I believe empowerment is all about choice. If we don’t see options, we feel trapped and powerless. I contend that we have a choice in everything and if we don’t think so, we can still choose how to approach the situation. When you feel stuck, it’s because you can’t see a way out and feel you have no choice.

According to Swift & Levin (1987), these three strategies constitute the cardinal principles of empowerment:

1. Define the situations, conditions or problems which they face

2. Participate in the elaboration of the solution

3. Act on the decisions they have taken.

This sounds good and is something we can all try to do. I love the whole idea of being empowered, moving forward, taking control of my life. 

In the community psychology context, empowerment usually applies to the marginalized people of a society. Is there a time when the idea of empowerment is a bad thing? I was pretty shocked to read about this policy in Zimbabwe which takes effect April 15. This news clip is pretty informative.

Do you think that a previously marginalized part of society has the right to take control of someone else’s hard work and business? Is there perhaps a better way to level the playing field? Empowerment sounds like such a wonderful thing but like any good idea, it can go too far. Maybe we should think about this idea of empowerment and use it with a little caution.

First, depression and stress can cause physical, sometimes irreversible problems in the body. The most disturbing are the structural changes in the brain that researchers are finding through imaging studies. Here are some highlights:

Your prefrontal cortex (PFC) is divided into two sides, each with different functions. The left side is associated with creating positive feelings and inhibiting negative ones. MRIs show reduced blood flow to that side of the PFC in depressed patients and it is measurably smaller. It is also responsible for turning off the amygdala. When the left PFC is not activated, the amygdala runs unchecked.

The amygdala tells us how negatively we see an event and can control the severity of depression by its output. The longer it stays active, the worse we think things are. It too will become smaller from recurrent depression.

The hippocampus is associated with learning and memory. It shrinks in people and animals under repeated stress. Prolonged stress (and depression) kills cells in the hippocampus and starts a decline in cognitive abilities.

The brain has plasticity, meaning it’s able to change its actual structure/shape and grow new neurons. This is what allows us to continue to learn and create new memories. Atrophy of the brain structures mentioned above is seen in people with long term depression. However, it may be possible to prevent these effects with early treatment. Treatment has also been shown to stimulate the growth of new neurons.

The second area of information that was new to me is the idea that depression is all in the body, not the head. Bruce Charlton is a research psychiatrist in England. He claims that depression is a completely physical disorder, one that is misread by the brain. Sickness or pain is interpreted as sadness. Lack of energy, loss of pleasure in activities, poor memory and the inability to concentrate are all the body’s way of conserving energy when it isn’t well. “Major depressive disorder,” he says, “is sickness behavior inappropriately activated and sustained….Antidepressants do not make people happy. Their effect on mood is no more remarkable than the fact that it is easier to be happy without a headache.” (As quoted in Psychology Today article by Morano).

This actually makes sense. My NP told me recently that antidepressants help fibromyalgia, chronic fatigue and other painful diseases. So here’s a crazy thought: maybe the reason antidepressants are so overprescribed in this country is because we’re treating all sorts of things with those magic pills. Is it all mental or all physical? Does it matter? Relief is good and returning to a functional life is great. Keeping your brain from withering away is also pretty cool.

So what’s the point? We should really eliminate stress whenever possible and find healthy, effective ways to deal with the stuff that isn’t going away. That’s common sense. Exercise is your friend! (It’s been shown to stimulate the same regenerative pathways as antidepressants).  I think it’s important to get the word out that antidepressants can do more than just cheer you up. If you or someone you know is suffering from recurrent depression or a painful, chronic condition, you might want to do some research and then talk to your doctor. Don’t try to tough it out for too long. Early treatment of depression could prevent your brain from shrinking. That’s worth thinking about.

Here’s a highly educational video clip about the structures of the brain:

Experiments have shown that lowering people’s serotonin levels does not make them depressed, nor does it worsen their symptoms if they are already depressed (Head Fake). Some researchers say that antidepressants actually deplete our neurotransmitters over time, which is why the medication may stop working. (Antidepressants Deplete Neurotransmitters). We also know there are newer drugs that don’t affect serotonin but still work well for many people. Welbutrin (buproprion) can relieve depression as well as Prozac by acting on the dopamine, norepinephrine, and cholinergic systems (Depression Post 4: The Serotonin Theory (and why it’s probably wrong) . There is a very effective antidepressant drug called Tianeptine (Stablon, Coaxil, Tatinol) that acts as a non-sedating anti-anxiety agent and a non-stimulating mood-brightener by INCREASING serotonin reuptake, the exact opposite of SSRIs. It has few side effects and also works well on other diseases such as fibromyalgia, erectile dysfunction and particularly asthma (two double-blind placebo-controlled crossover trials, and a 25,000+ patient open-label study lasting over seven years, all showing effectiveness (Lechin F, van der Dijs B, Lechin AE (November 2004). “Treatment of bronchial asthma with tianeptine”. Methods and Findings in Experimental and Clinical Pharmacology)). Although all of Europe, Latin America and Asia use it, we can’t get tianeptine here because its patent expired. A new patent would mean expensive FDA trials and then it could only be sold as a generic. Where’s the profit in that? If it shows up in the US anytime soon, it will probably be as an IBS drug. I personally think our American pharmaceutical companies have too much invested in the SSRI dogma to let in a drug that contradicts it AND works.

