Taking to the Stage to Battle Mental Illness

In small theater spaces across the United States, people fighting psychiatric illness are learning that acting can be a powerful form of therapy, while the shows they put on help educate audiences through deeply personal accounts of mental health issues.

“Theater arts can really give patients a very valuable additional opportunity to piece their lives back together,” said David A. Faigin, department of psychology, Bowling Green State University, Bowling Green, Ohio. He believes the approach works by “focusing on the same things that standard interventions focus on: community reintegration and social reintegration.”

Faigin, along with Bowling Green professor of clinical psychology Catherine Stein, co-authored a review of theater as mental health therapy in a recent issue of of Psychiatric Services.

More and more, mental health professionals are viewing the arts — visual arts, dance, writing — as key tools in patients’ recovery, and theater is no exception.

Faigin has tracked the efficacy of the technique through the Stars of Light group, a community theater linked to the Janet Wattles Center, a mental health agency serving adults in the Rockford, Ill. area.

Stars of Light has had a 15-year partnership with the Wattles Center, putting on productions using amateur actors diagnosed with a wide range of mental health problems. Faigin described the effort as “an exciting exemplar of a grass-roots, community-based theater setting devoted to involving and helping people with psychiatric disabilities.”

He estimates there are about 20 similar groups scattered across the country in places like Chicago, Memphis and Connecticut. In these programs, artistic directors work with mental health staff to help bring structure to an environment where patients are free to generate the artistic content necessary to stage theatrical productions. That means everything from script development (often involving autobiographical content) to final performances at churches and community centers.

These kinds of theaters are not large, typically involving between six and 12 volunteer actors. Sometimes they are closely connected and managed by a psychiatric facility, and sometimes they are entirely independent.

The idea of meshing therapy with the dramatic arts isn’t new. As Faigin pointed out, psychotherapy has long employed role-playing techniques to help patients tackle past traumas, depression or personality disorders, and to foster awareness and self-esteem.

“Research has shown that chronic mental illness is so incredibly disruptive of so many aspects on one’s life — family dynamics, relationships, employment — that there’s sort of a broken self there in terms of meaning and purpose,” Faigin noted. But for many patients, performance “sparks a real process of identity development by being forced to get up on stage and be themselves — quite literally — [and] by sharing their own personal stories in recovery.”

At the same time, acting by its very nature can also give the patient “a break from everyday life, by being somebody else for a half-hour,” Faigin said.

“They have a creative voice and express themselves as someone who has something to say,” he explained. “It’s a very in-your-face opportunity that forces the patients to ‘own it,’ because they’re accountable when they’re up on stage in a live performance in ways that they are not in the privacy of their home.”

Other experts agreed that theater can play a role in mental health care.

“Mostly my experience has been with patients who have found it very useful to enroll in acting courses,” said Marvin Aronson, a private practitioner in individual, group, and couples therapy, as well as former director of the group therapy department at the Postgraduate Center for Mental Health in New York City. “It’s not putting on a play or a long-term consuming involvement, but the principle is probably not so different. The setting gives them a license to learn how people spontaneously express feelings, and be exposed to people who are not inhibited.”

People who often benefit most from the approach are those who have had past experiences that have taught them to shut down their emotional responses, he added.

“Acting gives them an excuse, in essence, to learn how to express themselves,” Aronson said.

Robin F. Goodman, a clinical psychologist, art therapist and past president of the American Art Therapy Association, agreed.

“Lots of times there are experiences that have happened to you that are housed in non-verbal ways, and the arts are a way to access some of this stuff in terms of a feeling, an emotion, a movement, a song,” she noted. “The experience of theater can be a terrific way to get out some of these things.”

And it’s not only the acting that’s important. Mounting any kind of theatrical production involves a long timeline and teamwork from start to finish.

“That’s a good challenge for patients, to have them accept a level of responsibility to and from themselves and their peers,” Faigin said. “They get support and they give it. So at an emotional level there’s a sense of feeling safe in a group, and part of a group, and feeling that people understand them.”

Audiences can benefit, too, often getting an inside look into the world of those with mental illness. By letting people with bipolar disorder and other conditions step out of the shadows, the plays help overturn the stigma long attached to such ills.

