![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 44 to 68 of 488. Go back in thread:
Posted by Rick on January 21, 2002, at 3:40:48
In reply to Re: MAOI dose and dizziness-Seamus, posted by Lisa01 on January 20, 2002, at 19:02:47
> It shows you how desperate we are for relief from symptoms--of Social Anxiety in my case--that we will put up with such things. I just sometimes wonder what the long-term result will be.
The general wisdom -- and I'm not saying it's 100% correct -- is that medication changes brain chemistry temporarily; while successful CBT can effect permanent changes.
On the other hand, the continuation vs. discontinuation summarized study below shows clear evidence of maintained post-treatment benefit from Klonopin (clonazepam), the med which has demonstrated the highest level of controlled-study efficacy to-date for SP. Despite the overblown fears of dependence, addiction (HUGELY exaggerated), and tolerance (excuse me, why have I been able to REDUCE my theraputic dose from 3mg to 1mg over two years??), this med is physically safer than AD's and generally a lot more tolerable. But I digress...I'd imagine the kinds of post-treatment Social Phobia benefits described here would likely apply to MAOI responders as well.
P.S. Despite my Klonopin boosterism I think if you stick it out you have a great chance of doing well with Parnate. And if even if not, there are quite a few meds than can help, with some promising new ones in development.
Rick
-----J Clin Psychopharmacol 1998 Oct;18(5):373-8
Discontinuation of clonazepam in the treatment of social phobia.
Connor KM, Davidson JR, Potts NL, Tupler LA, Miner CM, Malik ML, Book SW, Colket JT, Ferrell F.
Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina 27710, USA.
Patients with social phobia who responded well to 6 months of open-label treatment with clonazepam were assigned to receive either continuation treatment (CT) with clonazepam for another 5 months, or to undergo discontinuation treatment (DT) using a clonazepam taper at the rate of 0.25 mg every 2 weeks, with double-blind placebo substitution. Clinical efficacy was compared between the CT and DT groups using three different social phobia scales. Benzodiazepine withdrawal symptoms were also measured. Relapse rates were 0 and 21.1% in the CT and DT groups, respectively. Subjects in the CT group generally showed a more favorable clinical response at midpoint and/or endpoint, although even in the DT group clinical response remained good. With respect to withdrawal symptoms, the rates were low in both groups (12.5% for CT and 27.7% for DT) with no real evidence suggesting significant withdrawal difficulties. At the end of 11 months of treatment with clonazepam, however, a more rapid withdrawal rate was associated with greater distress. This study offers preliminary evidence to suggest that continuation therapy with clonazepam in the treatment of social phobia is safe and effective, producing a somewhat greater clinical benefit than a slow-taper discontinuation regime. However, even in the DT group, withdrawal symptoms were not found to be a major problem. The study can be taken as supportive of benefit for longterm clonazepam treatment in social phobia, as well as being compatible with a reasonably good outcome after short-term treatment and slow taper.
Posted by spike4848 on January 21, 2002, at 9:47:56
In reply to Brain Chemistry/Lasting Social Phobia Benefits » Lisa01, posted by Rick on January 21, 2002, at 3:40:48
> The general wisdom -- and I'm not saying it's 100% correct -- is that medication changes brain chemistry temporarily; while successful CBT can effect permanent changes.
responders as well.Hey Rick,
I think we are pretty much in agreement. As I understand it, *any* active treatment *modified* brain chemistry. With medication, active treatment last only as long as the duration you take it. With CBT, you retrain behavior, and thus "treating" the brain for as long as the behavioral changes last. Often these changes can be life long. So if we are able to correct any maladaptive behavior contributing to our illness, and maintain that behavior, we can in a sense permenently change brain chemistry.
I am not sure if an "imbalance" in brain neurotransmiters levels is the etilogy of mood disorders. These imbalances we see may just be secondary to the real pathologic process. We simply just don't know enough about the brain.
We know the human brain in the most complex of all the organs. Many scientists believe we will never completely understand how it works. We need something "smarter" than our own brains to figure out the inner workings of the brain. Thus, we may never fully realize the pathology of mood disorders.
