When you think of clinical depression, you probably think of feeling sad and down for long periods of time; losing your energy and your interest in things you used to enjoy; sleeping too much or too little, or eating too much or too little. But besides these, depression can actually change your ability to think. It can impair your attention and memory, as well as your information processing and decision-making skills. It can also lower your cognitive flexibility (the ability to adapt your goals and strategies to changing situations) and executive functioning (the ability to take all the steps to get something done).
For people with severe depression, medications can provide some relief of low mood and energy, bolster the motivation to engage in enjoyable and important activities, and help people return to normal sleeping and eating patterns. (Notably, antidepressants are less helpful in general for mild and moderate depression.)
But we don’t know whether antidepressant medications treat cognitive impairment related to depression. Recently, an international research team attempted to answer this question as part of a larger study on depression treatment. Their results were published in The Lancet last month.
To study the effect of three common antidepressant medications on depression-related cognitive impairment, the researchers asked over 1,000 people with depression who were taking either escitalopram (Lexapro), sertraline (Zoloft), or venlafaxine-XR (Effexor-XR) to go through extensive cognitive testing. In short, none of the medications helped. Of these patients, 95% showed no improvement on any of the cognitive impairments mentioned above, and none of the three drugs was better than the others at improving cognitive symptoms.
This result is not completely surprising — antidepressant medications are mainly meant to help improve mood and increase the ability to participate in beneficial and enjoyable activities, two key aspects of depression treatment. It’s also worth noting that different parts and processes of the brain are responsible for cognitive (versus emotional) functioning; this may explain why the three drugs tested didn’t seem to help improve cognitive symptoms. New drugs for depression may be able to address these symptoms as well.
Beyond medications, problem-solving treatment can train people how to improve their problem-solving skills, and cognitive behavioral therapy can teach people to recognize and challenge distorted thinking patterns. Another approach, cognitive remediation therapy, uses practice drills to improve memory and executive functioning. Combining these behavioral interventions with antidepressants may yield better results for improving depression-related cognitive impairments.
There are some limitations to this study: it’s not known if the participants had cognitive impairments before they developed depression, and the length of drug treatment and follow-up was short — eight weeks in total. However, this study is important because the cognitive impairment symptoms of depression have received little attention — and haven’t necessarily been the target of medications for depression. It shows that we have a long way to go in helping people with depression return to a normal level of full mental functioning. When I was in training, one of my beloved mentors declared, “I never use a drug until it’s been on the market for 20 years.” I was young enough then that I couldn’t fathom being a doctor for 20 years, let alone waiting two decades to use a new drug. As my career has progressed, I’ve seen many new drugs released to the market. Some of them are truly miraculous, bringing people longer, healthier, and more productive lives. Many of them have not withstood the test of time. More than a few have even been taken off the market. Even though the Food and Drug Administration diligently reviews each new medicine before it’s approved for use, we often learn much more about a drug after its release into the general population.
I reflected on that memory when I read a recent editorial in The New England Journal of Medicine (NEJM) about insulin resistance. In his editorial, the author tells us of the “long, strange trip” of a class of medications called thiazolidinediones, which help people who have type 2 diabetes or pre-diabetes to be more sensitive to the insulin that they make in their bodies. (Many diabetes medications work by helping the body lower its resistance to insulin in different ways.)
When they were first released, these medicines were widely accepted and adopted. We do, after all, have an epidemic of obesity and diabetes in the United States, and they seemed to work very well for people. They seemed a great alternative to insulin, which has to be injected. Then, after about 6 years on the market, these drugs began to be linked to liver disease and congestive heart failure — and maybe even cancer. Even though longer-term studies did not show that there was a definite risk of heart attack or cancer, these drugs became unpopular and fell into disuse. We were not willing to take a chance with our patients when we had other good options.
And yet, some researchers continued to wonder if there was any safe role for these very potent medications with their many positive effects, despite the concerns. The same NEJM issue as the editorial referenced above also contains a study that showed that certain carefully selected patients might, in fact, have fewer strokes if they took a medication called pioglitazone, which is in the thiazolidinedione class of medicines. Interestingly, the patients in this trial were already on extremely comprehensive stroke prevention regimens — and still they decreased their risk of a future stroke by 24%. These patients, all of whom were at risk of developing diabetes, had a slower rate of progression to diabetes as well.