“When these patients publicly share their own stories and their own voices they inevitably raise awareness about mental health issues, so it also offers a very important public health benefit,” Faigin explained.

He said he’s often seen theater help move patients to a better place, no matter what their diagnosis. “It gives them a real sense of purpose, a real creative spirit and a real creative voice. It can be a very powerful thing.”

Technorati Tags: Depression, Mental Health, mental illness, psychiatric illness

Depression May Increase Chances of Getting Alzheimer’s

As if depression wasn’t bad enough on its own, new research suggests older adults with depressive symptoms are at increased risk of developing Alzheimer’s disease.

Alzheimer’s is a fatal brain disorder marked by memory loss and an inability to function in daily life. Researchers have long known that depression and Alzheimer’s disease are linked, but it wasn’t clear whether depression was a risk factor for Alzheimer’s or a symptom of the disease. [Alzheimer's self-test works well]

Now, two studies published in the July 6 issue of the journal Neurology conclude that depression is indeed separate from Alzheimer’s and that depressive symptoms can raise the risk of dementia by 50 percent.

The studies didn’t address the question of why depression might contribute to later cognitive decline. One theory, said study author Robert Wilson, a neuropsychologist at Rush University Medical Center in Chicago, is that depression fundamentally alters the brain.

“There may be some actual structural changes associated with depression that render depressed individuals, by the time they reach old age, a little bit more vulnerable” to dementia, Wilson told LiveScience.

Risk factor or symptom?

Alzheimer’s is caused by protein plaques and tangles that build up in and around nerve cells in the brain, causing cell death. Exactly why the plaques and tangles form is a mystery, but previous brain-anatomy studies suggested depression isn’t to blame, Wilson said.

To Wilson, it seemed likely that depression was a risk factor for dementia, not a symptom of the disease. To test the theory, he and his colleagues analyzed data on older adults from Chicago’s South Side who had undergone evaluation for depression and Alzheimer’s every three years. About 350 of these individuals were diagnosed with dementia, which is most commonly caused by Alzheimer’s.

By comparing the participants’ self-reported depression ratings and dementia diagnoses, the researchers found “virtually no change” in depressive symptoms seven years prior to the dementia diagnosis and three years after it, Wilson said. Interviews with family members and caregivers confirmed that observable signs of depression also held steady.

The results suggest depression is not an inevitable symptom of Alzheimer’s, Wilson said.

“It’s not to say that people with Alzheimer’s never have depression,” he said. “We think they’re as likely to have depression as they were before the disease.”

Depression and dementia are linked, however. The second study, headed by epidemiologist Jane Saczynski of the University of Massachusetts Medical School, used data from the famous Framingham Heart Study to track depression and dementia in 949 people over 17 years.

At the beginning of the study, none of the participants had any dementia symptoms; by the end, 136 had developed Alzheimer’s and 28 had other dementias. Of those who had depressive symptoms at the beginning of the study, 21.6 percent later developed dementia, compared with 16.6 percent of non-depressed individuals. After controlling for factors like smoking and genetics, the researchers found that depression raised the risk of later dementia by 50 percent.

The long time frame makes it less likely that the participants already had dementia-related damage at the beginning of the study, Saczynski said. And because the depression showed up so much earlier than the dementia, the study, like Wilson’s, supports the notion of depression as a dementia risk factor, not a symptom.

Dementia by a thousand cuts

Exactly how a mood disorder like depression can contribute to Alzheimer’s disease isn’t known, but the effect is probably cumulative.

One theory, Saczynski said, is that depression weakens the body’s defenses against dementia by affecting the brain’s blood supply. Cardiovascular disease (another risk factor for Alzheimer’s) and depression are often clinically linked, Saczynski said, perhaps because of reduced blood flow to the brain. These vascular changes might render the brain more vulnerable to Alzheimer’s-related damage.

Another possibility is that the chronic stress of depression changes the brain’s structure. Studies on animals find that the brains of mice and rats kept in stressful conditions show changes in areas associated with memory and learning.

