It's time to relegate prescription medications for anxiety and depression to last resort treatment

Dr. Carlo Carandang's picture
Depression and anxiety

I recently wrote a book on treating anxiety disorders, Anxiety Protocol, and asked a psychiatrist colleague to review the book. He stated he liked the book very much, and was in full agreement with the recommendation of cognitive behavioral therapy (CBT) as first-line treatment for anxiety disorders. However, he disagreed initially with my recommendation that prescription medication for anxiety disorder should be last resort treatment, and only then should be prescribed for severe cases or for psychotherapy-resistant cases. My colleague went on to opine that in moderate to severe cases, he saw the use of prescription medication “in association” with CBT, or as an adjunct to CBT, not as a “last resort.” Otherwise, he found contents of the book very useful.

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I thanked my colleague for the comment on prescription medication as a last resort treatment. When I wrote the book, it was intended for end-users to help and educate themselves about anxiety. I worded it so, about pharmacotherapy being “last resort,” as there is such a focus on prescription medications as first-line treatment for anxiety- I had to emphasize this point with such language. Both patients and physicians overtly favor medication treatment…it seems easy, convenient, and good results are to be had in just a few weeks of treatment. But this is not an infection that needs an antibiotic. Anxiety and depression are still psychological disturbances, requiring psychosocial interventions to address them. Sure, the biological aspects of severe cases of anxiety and depression are there for psychiatrists to treat with their vast knowledge of pharmacotherapy and psychopathology. But for the vast majority of people with anxiety and depression, what they really need is to adjust their maladaptive coping styles, address their distorted thoughts and attributions, and address their behaviors which serve to perpetuate and maintain the vicious, negative cycles of anxiety and depression.

While primary care physicians are responsible for most of the prescribing of medication for anxiety and depression before considering CBT, I have also witnessed psychiatrists prescribing medication before fully implementing CBT. I should know…I have done that in the past… psychiatrists just mentioning as an after-thought some behavioral work to their depressed and anxious patients, some recommendations for relaxation, then onto the prescription pad. So what is the person with anxiety and depression supposed to do in the face of such bias in practice towards prescribing medications for even mild cases, and before CBT? My use of the word "last resort" is a backlash to the prominent prescription of medications before CBT is fully implemented for anxiety disorders and depression.

When you look at the treatment guidelines for anxiety and depression from the American Psychiatric Association (APA), you see contradictory findings with regards to pharmacotherapy versus psychotherapy. For the APA major depressive disorder guidelines, it states on page 17: “An antidepressant medication is recommended as an initial treatment choice for patients with mild to moderate major depressive disorder,” while in another section, it also states on page 17: “Use of a depression-focused psychotherapy alone is recommended as an initial treatment choice for patients with mild to moderate major depressive disorder,” and these two statements seem to contradict each other (APA, 2010). The APA panic disorder guidelines state the following on page 11: “The use of a selective serotonin reuptake inhibitor (SSRI), serotonin-norepinephrine reuptake inhibitor (SNRI), tricyclic antidepressant (TCA), benzodiazepine (appropriate as monotherapy only in the absence of a co-occurring mood disorder), or cognitive-behavioral therapy (CBT) as the initial treatment for panic disorder is strongly supported by demonstrated efficacy in numerous randomized controlled trials,” so this states that medication or CBT is first-line treatment for panic disorder (APA, 2009a). For the APA post-traumatic stress disorder (PTSD) guidelines, it states on page 13: “SSRIs are recommended as first-line medication treatment for PTSD,” while it states on page 14: “For patients with a diagnosis of ASD or PTSD, available evidence and clinical experience suggest that a number of psychotherapeutic interventions may be useful. Patients with ASD may be helped by cognitive behavior therapy and other exposure-based therapies,” failing to mention in what order or combination to use pharmacotherapy versus psychotherapy (APA, 2004). And with the updated APA PTSD guidelines, it has further evidence that SSRIs may not be effective for combat-related PTSD (APA, 2009b). For the APA obsessive compulsive disorder (OCD) guidelines, it states on page 4: “The guideline recommends CBT or a serotonin reuptake inhibitor (SRI; i.e., SSRIs or clomipramine) as first-line treatments for OCD” (APA, 2013). There are no APA treatment guidelines for generalized anxiety disorder (GAD), social phobia, and specific phobia.