Spike
PS Rick ... I alway enjoy reading your posts ... they are very informative and insightful
Posted by Lorraine on January 21, 2002, at 11:40:32
In reply to Brain Chemistry/Lasting Social Phobia Benefits » Lisa01, posted by Rick on January 21, 2002, at 3:40:48
> > It shows you how desperate we are for relief from symptoms--of Social Anxiety in my case--that we will put up with such things. I just sometimes wonder what the long-term result will be.
>
> The general wisdom -- and I'm not saying it's 100% correct -- is that medication changes brain chemistry temporarily; while successful CBT can effect permanent changes.
>
> On the other hand, the continuation vs. discontinuation summarized study below shows clear evidence of maintained post-treatment benefit from Klonopin (clonazepam), the med which has demonstrated the highest level of controlled-study efficacy to-date for SP. Despite the overblown fears of dependence, addiction (HUGELY exaggerated), and tolerance (excuse me, why have I been able to REDUCE my theraputic dose from 3mg to 1mg over two years??), this med is physically safer than AD's and generally a lot more tolerable. But I digress...I'd imagine the kinds of post-treatment Social Phobia benefits described here would likely apply to MAOI responders as well.
>
> P.S. Despite my Klonopin boosterism I think if you stick it out you have a great chance of doing well with Parnate. And if even if not, there are quite a few meds than can help, with some promising new ones in development.
>
> Rick
> -----
>
> J Clin Psychopharmacol 1998 Oct;18(5):373-8
>
> Discontinuation of clonazepam in the treatment of social phobia.
>
> Connor KM, Davidson JR, Potts NL, Tupler LA, Miner CM, Malik ML, Book SW, Colket JT, Ferrell F.
>
> Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina 27710, USA.
>
> Patients with social phobia who responded well to 6 months of open-label treatment with clonazepam were assigned to receive either continuation treatment (CT) with clonazepam for another 5 months, or to undergo discontinuation treatment (DT) using a clonazepam taper at the rate of 0.25 mg every 2 weeks, with double-blind placebo substitution. Clinical efficacy was compared between the CT and DT groups using three different social phobia scales. Benzodiazepine withdrawal symptoms were also measured. Relapse rates were 0 and 21.1% in the CT and DT groups, respectively. Subjects in the CT group generally showed a more favorable clinical response at midpoint and/or endpoint, although even in the DT group clinical response remained good. With respect to withdrawal symptoms, the rates were low in both groups (12.5% for CT and 27.7% for DT) with no real evidence suggesting significant withdrawal difficulties. At the end of 11 months of treatment with clonazepam, however, a more rapid withdrawal rate was associated with greater distress. This study offers preliminary evidence to suggest that continuation therapy with clonazepam in the treatment of social phobia is safe and effective, producing a somewhat greater clinical benefit than a slow-taper discontinuation regime. However, even in the DT group, withdrawal symptoms were not found to be a major problem. The study can be taken as supportive of benefit for longterm clonazepam treatment in social phobia, as well as being compatible with a reasonably good outcome after short-term treatment and slow taper.
Posted by Rick on January 21, 2002, at 13:00:37
In reply to Re: Brain Chemistry/Lasting Social Phobia Benefits » Rick, posted by spike4848 on January 21, 2002, at 9:47:56
Posted by Rick on January 21, 2002, at 13:22:46
In reply to Re: Great info of enormous usefulness nm » Rick, posted by Lorraine on January 21, 2002, at 11:40:32
Lorraine -
Glad you found it useful!
BTW, anything by Duke's JR (Jonathan RT) Davidson on anxiety -- especially social phobia -- is worth reading. He was listed as the second author in the Klonopin/clonazepam discontinuation abstract, and was the lead researcher for the original placebo-controlled study that demonstrated the med's appx 70% response rate in social phobia. Those just scratch the surface of the work he's done on SP etiology, measurement, and treatment.
Rick
Posted by Lorraine on January 21, 2002, at 19:25:28
In reply to Re: Great info of enormous usefulness nm » Lorraine, posted by Rick on January 21, 2002, at 13:22:46
Rick:
You may have seen this
http://www.psychiatrist.com/supplenet/59s17/59s17toc.htm
> Lorraine -
>
> Glad you found it useful!