Something similar seems to happen in humans. One study, published in May in the journal Archives of General Psychiatry and co-authored by Rush University’s Wilson, revealed that Catholic nuns and priests who scored high on anxiety and depression measures had different brains than other clergy did. The nerve cells in the depressed group’s hippocampi ¾ brain areas associated with memory and emotion ¾ were shorter and less branched-out than normal nerve cells.

The researchers didn’t link these brain changes to Alzheimer’s, but the findings suggest depression “takes a toll,” Wilson said.

Blunting the vulnerability

If depression is a risk factor for Alzheimer’s disease, it is just one of many. Family history is another, as is the presence of a gene called ApoE4. Lifestyle factors like diet, exercise and cognitive engagement may also contribute, although a National Institutes of Health panel determined in May that the evidence for these factors is not yet strong enough to warrant recommendations for Alzheimer’s prevention.

In the case of depression, these lifestyle factors could make a difference. Exercise and diet might combat vascular disease linked to depression, Saczynski said. And, Wilson said, stressed mice and rats that exercise, take antidepressants and eat well show fewer brain changes than those that don’t.

“Diet and exercise seem to lessen the impact,” Wilson said. “So if we’re on the right track here, there do seem to be tools that can blunt the vulnerability.”

Technorati Tags: Alzheimer's disease, Depression, Depression and dementia

Antidepressant may aid domestic abusers who drink

A combination of antidepressants, alcohol counseling and behavioral therapy may help curb violent tendencies in men with drinking problems, a small clinical trial suggests.

U.S. government researchers found that adding the antidepressant fluoxetine (Prozac) to alcohol treatment and behavioral therapy worked better than the latter two alone in reducing anger and aggression among alcoholic men with a history of violence toward their partners.

The clinical trial was small — only 24 men completed the study — and lasted only three months, but the findings lay the groundwork for larger trials, according to Dr. David T. George and colleagues at the National Institute on Alcohol Abuse and Alcoholism.

If the current results are confirmed, they say, antidepressant therapy could help improve treatment of alcohol-dependent perpetrators of domestic violence.

It’s estimated that as many as 70 percent of domestic-violence perpetrators have an alcohol-abuse problem.

As it stands, behavioral therapy is the typical treatment for abusers — often in the form of court-mandated batterer intervention programs. But studies suggest that such programs do little to curb violent behavior, George and his colleagues note.

For their study, reported in the Journal of Clinical Psychiatry, the researchers recruited 60 men who were seeking treatment for alcoholism and had a history of physically abusing their “significant other.”

All of the men underwent treatment for their alcohol dependence, including behavioral therapy and support from self-help groups, like Alcoholics Anonymous. They also received individualized cognitive- behavioral therapy to address their domestic violence; the goal was to help them recognize the “perceived threats” in their lives that typically spurred their aggression and develop non-violent ways to deal with them.

In addition to those therapies, half of the men were randomly assigned to take fluoxetine everyday for three months. The rest were given placebo capsules and served as a “control” group.

Overall, only 24 men completed the three-month study; many of those who dropped out did so because they had started drinking again and were readmitted for in-patient treatment.

Still, the researchers found, of the men who did complete the study, those on the antidepressant showed greater reductions on a standard measure of anger, irritability and aggressive behavior.

When the men’s spouses and partners were surveyed about any physical and non-physical abuse they’d suffered during the study period, the researchers found that men in both the antidepressant and placebo groups improved to a similar degree.

According to George’s team, the rationale behind giving antidepressants in this context is that perpetrators of domestic violence have been shown to have a “heightened sensitivity” to environmental stressors, with a possible role for chemical messengers in the brain such as serotonin, which is involved in regulating mood.

Fluoxetine is in the class of antidepressants known as selective serotonin reuptake inhibitors (SSRIs), which are designed to enhance the action of serotonin in the body. It is approved by the U.S. Food and Drug Administration for major depression, obsessive-compulsive disorder, and other conditions, and is available as an inexpensive generic drug.

The current study appears to be the first to test a medication for treating perpetrators of domestic abuse, according to George and his colleagues. Many questions remain — including whether the short-term changes in the antidepressant group’s self-reported anger and aggression translate into fewer violent incidents over time.