The APA treatment guidelines for anxiety and depression seem contradictory, and even recommend pharmacotherapy as monotherapy as first-line treatment for mild to moderate cases of depression, and pharmacotherapy as monotherapy as first-line treatment for panic disorder, PTSD, and OCD. Again, there are no APA treatment guidelines on GAD, social phobia, and specific phobia.

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It seems counterintuitive to even rely on pharmacotherapy as a first-line treatment for mild to moderate cases of anxiety and depression, given the significant side effect profiles of antidepressants and benzodiazepines. For all anxiety disorders, CBT has higher level of evidence of effectiveness than any other type of psychotherapy, and for depression, CBT and other psychotherapeutic modalities have been shown to be effective (Clark, 2011).

Given that CBT is effective as first line treatment for all anxiety disorders, and that CBT and other psychotherapeutic modalities are effective as first line treatment for major depressive disorder, it seems logical to start with the most benign treatment modality, especially for mild to moderate cases. There has been “treatment creep” with prescription medications, to the point where treatment guidelines from the APA are suggesting prescription medications as monotherapy even for mild cases. No wonder, given that the majority of the thought leaders in psychiatry have direct connections to the pharmaceutical industry that has profited immensely off the backs of psychiatric patients.

It’s time to relegate prescription medications as “last resort treatment” for anxiety and depression- reserved only for the most severe cases or for those who have failed psychotherapy. This may sound controversial to those who consider medication in association with or as an adjunct to psychotherapy. This statement, “last resort treatment,” may be controversial to many clinicians, but it is meant to educate, raise awareness, and encourage physicians to avoid the indiscriminate use of psychotropic medications for anxiety and depression before even trying other strategies, such as CBT, which has evidence to back its position as first line treatment. Psychotherapy also has longer lasting, beneficial effects for anxiety and depression than any medication, especially CBT. In addition, there are self–help and/or alternative interventions which are effective for milder cases of anxiety and depression, such as on AnxietyBoss.com, and do not have the need to rely on pharmacotherapy.

The take home message of this article is for clinicians and patients to think about CBT, self-help, and/or alternative interventions for milder cases of anxiety and depression, before resorting too quickly to medication. After much discussion with my colleague who reviewed my book, he finally conceded and agreed that recommending psychotropic medications as “last resort” for anxiety and depression is not so controversial after all.