What grabbed me about this story? First, it would seem that the drugs in question are neither panacea nor pariah. Pioglitazone, in fact, might a very good drug to prevent stroke in a very select population.
But, can we define that select population? That might be the most interesting tale of the past decades. Twenty years ago, we could only guess, based on certain characteristics of a patient, whether a medication would be effective. Today, we know certain people’s genetics make them better candidates for certain medications than other people. We are close to being able to tailor a medication to the patient at the level of his or her genes. When we are able to do this in an effective, safe, and efficient way, we will be able to deliver truly personalized medicine. As a clinician, I find this truly exciting. It would be wonderful to say to a patient, “This drug might have the following side effects — but I know they won’t affect you!”
My mentor may well have been right that it takes 20 years to know how a drug works and for whom it will work. He would not be surprised by the strange story of thiazolidinediones. He would undoubtedly be overjoyed by the idea that the past 20 years of laboratory and clinical research has brought us that much closer to truly personalized care. y often caused by our thoughts, feelings, and resulting behaviors. And an exciting new study now demonstrates that treatments aimed at our beliefs and attitudes can really help.
When our back hurts, it’s only natural to assume that we’ve suffered an injury or have a disease. After all, most pain works this way. When we cut our finger, we see blood and feel pain. When our throat hurts, it’s usually because of an infection.
But back pain is different. There simply isn’t a close connection between the condition of the spine and whether or not people experience pain. Research has shown that a majority of people who have never had any significant back pain have the very same “abnormalities” (such as bulging or herniated spinal discs) that are frequently blamed for chronic back conditions. And then there are the millions of people with severe chronic back pain who show no structural abnormalities in their back at all.
On top of this, it turns out that people in developing countries, who do back-breaking labor and don’t have easy access to medical treatment, have much fewer incidents of chronic back pain than people in the developed world who sit in ergonomically designed chairs, sleep on fancy mattresses, and have ready access to spinal imaging, surgery, and medications.
Because there’s so little correlation between the condition of the spine and any given person’s experience with back pain, clinicians and researchers have begun looking instead at treatments that address the psychological and behavioral patterns that can lock people into years of suffering. And they’ve just demonstrated that two of these treatments work much better than traditional medical interventions alone.
What actually helps back pain
Last week, researchers at the University of Washington published a landmark study in The Journal of the American Medical Association that showed training people with chronic low back pain in either mindfulness or cognitive behavioral therapy (CBT) works significantly better than medical care alone to reduce both their disability and pain-related suffering. The researchers randomly assigned 320 adults, ages 20 to 70, to either an eight-week class in one of these methods, or to “usual care.” The subjects who attended the classes saw significantly more improvement in their pain and disability than those receiving usual care — and this greater improvement was still evident a full year later, when the study ended.
Mindfulness training teaches us to be aware of, and accept, moment-to-moment physical sensations of discomfort, while letting go of our usual negative reactions. So instead of spending hours each day thinking about how much we hate our back pain, worrying about our prognosis, and seeking relief, we learn how to be with the pain — paying attention to how it actually feels at each moment and relaxing our tendency to tense up against it, while observing our worried or distressed thoughts and feelings coming and going.
CBT takes a somewhat different approach. It helps us learn to observe and identify our negative thoughts about our condition, and replace them with more realistic ones.
Both methods help us see the functioning of our minds more clearly, and the role that anxious, angry, and frustrated thoughts and feelings about our condition play in increasing our fear and stress.
And as it turns out, it is precisely this fear and stress that maintains most chronic back pain. This explains why events such as childhood physical and sexual abuse, painful losses, and job dissatisfaction have all been shown to be risk factors for the condition.
Take action for back pain relief
The excellent news is that for most of us, chronic back pain needn’t derail our lives. CBT is available at many pain clinics, as is mindfulness training.
You might also try on your own. You could explore CBT using the book on which the University of Washington class was based: The Pain Survival Guide: How to Reclaim Your Life. Alternatively, you can try mindfulness practice by following recorded instructions. While there are many resources for these, you can listen for free to some that I recorded at mindfulness-solution.com.