Larger studies, the researchers write, are needed to determine whether fluoxetine or other SSRIs have a role in curbing aggressive behavior in people with alcohol problems.

They note that ongoing studies using brain-imaging technology known as functional MRI are investigating the ways in which fluoxetine affects brain function in perpetrators of domestic abuse.

SOURCE: http://link.reuters.com/bep76m Journal of Clinical Psychiatry, online June 29, 2010.

Technorati Tags: antidepressants, Fluoxetine, prozac

Perfectionists At Risk for Postpartum Depression

New mothers who think they should be perfect parents might be at risk for postpartum depression, a new study suggests.

The results show that a type of perfectionism in which individuals feel others expect them to be perfect, known as “socially prescribed perfectionism,” is associated with postpartum depression for first-time mothers.

The study is one of the first to look how perfectionism affects women’s ability to adjust to life after childbirth. It involved 100 first-time mothers in Toronto, Canada, who filled out questionnaires to assess their level and type of perfectionism as well as feelings of depression.

The link between perfectionism and postpartum depression was strongest amongst those who try to deal with perfectionism by appearing as if they don’t have a problem.

“What this suggests is that there might be some new mothers out there who might seem like everything is fine, in fact it might seem like everything is perfect,” said Gordon Flett, a professor of psychology at York University in Canada. “[But] in fact it’s just the opposite, that they’re feeling quite badly but they’re pretty good at covering it up.”

This finding is particularly concerning, because it means friends and family might not realize their loved one is suffering from depression.

“This tendency to put on this front usually means that people don’t tell other people when they’re doing badly, so somebody might not know that a young women is having difficulty; they might have no clue whatsoever,” Flett said. “And there’s sadly some cases where the family says ‘We thought everything was fine,’ and the next thing we know, the person is no longer with us,” he said.

The results underscore the need to dispel the myth of the “perfect parent,” Flett said.

“I think it’s just important for new mothers and fathers to just realize, ‘Hey, you haven’t got a lot of experience with this, you don’t’ need to be perfect, you don’t need to be absolutely the best parent in the world,’” Flett said. “You need to just be able to experience the role, do your best, and your best is good enough.”

But if these perfectionistic mothers tend to hide their depression, how can friends and physicians identify that there’s a problem?

One clue might be when a woman appears to be adjusting a little too well to her new life as a mother - someone who “appears to be making [the situation] much more rosier than it is, who seems to be doing absolutely amazingly well with this transition,” Flett said.

The key is to try to get new mothers to speak about their experience in realistic terms as opposed to just saying what they think people want to hear.

The issue could also be addressed through classes for parents-to-be, Flett said. “They could very easily incorporate an emphasis on not wanting to be perfect, and to not be too hard on yourself as you’re making the transition,” he said.

The results were presented May 30 at the Association for Psychological Science Convention in Boston.

Technorati Tags: perfectionism and postpartum depression, Perfectionists, Postpartum Depression

Brain Changes in MS May Spur Depression

Brain atrophy may be a major reason why the lifetime risk of depression in multiple sclerosis patients is as high as 50 percent, new research suggests.

This atrophy, marked by a shrinkage of brain mass, occurs in the hippocampus, a part of the brain involved in a number of functions, including mood and memory.

For this study, researchers at the University of California, Los Angeles used MRI scans to compare the brains of multiple sclerosis (MS) patients and healthy people. The scan results showed that three important sub-regions of the hippocampus were smaller in MS patients.

The research team also identified a link between this brain atrophy and hyperactivity of the hypothalamic-pituitary-adrenal (HPA) axis, a part of the neuroendocrine system that controls reactions to stress and regulates many physiological functions. Excessive activity of the HPA axis may be associated with both atrophy of the hippocampus and the development of depression, the researchers suggested.

The study was released online June 19 in advance of publication in an upcoming print issue of the journal Biological Psychiatry.

The connection between HPA hyperactivity and brain atrophy hasn’t received much attention, “despite the fact that the most consistently reproduced findings in psychiatric patients with depression (but without MS) include hyperactivity of the HPA axis and smaller volumes of the hippocampus,” senior study author Dr. Nancy Sicotte, an associate professor of neurology, said in a news release from the university.