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Comments

Many of those with 'mental problems' are commonly found instead to have food allergies, toxins in their systems, medical problems, and a host of other non-psychiatric situations. Dr. Lita Lee, author of The Enzyme Cure, said, "I have never believed that people 'just go nuts.' I have always believed that abnormal brain chemistry leading to mental problems is a direct result of abnormal body chemistry, poor nutrition and hormonal imbalances. " The physical sources of mental symptoms fall into four general categories: medical, toxins, allergies, and nutrition. Too much caffeine can cause anxiety or too many sweets can give you the "sugar blues." And many women have have endured mental disturbances as a result of hormonal changes during the menstrual cycle. Canadian Dr. Erwin Koranyi, reporting on this in the Archives of General Psychology in 1979, stated, "No single psychiatric symptom exists that cannot at times be caused or aggravated by various physical illnesses. Allergies causes a vast array of standard physical problems such as Lyme Disease, certain forms of epilepsy, diabetes, hepatitis, back problems, toxicity,and glandular malfunctions., yet it is the last thing the medical system will look for. Dr. William Philpott found that 92% of those with mental disorders reacted to one or more substances as follows: · Wheat - 64% · Mature corn - 51% · Pasteurized whole cow milk - 50% · Tobacco - 75% with 10% becoming grossly psychotic, with delusions, hallucinations, and, especially, paranoia · Hydrocarbons - 30%. Weakness was common. Some participants reacted with delusions or suicidal inclinations.
Thank you for your comments. Psychiatrists, who are medical doctors, do include medical and toxic causes of psychiatric symptoms when evaluating someone for mental illness. Mental illness is not diagnosed until the medical, toxic, and infectious causes are ruled out. For example, someone can have kidney failure and present with psychosis; someone can have cocaine intoxication and present with manic symptoms; someone can have thyroid disease and present with depression; someone can have tertiary syphilis and present with psychosis; and yes, someone who has too much caffeine can present with anxiety. But the main theme of this article was to focus on non-medication ways to deal with bonafide anxiety and depression, after medical causes are ruled out.
Thank you for your explanation! Since the US is the biggest user of psychotropic drugs, even after non-medication ways to deal with anxiety and depression it does not say much for the success rate of that protocol. The use of antidepressants in the US for instance, has soared. In 1998, 11.2 million Americans used these drugs. By 2010, it was 23.3 million. American children are three times more likely to be prescribed psychotropic medications for conditions such as ADHD and bipolar disease than European children are, a new study finds. Researcher Julie Zito, from the pharmaceutical health services research department in the School of Pharmacy at the University of Maryland finds; "Since most of the use is 'off-label' -- without adequate evidence of benefits and risks, close monitoring should be considered when these medications are used." (24 online edition of Child and Adolescent Psychiatry and Mental Health.) Does this mean an over prescription of psychotropic drugs or is America a very sick nation?
Dear Hans, you bring up many interesting and controversial points. Regarding prescription of psychotropic drugs in America, there is a paradox- people with severe mental illness like schizophrenia are under-treated, while people with milder forms of mental illness such as anxiety disorders and depressive disorders are over-treated. As stated in the article, mild to moderate cases of anxiety and depression do not need a medication solution- CBT is effective, and the positive effects of CBT last even after CBT is completed, unlike medications where symptoms are more likely to return when medication treatment is discontinued. But unfortunately, doctors and patients/consumers are seemingly attracted to the medication solution as first line treatment for anxiety and depression. Regarding your comments about ADHD and bipolar disorder in the pediatric population, it appears that over-diagnosis is the problem in America, and that in turn may be associated with higher rates of treatment with psychotropic medications. In particular, pediatric bipolar disorder is controversial in itself, as many experts wonder about the validity of this diagnosis.
Hi Carlo. Thank you for your reply. Many diagnoses are related to symptoms, not diseases. With other words, they are labels, and each label has a certain known amount of chemicals called drugs to suppress (rather than cure) them. Fight or flight responses are responsible for many of the symptoms of mental health issues like depression, anxiety, restlessness, sleeping disorders, anger, irritability, bipolar (activation of the sympathetic nervous system through the release of norempinephrine followed by the activation of the parasympathetic systems activation of the 'rest and digest' response through the activation of the release of the neurotransmitter acetylcholine.) and social withdrawal as in ADD/ADHD. Hans Selye, in his book 'The stress of life' explains it all very eloquently and is well worth reading even though it was published quite a few years ago. The 'we are what we eat' bell has never pealed louder than it does today.
Diagnoses are not labels...diagnosis is prognosis...diagnosis predicts clinical course, and directs treatment. Someone with schizophrenia has a different clinical course and prognosis than someone with major depressive disorder. Psychiatric diagnoses are validated via longitudinal studies. The problem with psychiatric diagnosis is that there are no objective biomarkers to confirm the clinical diagnoses. But in the hands of a skilled and experienced psychiatrist, accurate psychiatric diagnosis and treatment can save someone's life. What you are talking about are mental health problems, which are not mental illness- big difference. Sure, the fight or flight response is a natural reaction to feared stimuli in the environment. The stress-diathesis model is well-known. Again, if you read my article, I am in favor of natural solutions to treating mild to moderate anxiety and depression- I overtly recommended that prescription medications be relegated to last resort.