Additionally, for a comprehensive guide to using mindfulness along with rehabilitation to work through chronic back pain, you can consult a book I co-authored on the subject: Back Sense: A Revolutionary Guide to Halting the Cycle of Chronic Back Pain.
For people with severe depression, medications can provide some relief of low mood and energy, bolster the motivation to engage in enjoyable and important activities, and help people return to normal sleeping and eating patterns. (Notably, antidepressants are less helpful in general for mild and moderate depression.)
But we don’t know whether antidepressant medications treat cognitive impairment related to depression. Recently, an international research team attempted to answer this question as part of a larger study on depression treatment. Their results were published in The Lancet last month.
To study the effect of three common antidepressant medications on depression-related cognitive impairment, the researchers asked over 1,000 people with depression who were taking either escitalopram (Lexapro), sertraline (Zoloft), or venlafaxine-XR (Effexor-XR) to go through extensive cognitive testing. In short, none of the medications helped. Of these patients, 95% showed no improvement on any of the cognitive impairments mentioned above, and none of the three drugs was better than the others at improving cognitive symptoms.
This result is not completely surprising — antidepressant medications are mainly meant to help improve mood and increase the ability to participate in beneficial and enjoyable activities, two key aspects of depression treatment. It’s also worth noting that different parts and processes of the brain are responsible for cognitive (versus emotional) functioning; this may explain why the three drugs tested didn’t seem to help improve cognitive symptoms. New drugs for depression may be able to address these symptoms as well.
Beyond medications, problem-solving treatment can train people how to improve their problem-solving skills, and cognitive behavioral therapy can teach people to recognize and challenge distorted thinking patterns. Another approach, cognitive remediation therapy, uses practice drills to improve memory and executive functioning. Combining these behavioral interventions with antidepressants may yield better results for improving depression-related cognitive impairments.
There are some limitations to this study: it’s not known if the participants had cognitive impairments before they developed depression, and the length of drug treatment and follow-up was short — eight weeks in total. However, this study is important because the cognitive impairment symptoms of depression have received little attention — and haven’t necessarily been the target of medications for depression. It shows that we have a long way to go in helping people with depression return to a normal level of full mental functioning. When I was in training, one of my beloved mentors declared, “I never use a drug until it’s been on the market for 20 years.” I was young enough then that I couldn’t fathom being a doctor for 20 years, let alone waiting two decades to use a new drug. As my career has progressed, I’ve seen many new drugs released to the market. Some of them are truly miraculous, bringing people longer, healthier, and more productive lives. Many of them have not withstood the test of time. More than a few have even been taken off the market. Even though the Food and Drug Administration diligently reviews each new medicine before it’s approved for use, we often learn much more about a drug after its release into the general population.
I reflected on that memory when I read a recent editorial in The New England Journal of Medicine (NEJM) about insulin resistance. In his editorial, the author tells us of the “long, strange trip” of a class of medications called thiazolidinediones, which help people who have type 2 diabetes or pre-diabetes to be more sensitive to the insulin that they make in their bodies. (Many diabetes medications work by helping the body lower its resistance to insulin in different ways.)
When they were first released, these medicines were widely accepted and adopted. We do, after all, have an epidemic of obesity and diabetes in the United States, and they seemed to work very well for people. They seemed a great alternative to insulin, which has to be injected. Then, after about 6 years on the market, these drugs began to be linked to liver disease and congestive heart failure — and maybe even cancer. Even though longer-term studies did not show that there was a definite risk of heart attack or cancer, these drugs became unpopular and fell into disuse. We were not willing to take a chance with our patients when we had other good options.
And yet, some researchers continued to wonder if there was any safe role for these very potent medications with their many positive effects, despite the concerns. The same NEJM issue as the editorial referenced above also contains a study that showed that certain carefully selected patients might, in fact, have fewer strokes if they took a medication called pioglitazone, which is in the thiazolidinedione class of medicines. Interestingly, the patients in this trial were already on extremely comprehensive stroke prevention regimens — and still they decreased their risk of a future stroke by 24%. These patients, all of whom were at risk of developing diabetes, had a slower rate of progression to diabetes as well.
What grabbed me about this story? First, it would seem that the drugs in question are neither panacea nor pariah. Pioglitazone, in fact, might a very good drug to prevent stroke in a very select population.