“So the next step is to compare MS patients with depression to psychiatric patients with depression to see how this disease progresses in each,” she added.

Along with being one of the most common symptoms in patients with multiple sclerosis, depression “impacts cognitive function, quality of life, work performance and treatment compliance. Worst of all, it’s also one of the strongest predictors of suicide,” noted lead author Stefan Gold, a postdoctoral fellow in the UCLA Multiple Sclerosis Program.

Technorati Tags: Brain atrophy, Depression, hippocampus

Exercise Lifts Mood, but Does It Work Against Depression?

At his research clinic in Dallas, psychologist Jasper Smits is working on an unorthodox treatment for anxiety and mood disorders, including depression. It is not yet widely accepted, but his treatment is free and has no side effects. Compare that with antidepressant drugs, which cost Americans $10 billion each year and have many common side effects: sleep disturbances, nausea, tremors, changes in body weight.

This intriguing new treatment? It’s nothing more than exercise. (See how to handle illness at any age.)

That physical activity is crucial to good health - both mental and physical - is nothing new. As early as the 1970s and ’80s, observational studies showed that Americans who exercised were not only less likely to be depressed than those who did not but also less likely to become depressed in the future. (See the Year in Health for 2009 from A to Z.)

In 1999, Duke University researchers demonstrated in a randomized controlled trial that depressed adults who participated in an aerobic-exercise plan improved as much as those treated with sertraline, the drug that, marketed as Zoloft, was earning Pfizer more than $3 billion annually before its patent expired in 2006.

Subsequent trials have repeated these results, showing again and again that patients who follow aerobic-exercise regimens see improvement in their depression comparable to that of those treated with medication, and that both groups do better than patients given only a placebo. But exercise trials on the whole have been small, and most have run for only a few weeks; some are plagued by methodological problems. Still, despite limited data, the trials all seem to point in the same direction: exercise boosts mood. It not only relieves depressive symptoms but also appears to prevent them from recurring. (See the top 10 medical breakthroughs of 2009.)

“I was really surprised that more people weren’t working in this area when I got into it,” says Smits, an associate professor of psychology at Southern Methodist University.

Molecular biologists and neurologists have begun to show that exercise may alter brain chemistry in much the same way that antidepressant drugs do - regulating the key neurotransmitters serotonin and norepinephrine. At the University of Georgia, neuroscience professor Philip Holmes and his colleagues have shown that over the course of several weeks, exercise can switch on certain genes that increase the brain’s level of galanin, a peptide neurotransmitter that appears to tone down the body’s stress response by regulating another brain chemical, norepinephrine.

The result is that exercise primes the brain to show less stress in response to new stimuli. In the case of lab rats and mice, those stimuli include being plunged into very cold water or being suspended by the tail. And while those are not exactly problems most people face, the thinking is that the human neurochemical response may well react similarly, with exercise leaving our brain less susceptible to stress in the face of harmless but unexpected events, like missing an appointment or getting a parking ticket. A little bit of mental strain and excess stimulation from exercise, in other words, may help us to keep day-to-day problems in perspective.

Researchers wonder whether this interaction between body and brain may, evolutionarily speaking, be hardwired. “It occurs to us that exercise is the more normal or natural condition and that being sedentary is really the abnormal situation,” Holmes says.

Read about whether there’s a genetic link between migraines and depression.

Read about how ecotherapy is being used to treat environmental depression.

Humans (and lab rats) never evolved to be cooped up, still, all day long. Our brains simply may not be built for an environment without physical activity. Research has also suggested that exercise may be an effective treatment for not just depression but also related anxiety disorders and even substance dependence.

Other scientists have found that in mammals, exercise also boosts the production of brain-derived neurotrophic factor (BDNF), a substance that supports the growth and maintenance of brain cells. In depressed patients, BDNF has been shown to help repair brain atrophy, which can lift symptoms of the disease. (See a special on how to live 100 years.)

