinician-rated symptoms

10. Cognitive therapy vs. Behavioral Activation vs. Antidepressants: Long-Term Maintenance of Gains After Treatment Discontinuation Dobson et al., 2008

11. Psychotherapy vs. Antidepressants: Long-Term Cost-Effectiveness Dobson et al., 2008

12. Adverse Effects of Antidepressants • Drug-induced treatment resistance and chronic depressive symptoms • Long-term use of antidepressant medication, even when immediately beneficial, may produce a state of “tardive dysphoria” in 30% to 50% of patients characterized by loss of drug efficacy with symptom exacerbation, increased risk of relapse, and diminished and potentially irreversible responsiveness to subsequent drug treatment (El-Mallakh et al., 2011; Fava, 2003; Fava & Offidani, 2010)

13. Prior Antidepressant Exposure and Treatment Response (Leykin et al., 2007)

14. Medication vs. Psychotherapy for Depression: A Summary • Antidepressants are as effective as psychosocial treatments in the short term for mild, moderate, and severe depression • The small advantage of antidepressants over placebo is the same with psychotherapy – what does this mean? • Psychotherapy is far more effective in preventing relapse • Psychotherapy is less expensive (vs. brand name antidepressants) • Psychotherapy is preferred by patients • More patients refuse or drop out of pharmacotherapy; psychotherapy has no adverse physical effects • Psychotherapy is difficult to access and not used by many

15. 60 Minutes Story on Antidepressants • http://www.youtube.com/watch?v=Zihdr36WVi4

16. Antidepressants in the News • Fallout from the 60 Minutes story on the placebo effect in antidepressants • http://ww2.psych.org/MainMenu/Newsroom/NewsReleases/2012-News-Releases/60-Minutes-Segment-on-Antidepressants-Irresponsible-and-Dangerous.aspx?FT=.pdf • http://www.huffingtonpost.com/dr-harold-koplewicz/placebo-effect_b_1332416.html • http://www.madinamerica.com/2012/02/the-american-psychiatric-associations-response-to-60-minutes-evidence-based-response-or-propaganda/ • http://www.psychologytoday.com/blog/the-skeptical-sleuth/201202/cbs-60-minutes-news-treating-depression-sorting-through-the-confu-0 • http://www.psychologytoday.com/blog/the-skeptical-sleuth/201203/irving-kirsch-d-j-vu-all-over-again • http://www.psychologytoday.com/blog/who-we-are/201203/demonizing-kirsch-will-get-us-nowhere • http://www.psychologytoday.com/blog/our-empathic-nature/201203/the-media-war-anti-depressants

17. Drug Treatments for Mood Disorders • Antidepressant medications • CDC study: http://www.cdc.gov/nchs/data/databriefs/db76.htm • Key findings include: • Eleven percent of Americans aged 12 years and over take antidepressant medication. • More than 60% of Americans taking antidepressant medication have taken it for 2 years or longer, with 14% having taken the medication for 10 years or more.

18. Many Americans Take Antidepressant Medications Overall average CDC, 2011

19. Drug Treatments for Mood Disorders • Newer generation antidepressants (e.g., SSRIs) • First SSRI was Prozac (1987) 2010 1990

20. Basis of Prozac’s FDA Approval • A note about FDA requirements for approval • 5 Prozac studies involving 1,132 depressed patients • Each trial lasted between 4 - 8 weeks • The trials included a 1- to 2-wk washout period during which patients were given placebo, prior to random assignment. Those whose scores improved 20% or more were excluded from the study prior to random assignment. • Replacement of patients who investigators determined were not improving after 2 weeks was allowed in three Prozac trials. • Many patients were given a sedative medication to minimize adverse effects. • Investigators coded suicide attempts as “overdose” to minimize apparent adverse effects. • Depressive symptoms were measured only using the clinician-rated Hamilton Rating Scale for Depression. Self-report symptoms were not assessed.

21. Basis of Prozac’s FDA Approval • 3 trials showed a statistically significant advantage of Prozac vs. placebo; 2 did not • Averaged across all trials: • Average improvement with Prozac = 8.30 points on HAM-D • Average improvement with placebo = 7.34 points on HAM-D • 89% of drug effect duplicated with placebo • The FDA approved Prozac for adults in 1987