But, can we define that select population? That might be the most interesting tale of the past decades. Twenty years ago, we could only guess, based on certain characteristics of a patient, whether a medication would be effective. Today, we know certain people’s genetics make them better candidates for certain medications than other people. We are close to being able to tailor a medication to the patient at the level of his or her genes. When we are able to do this in an effective, safe, and efficient way, we will be able to deliver truly personalized medicine. As a clinician, I find this truly exciting. It would be wonderful to say to a patient, “This drug might have the following side effects — but I know they won’t affect you!”
My mentor may well have been right that it takes 20 years to know how a drug works and for whom it will work. He would not be surprised by the strange story of thiazolidinediones. He would undoubtedly be overjoyed by the idea that the past 20 years of laboratory and clinical research has brought us that much closer to truly personalized care. y often caused by our thoughts, feelings, and resulting behaviors. And an exciting new study now demonstrates that treatments aimed at our beliefs and attitudes can really help.
When our back hurts, it’s only natural to assume that we’ve suffered an injury or have a disease. After all, most pain works this way. When we cut our finger, we see blood and feel pain. When our throat hurts, it’s usually because of an infection.
But back pain is different. There simply isn’t a close connection between the condition of the spine and whether or not people experience pain. Research has shown that a majority of people who have never had any significant back pain have the very same “abnormalities” (such as bulging or herniated spinal discs) that are frequently blamed for chronic back conditions. And then there are the millions of people with severe chronic back pain who show no structural abnormalities in their back at all.
On top of this, it turns out that people in developing countries, who do back-breaking labor and don’t have easy access to medical treatment, have much fewer incidents of chronic back pain than people in the developed world who sit in ergonomically designed chairs, sleep on fancy mattresses, and have ready access to spinal imaging, surgery, and medications.
Because there’s so little correlation between the condition of the spine and any given person’s experience with back pain, clinicians and researchers have begun looking instead at treatments that address the psychological and behavioral patterns that can lock people into years of suffering. And they’ve just demonstrated that two of these treatments work much better than traditional medical interventions alone.
What actually helps back pain
Last week, researchers at the University of Washington published a landmark study in The Journal of the American Medical Association that showed training people with chronic low back pain in either mindfulness or cognitive behavioral therapy (CBT) works significantly better than medical care alone to reduce both their disability and pain-related suffering. The researchers randomly assigned 320 adults, ages 20 to 70, to either an eight-week class in one of these methods, or to “usual care.” The subjects who attended the classes saw significantly more improvement in their pain and disability than those receiving usual care — and this greater improvement was still evident a full year later, when the study ended.
Mindfulness training teaches us to be aware of, and accept, moment-to-moment physical sensations of discomfort, while letting go of our usual negative reactions. So instead of spending hours each day thinking about how much we hate our back pain, worrying about our prognosis, and seeking relief, we learn how to be with the pain — paying attention to how it actually feels at each moment and relaxing our tendency to tense up against it, while observing our worried or distressed thoughts and feelings coming and going.
CBT takes a somewhat different approach. It helps us learn to observe and identify our negative thoughts about our condition, and replace them with more realistic ones.
Both methods help us see the functioning of our minds more clearly, and the role that anxious, angry, and frustrated thoughts and feelings about our condition play in increasing our fear and stress.
And as it turns out, it is precisely this fear and stress that maintains most chronic back pain. This explains why events such as childhood physical and sexual abuse, painful losses, and job dissatisfaction have all been shown to be risk factors for the condition.
Take action for back pain relief
The excellent news is that for most of us, chronic back pain needn’t derail our lives. CBT is available at many pain clinics, as is mindfulness training.
You might also try on your own. You could explore CBT using the book on which the University of Washington class was based: The Pain Survival Guide: How to Reclaim Your Life. Alternatively, you can try mindfulness practice by following recorded instructions. While there are many resources for these, you can listen for free to some that I recorded at mindfulness-solution.com.
Additionally, for a comprehensive guide to using mindfulness along with rehabilitation to work through chronic back pain, you can consult a book I co-authored on the subject: Back Sense: A Revolutionary Guide to Halting the Cycle of Chronic Back Pain.
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