Smits says his exercise treatment appeals to patients for two main reasons. First, exercise doesn’t carry the same stigma among patients (and some providers) that depression medication and psychotherapy do. Second, the mood-enhancing benefits of exercise can kick in fast - a lot faster than, say, its impact on weight loss or cardiovascular health. “By and large, for most people, when they exercise 30 minutes - particularly when it’s a little bit more demanding and they get their heart rate up - they feel better,” Smits says. “You get an immediate mood lift.” (See how a recent study is linking antidepressant use with miscarriages.)

That effect doesn’t reflect the longer-term changes in the brain that Holmes studies. But Smits uses the immediate mood boost as a way to motivate patients with depression (which, of course, manifests in a chronic lack of motivation) to get moving. Instead of a barrier to exercise, Smits suggests, depression can become a reason to exercise. “You feel crappy, so you get on the treadmill, and you look back and you say, ‘Wow, I feel much better,’ ” he says.

Yet for all the potential clinical benefits, the big questions about exercise treatment remain unanswered: How much? How long? In which patients? In their recent book for therapists, Exercise for Mood and Anxiety Disorders (Oxford University Press, 2009), Smits and co-author Michael Otto at Boston University suggest precise exercise doses that they hope will aid psychologists and primary-care doctors in prescribing exercise as treatment - which can be administered in combination with other treatments, of course. (Comment on this story.)

Smits and Otto recommend the familiar 30 minutes of moderate-intensity aerobic exercise, like walking, five times per week, or 30 minutes of high-intensity aerobic exercise three times a week. These doses, which are regularly recommended for physical fitness, are the only ones that have been well tested for depression. “But we can’t say at this point that more wouldn’t be better,” Smits says. “Or maybe less would be better. We really don’t know.” Too few tests have been run. It is also unclear whether anaerobic exercise, like weight lifting, would have the same mood-lifting effects, or whether exercise works as well in severely depressed patients as it does in sufferers of mild to moderate depression.

For now, then, data on exercise are only suggestive. The clinical literature on antidepressant drugs is massive, since large-scale, rigorous studies are required for market approval from the FDA. The trials on exercise have all been smaller, perhaps in part because they need no government approval. “If you look at FDA standards [for evidence], it’s not clear that exercise would meet that standard,” says James Blumenthal, the Duke University professor of medical psychology who ran Duke’s 1999 exercise study as well as a 2007 follow-up with more than 200 patients, which Blumenthal believes is the largest such trial to date.

But the evidence is mounting, and it’s hard to argue with a free treatment that is exempt from side effects for a pervasive and debilitating mental-health scourge - especially when so many other health benefits of exercise are incontrovertible. “I think that we have reason to be optimistic,” Blumenthal says. “For people who at least want to consider exercise as a possible treatment, and for whom exercise is safe, it’s definitely worth a shot.”

Technorati Tags: antidepressant drugs, anxiety disorders, mood disorders, zoloft

Nurses at crowded hospitals more likely depressed

Nurses who work in hospital wards that are usually filled to capacity may have a higher risk of depression than their counterparts in less-crowded hospitals, Finnish researchers suggest.

Their new study found that hospital staffers who worked in the most crowded wards were twice as likely to take sick leave for depression as staff who worked in wards with “optimal” numbers of patients. The large majority of workers in the study — 93 percent — were nurses.

The findings, published online May 4 in the Journal of Clinical Psychiatry, don’t prove that hospital overcrowding contributed to the nurses’ depression. But they raise the possibility that chronic stress due to a heavy workload might impair some hospital workers’ mental health, lead researcher Dr. Marianna Virtanen, of the Finnish Institute of Occupational Health in Helsinki, told Reuters Health in an e-mail.

For the study, Virtanen and her colleagues used data from 16 hospitals to look at monthly bed-occupancy rates for the years 2003 and 2004. They then linked that information to data on sick leave for 5,166 staff members in 2004 and 2005.

Wards that, for the year, had no more than 85 percent of beds filled on average were considered to be operating at optimal capacity. Wards that topped 85 percent were deemed to be overcrowded.

Overall, Virtanen’s team found, staff in the most crowded wards — where more than 95 percent of beds were filled, on average - had double the risk of taking sick leave for depression as their counterparts in wards with an optimal number of patients. The researchers took into account factors such as workers’ age and area of medical specialty.