So if we aren’t correcting a serotonin imbalance, what’s really going on in there? “It is not possible to explain either the disease or its treatment based solely on levels of neurotransmitters,” says Yale University neurobiologist Ronald Duman (Depression: Beyond Serotonin). Current evidence indicates that depression is a neurodegenerative disorder, affecting the structure and function of brain and nerve cells. Serotonin may play some part in all of this but most likely, it’s not the main cause. So why are patients still being told an outdated story that scientists and (hopefully) our doctors know isn’t true? Here’s one possible reason that the word hasn’t spread: Since 1992, the FDA has been funded in large part by the drug companies. Instead of watching out for the safety and well-being of Americans, the FDA’s new role is to work in partnership with drug companies and get new drugs to market, so we can all be healthier and happier. The medical journals take advertising money from the pharmaceutical companies, so there is debate on the validity of published studies. We already know the drug companies are trying to influence doctors. Who can you trust?

Just in case you think I’m an alarmist, read this interview with author and investigative reporter Robert Whitaker. 

It would seem that the easiest way to disseminate information to patients about prescription drugs would be via doctors and other medical professionals. After all, they are fully informed about the benefits and risks of the products they prescribe, right? Where does that information come from? Most of us are aware, to some degree, that pharmaceutical companies and doctors have an intertwined and some might say incestuous relationship. Drug companies routinely provide perks to medical professionals along with the latest information about new drugs. The question is, do those benefits influence what drugs are prescribed and how often?

Doctor Training

An article by Duff Wilson in the New York Times this month states “ More than half of the nation’s medical residency programs to train doctors in internal medicine accepted financial support from the drug industry, even though three-fourths of the programs’ directors said accepting the aid was “not desirable,” a survey found.“  The drug companies paid for educational materials and meals, among other things. Wilson points out the obvious conflict of interest as new doctors begin to prescribe drugs during a “formative time in their careers”.

Wilson’s article also tells us that other surveys have shown that although residents don’t think their own actions are influenced by these gifts, they believe their colleagues are. Even small gifts such as a pen or meals have been shown to influence what medications a doctor may prescribe.

Some internal medicine residency programs have opted to stop accepting financial support or other benefits from the drug companies, in order that residents not be influenced inappropriately.

Dr. Kevin Pho wrote an interesting op-ed piece in USA Today last year. He talks about the voluntary ban by pharmaceutical companies on giving away pens and pads with drug names on them. He points out that these trinkets were the least of the problem. Medication sampling is the common practice of drug reps leaving brand name medications for doctors to try. Patients end up paying for expensive refills. A study showed that out-of-pocket costs increase almost 50% for patients who started out on free samples, versus those who did not.

Also from Dr. Pho’s article:  “Research shows that many doctors rely more on the pharmaceutical industry’s own information about a medication than on checking independent sources for evaluations of the drug.” …“a report by BlueCross BlueShield found that more than half the doctors in a group of “high-prescribing” physicians used information from drug companies as their primary source on new medications, compared with 26% who used medical journals.”

Is it just me, or does that seem a little scary?

Is it All in Our Heads?

In a recent article in Newsweek, psychiatrist Dr. Klitzman talks about his experience of taking antidepressants and how the medication helped him return to a functional life (A Doctor Disagrees. Antidepressants have helped not only my patients, but myself.). Included in his article is a link to another Newsweek story titled The Depressing News about Antidepressants by Sharon Begley. Begley tells us that the bulk of research shows all types of antidepressants are quite effective and overall they help about 75% of people who take them. But, a large study done by Kirsch and Sapirstein in 1998 revealed that 75% of those patients on a placebo also improved. In effect, three quarters of the relief from antidepressants may be purely psychological, not chemical. Kirsch’s controversial message was not well received nor was the next comprehensive study in 2002, which set off quite a debate among scientists.

A third article increases the dilemma. A recent study of 348 patients showed that over 4 years, 62% of them would go from mild to severe depression if left untreated (Untreated, Mild May Become Major Depression). It appears not treating patients with even mild depression is the wrong choice. So should doctors hand over a prescription, or insist their patients go to therapy first? What if insurance won’t cover therapy but will pay for anti-depressants?

To me, this is a public health issue. There are approximately 27 million people in this country taking some form of antidepressant. Is it irresponsible of physicians to dispense antidepressants without an evaluation by a mental health professional? Should the word be spread that antidepressants may not actually be helping people and can have harmful side effects (ironically, even suicide)? This could potentially save millions of dollars in prescription costs for both insurance companies and patients. Or do we continue to keep quiet in hopes that placebo or not, people suffering from depression will find relief by taking medication? Is it irresponsible to tell people their “happy pills” are probably doing nothing for them physically? Is it irresponsible not to tell them? My personal view is that knowledge and information are empowering. I think we should examine why the act of taking antidepressants works for so many people, and figure out what else we could be doing to help that doesn’t require a bottle of pills.

What do you all think?