>
> BTW, anything by Duke's JR (Jonathan RT) Davidson on anxiety -- especially social phobia -- is worth reading. He was listed as the second author in the Klonopin/clonazepam discontinuation abstract, and was the lead researcher for the original placebo-controlled study that demonstrated the med's appx 70% response rate in social phobia. Those just scratch the surface of the work he's done on SP etiology, measurement, and treatment.
>
> Rick
Posted by Rick on January 21, 2002, at 21:45:43
In reply to Re: Some links » Rick, posted by Lorraine on January 21, 2002, at 19:25:28
Lorraine -
Yes I've seen it, and it's nice that the Journal of Psychiatry (or Glaxxo Smith Kline??) has made that supplement available electronically for free.
The same journal also published an updated supplement on Social Anxiety in 2001. I had to order the hardcopy, purchased online from the Orders section at http://www.psychiatrist.com , but it was well worth the $10. (Don't know if that would be possible at the moment though, because I just visited the site to verify that this price still applies, and the Orders link doesn't seem to be functioning properly.)
I've pasted the table of contents for the 2001 supplement below.
Volume 62 2001 Supplement 1
Advances and Emerging Treatments in Social Phobia
3 Disclosure Statements.
4 Introduction: Advances and Emerging Treatments in Social Phobia. Jonathan R. T. Davidson
5 Social Phobia: Prevalence and Diagnostic Threshold. Ariel J. Lang and Murray B. Stein
11 Social Anxiety Disorder: An Unrecognized Problem in Primary Care. David J. Katzelnick and John H. Greist
17 Social Anxiety Disorder: Comorbidity and Its Implications. R. Bruce Lydiard
25 Social Phobia: Etiology, Neurobiology, and Treatment. Nicholas J. Coupland
36 Current Status of Psychotherapeutic Interventions for Social Phobia. Richard G. Heimberg
43 Treatment of Social Phobia With Antidepressants. Franklin R. Schneier
50 Benzodiazepines and Anticonvulsants for Social Phobia (Social Anxiety Disorder). James W. Jefferson
Rick> Rick:
>
> You may have seen this
>
> http://www.psychiatrist.com/supplenet/59s17/59s17toc.htm
>
> > Lorraine -
> >
> > Glad you found it useful!
> >
> > BTW, anything by Duke's JR (Jonathan RT) Davidson on anxiety -- especially social phobia -- is worth reading. He was listed as the second author in the Klonopin/clonazepam discontinuation abstract, and was the lead researcher for the original placebo-controlled study that demonstrated the med's appx 70% response rate in social phobia. Those just scratch the surface of the work he's done on SP etiology, measurement, and treatment.
> >
> > Rick
Posted by Elizabeth on January 22, 2002, at 23:30:23
In reply to Brain Chemistry/Lasting Social Phobia Benefits » Lisa01, posted by Rick on January 21, 2002, at 3:40:48
Lisa:
Medications typically work as long as you're taking them (sometimes people develop tolerance, but this doesn't generally happen with most common psychiatric drugs). The evidence regarding talk therapies (mainly CBT, although other talk therapies are now being studied too) is less clear. Advocates of CBT and other nonmedical therapies have claimed that these therapies get to the "root of the problem" and therefore can permanently cure mental disorders (medications that are used presently constitute "treatment" rather than a "cure"). On the other hand, some studies show that people who don't remain in therapy frequently relapse.
Personally, I didn't have much luck with CBT, but I think that each person is different. Another type of talk therapy, interpersonal therapy (IPT), seems promising for social phobia, and I think that group therapy can be helpful too (there are lots of CBT and IPT groups, some of which are specifically intended for people with SP).
I do think that, if you can afford it and if you can find a therapist who you "click" with, it's nice to be in *some* sort of talk therapy (depending on what you feel most comfortable with). My impression is that family or marital counseling can be especially helpful for couples or families where one or more members suffer from a mental disorder. On the other hand, I believe that it's usually not prudent to attempt to treat serious mental illness with talk therapy alone. (Social phobia comes in mild forms too, of course.)