But Carlo, Depression, Alzheimers, dementia, Parkinson's and schizophrenia are different labels (diagnosis) but often have the same origin (cause). The one cause might affect different areas of the brain. Inflammation and other immune processes are increasingly linked to psychiatric diseases, Anti-casein IgG associations with bipolar I diagnoses, psychotic symptom history, and mania severity scores suggest that casein-related immune activation may relate to the psychosis and mania components of this mood disorder. In testing patients classified as "schizophrenic," Dr. William Philpott found that 92% reacted to one or more substances as follows: · Wheat - 64% · Mature corn - 51% · Pasteurized whole cow milk - 50% · Tobacco - 75% with 10% becoming grossly psychotic, with delusions, hallucinations, and, especially, paranoia · Hydrocarbons - 30%. Weakness was common. Some participants reacted with delusions or suicidal inclinations. A study published in the American Journal of Epidemiology have established a link between Parkinson's and the consumption of dairy. Korsakoff's syndrome seems to be related to potato allergies. The undigested potato ferments in the gut producing ethyl alcohol. This leads to brain damage. Peptides associated with digestion of dietary proteins (e.g., milk, wheat) are in the opioid family (e.g., Fukudome & Yoshikawa, 1992; Ziodrou, Streaty, & Klee, 1979) and have psychoactive properties that can affect cognition and the release of neurotransmitters (Kampa, Loukas, Tsapis & Castanas, 2001). Opioids alter behavior because of their ability to bind to endorphin and enkephalin receptors in the brain. The orthomolecular/ecology-minded practitioners have found that a huge spectrum of mental and emotional symptoms can be triggered by allergies, including agitation, anxiety, compulsions, lack of concentration, brain fag, confusion, weepiness, delirium, delusion, depression, disorientation, drowsiness, epilepsy (Rolandic), hallucinations, hyperactivity, hyper-arousal episodes (i.e. palpitations, sweating, trembling), hypersensitivity, hysteria, impatience, insomnia, irritability, jumpiness, lethargy, mania, mental slowness, mental fogginess, nightmares, panic, paranoia, psychoses, rage, restlessness, and tension-fatigue syndrome. Dr. James C. Breneman, chairman of the Food Allergy Committee of the American College of Allergists, states in his 1984 textbook on food allergy that brain allergy is a common cause of everything from "poor concentration and neurosis to epilepsy and schizophrenia." Dr. Randolph also states that depression, especially when associated with other symptoms of allergy, may very well be due to food allergy. The above are not recent discoveries, but, how many workers in the psychiatric field conduct allergy tests? The average MD doesn't! Even when pressured they seem to be reluctant. I'd be interested to know if you do.
I wonder, since you are in favor of natural solutions, if allergy testing fits into that routine? As a Clinical Kinesiologist I have found that a huge spectrum of mental and emotional symptoms can be triggered by allergies, including agitation, anxiety, compulsions, lack of concentration, brain fag, confusion, weepiness, delirium, delusion, depression, disorientation, drowsiness, epilepsy, hallucinations, hyperactivity, hyper-arousal episodes (i.e. palpitations, sweating, trembling), hypersensitivity, hysteria, impatience, insomnia, irritability, jumpiness, lethargy, mania, mental slowness, mental fogginess, nightmares, panic, paranoia, psychoses, rage, restlessness, and tension-fatigue syndrome. Many of the old time allergist like Theron Randolph, M.D, Ralph Moss, Ph.D, Phillpot et all, and more believed allergies to be the main culprit in mental health issues. Dr. James C. Breneman, chairman of the Food Allergy Committee of the American College of Allergists, states in his 1984 textbook on food allergy that brain allergy is a common cause of everything from "poor concentration and neurosis to epilepsy and schizophrenia." "Schizophrenia is rare in areas of the world where little or no cereal grains are used and more frequent in countries where wheat, rye or barley are commonly used." ( Food Allergies Made Simple, Agatha and Calvin Thrash and co-author Phyllis Austin) They cite two more interesting studies, one of which concluded that 80 percent of people with schizophrenia tested allergic to eggs. They also noted that caffeine can have a significant worsening effect on schizophrenia. Philpot found dairy protein to be the culprit. Zane R. Gard, M.D. discusses food additives in a 1987 issue of the Townsend Letter for Doctors. A different allergy is responsible for schizophrenia. But what percentage of practitioners use allergy testing to prove or disprove allergies from the aetiology of schizophrenia?
Hans, I appreciate your knowledge on this subject of allergens and psychiatric illness. I am familiar with the studies on this subject, and they are still in the preliminary stages of study. Should these findings be replicated and shown to be bonafide risk factors for mental illnesses such as schizophrenia, then allergy testing could be part of a psychiatrist's diagnostic assessment. And if allergens are proven to be one of the risk factors for developing mental illness, then this would be a modifiable risk factor, as opposed to family history (genetics) or history of trauma, which cannot be changed. I look forward to psychiatry embracing emerging, potentially modifiable risk factors such as allergens.
So do I! In the meantime, back to Clozaril, Abilify, Geodon, Invega, Latuda, Risperdal, Saphris, Seroquil, Zyprexa, I like to point out that none of these are proven to be the CAUSE of mental illness either and I look forward to ongoing studies in this field. I enjoyed the exchange! All the best with your book 'Anxiety Protocol'.