The overwhelming majority of nurses and other staff did not take leave for depression, regardless of ward crowding. Of 486 workers in the most crowded wards, 23 took leave due to depression over two years. That compared with 41 of 1,766 staff members in wards with optimal bed occupancy.

Still, the findings point to an additional concern about hospital overcrowding. Past studies, Virtanen said, have suggested that overcrowding may compromise patients’ care — increasing their odds of infection, for example.

“Good practice could be to keep the bed occupancy levels at a reasonable level,” she said.

Virtanen acknowledged that other factors not measured in the study — like hospitals’ financial difficulties or poor management — might explain the connection between overcrowding and staff’s depression risk.

SOURCE: http://article.psychiatrist.com/dao_1-login.asp?ID=10006863&RSID=93355739862602 Journal of Clinical Psychiatry, online May 4, 2010.

Technorati Tags: Depression, hospital overcrowding, Mental Health, risk of depression

Link Between Antidepressants and Miscarriage

Pregnancy is often fraught with complications, not least for women suffering from depression while carrying a child: new research suggests that women who take antidepressant medications during pregnancy may have an increased risk of miscarriage.

Scientists at the University of Montreal reported Monday, May 31, in the Canadian Medical Association Journal that women taking the drugs most often prescribed to treat depression and anxiety - including selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs) and the older tricyclics - had a significantly higher risk of miscarriage than a matched control group of women who did not take antidepressants. The study is the first of its kind to analyze which antidepressants and which doses are most likely to be associated with spontaneous abortion. Led by Anick BÉrard at the Faculty of Pharmacy at the University of Montreal, the research team also documented that two SSRIs, paroxetine (Paxil) and venlafaxine (Effexor), are associated with the greatest risk. (See TIME’s list of the 50 worst inventions.)

BÉrard analyzed data from a pregnancy registry she established in Quebec that collects records on births and spontaneous abortions occurring in hospitals in the Canadian province. The study included 69,742 women from the registry, 5,124 of whom had had a clinically recorded miscarriage. Among the women who had miscarried, 5.5% had filled at least one prescription for an antidepressant during pregnancy, compared with 2.7% of the control group. Researchers calculated that antidepressant users had a 68% higher risk of miscarriage than nonusers, after controlling for other influences that could potentially confound the association.

Overall, the risk was greatest among women who combined the use of two or more classes of antidepressants. When researchers looked at the small amounts of data on patients using specific drugs, they found that those taking paroxetine alone had a 75% higher rate of miscarriage than women without depression, while women taking venlafaxine had a more than doubled risk. “To my knowledge, we are the only ones to go further and look at which class [of antidepressant] and which dosage increased the risk most,” says BÉrard. (Read how postpartum depression can strike fathers.)

However, the study was an observational one that looked retrospectively at data already collected, which means that it’s possible that some part of the miscarriage risk picked up by BÉrard can be ascribed to depression itself rather than the drugs used to treat it. Indeed, the authors acknowledge that some past research has shown that women who are depressed during pregnancy are at increased risk of spontaneous abortion. But while acknowledging that limitation of the current study, BÉrard stresses that it’s unlikely that such a large difference - the 68% increase - could be wholly attributable to underlying causes. “The effect is too big,” she says, “and while it may explain a small portion, it wouldn’t explain the totality of the effect.” (Comment on this story.)

Still, obstetricians are not ready to stop writing prescriptions for antidepressants. Taken together, research on the risks of using antidepressants - and most other prescription drugs - for expectant moms and their developing babies is limited and often inconsistent. Evidence for the risks associated with depression drugs has been increasing in recent years, however, with studies finding a link between the medications, particularly when used during the first trimester, and as much as a sixfold increase in lung, heart and other congenital birth defects in newborns. BÉrard’s study adds solid evidence for a new risk factor, but because it is an observational study, says Dr. Alex Vidaeff, director of research in the division of maternal-fetal medicine at the University of Texas Medical School at Houston, “with this level of evidence, immediate changes in practice may be ill-advised.”

Such findings leave women with depression facing increasingly complicated treatment decisions when they are pregnant or considering starting a family. According to the American Congress of Obstetricians and Gynecologists (ACOG), depression during pregnancy is common: about 14% to 23% of pregnant women will experience depressive symptoms; in 2003, about 13% of women took an antidepressant at some point during pregnancy. But both antenatal depression and the use of antidepressant medications are associated with health risks to the newborn. Past studies have shown that pregnant women who are depressed are more likely to have premature births and low-birth-weight babies and that their infants are at increased risk of irritability, sleep problems and high blood levels of the stress hormone cortisol compared with babies born to mothers without depression.

As with many clinical decisions, depression treatment during pregnancy is a matter of balance. Experts advise women to discuss with their physician the severity of their depression or anxiety and weigh their past history of miscarriage before deciding whether to change medications or reduce their doses while carrying a child. For its part, the ACOG recommended in a 2009 report that women with severe depression stay on medication during pregnancy and that women who are psychiatrically stable may also be able to continue medication after consulting with their mental-health-care provider and obstetrician. Depressed women who are not taking antidepressants or are not helped by them should seek treatment, whether it is psychotherapy or other interventions that can help reduce symptoms of depression and anxiety.

Although BÉrard’s analysis did not include a side-by-side comparison of antidepressant use in alleviating women’s depressive or anxiety symptoms, other research has documented the importance of maintaining such treatment for women who otherwise would struggle to function at their best, much less under the added stress of expecting a child.

Technorati Tags: antidepressant medications, antidepressant use, antidepressants, anxiety, Effexor, Miscarriage, paxil

Certain Popular Antidepressants Linked to Cataracts in Seniors

A widely prescribed type of antidepressants known as selective serotonin reuptake inhibitors (SSRIs) appear to boost the risk for developing cataracts among seniors, according to the first study to explore the subject.

The increase in risk, reported in the June issue of the journal Ophthalmology, was calculated to be approximately 15 percent, the researchers found.

At that rate, 22,000 Americans would theoretically develop cataracts as a result of their antidepressant use, the study authors noted.

The research team, led by Mahyar Etminan of the Vancouver Coastal Health Research Institute in Canada, analyzed data concerning almost 19,000 patients over the age 65, and compared the findings to data from 190,000 men and women in the same age group not taking antidepressants.

Strong links to cataract risk were found for three specific SSRI drugs: fluvoxamine (Luvox), venlafaxine (Effexor) and paroxetine (Paxil), the researchers found. Each contributed to an elevated risk of 39 percent, 33 percent and 23 percent, respectively.

However, rising risk was only associated with the current use of such medications, not prior use, the authors noted.

Etminan’s team further observed that not all antidepressants appeared to be linked to an increased risk for cataracts, although they noted that the lack of an association was not definitive proof that there is in fact no risk.

“The eye’s lens has serotonin receptors, and animal studies have shown that excess serotonin can make the lens opaque and lead to cataract formation,” Etminan said in a news release from the American Academy of Ophthalmology. “If our findings are confirmed in future studies, doctors and patients should consider cataract risk when prescribing some SSRIs for seniors.”

Technorati Tags: antidepressant use, antidepressants, Effexor, luvox, paxil, serotonin reuptake inhibitors

For Depression, Phone Therapy May Be an Answer

When you’re depressed, do you need to meet a therapist in person? Maybe not, suggests a small new study, which finds that therapy by telephone is almost as effective as face-to-face.

Researchers at Brigham Young University had 30 people who were newly diagnosed with depression talk to a therapist by phone for 21 to 52 minutes. They did this instead of making eight visits to a clinic.

None of the participants got antidepressant medicine.

Six months later, 42 percent of the participants had recovered from depression. About 50 percent of patients recover from depression when face-to-face therapy is provided, the researchers said.

“Offering a phone or webcam option for psychotherapy does appear warranted from an efficacy point of view,” said study co-author Diane Spangler, a psychology professor, in a statement. “It’s more user-friendly — no commutes, more flexibility of place and time and has no side effects.”

But not everyone is willing to try phone therapy. A third of eligible participants declined it.

The study is published in the June issue of Behavior Therapy.

Technorati Tags: antidepressant medicine, Depression, phone therapy