Re Parnate dose:
Even many physicians don't know much about using MAOIs. Burns, if I recall, is a psychologist, so while the book you have is supposed to be a great self-help resource, I don't suggest relying on it for medical information.-elizabeth
Posted by OldSchool on January 23, 2002, at 14:33:08
In reply to Re: Brain Chemistry/Lasting Social Phobia Benefits » Rick, posted by Elizabeth on January 22, 2002, at 23:30:23
> Re Parnate dose:
> Even many physicians don't know much about using MAOIs. Burns, if I recall, is a psychologist, so while the book you have is supposed to be a great self-help resource, I don't suggest relying on it for medical information.The above information is totally incorrect. I have David Burns's book Feeling Good right in front of me and it clearly says "David Burns, MD." His credentials are the following according to the book. "Clinical Associate Professor of Psychiatry and Behavioral Sciences, Stanford University School of Medicine."
Clearly Burns is a psychiatrist, not a psychologist. I have his latest updated Feeling Good and while Im not a big fan of any kind of talk therapy, I found the updated drugs section in the second half of the book to be OUTSTANDING. In fact, the drugs section of Feeling Good is worth the price of the book IMO. Its written in plain English and is clear, concise, useful information about psychiatry drugs used to treat depression. I would rely on this information anyday. One thing I like about Burns is he obviously does not believe in overmedicating his patients and this is clearly obvious in his drugs section of Feeling Good.
His drug information is first class info.
Old School
>
Posted by Lisa01 on January 23, 2002, at 15:13:36
In reply to Re: David Burns is a psychiatrist , posted by OldSchool on January 23, 2002, at 14:33:08
> Clearly Burns is a psychiatrist, not a psychologist. I have his latest updated "Feeling Good" and while Im not a big fan of any kind of talk therapy, I found the updated drugs section in the second half of the book to be OUTSTANDING. In fact, the drugs section of "Feeling Good" is worth the price of the book IMO. Its written in plain English and is clear, concise, useful information about psychiatry drugs used to treat depression. I would rely on this information anyday. One thing I like about Burns is he obviously does not believe in overmedicating his patients and this is clearly obvious in his drugs section of Feeling Good.
>
> His drug information is first class info.
>
> Old SchoolI was quite sure that he could not have prescribed drugs as a psychologist--I believe only M.D.'s and psychiatrists only have this 'power'--and he talks extensively in the book about his prescribing experience with the various drugs and the feedback from his patients.
I would also point out that I did not take the dosage advise from the book alone but also from my family physician, who thought that beginning on the 10 mg. dose would be best. He has since approved a move to twice daily with a close watch on side effects (I still get dizzy and disoriented following the afternoon dose, but am waiting this out hoping for the benefits!)
Lisa
Posted by Cecilia on January 24, 2002, at 3:50:02
In reply to Re: David Burns is a psychiatrist , posted by Lisa01 on January 23, 2002, at 15:13:36
> > Clearly Burns is a psychiatrist, not a psychologist. I have his latest updated "Feeling Good" and while Im not a big fan of any kind of talk therapy, I found the updated drugs section in the second half of the book to be OUTSTANDING. In fact, the drugs section of "Feeling Good" is worth the price of the book IMO. Its written in plain English and is clear, concise, useful information about psychiatry drugs used to treat depression. I would rely on this information anyday. One thing I like about Burns is he obviously does not believe in overmedicating his patients and this is clearly obvious in his drugs section of Feeling Good.
> >
> > His drug information is first class info.
> >
> > Old School
>
> I was quite sure that he could not have prescribed drugs as a psychologist--I believe only M.D.'s and psychiatrists only have this 'power'--and he talks extensively in the book about his prescribing experience with the various drugs and the feedback from his patients.
>
> I would also point out that I did not take the dosage advise from the book alone but also from my family physician, who thought that beginning on the 10 mg. dose would be best. He has since approved a move to twice daily with a close watch on side effects (I still get dizzy and disoriented following the afternoon dose, but am waiting this out hoping for the benefits!)
>
> LisaDoes anyone know if anything happened to Dr. Burns? I used to read his web site (feelinggood.com) in which he would personally answer readers questions, but he stopped writing in it after Sep. 11 and now his web site has disappeared altogether. Dr. Burns is indeed a psychiatrist, but makes it clear in his web site that he has little faith in medication and believes CBT to be much more effective. I guess CBT works well for some people, but I`ve never figured how you make yourself BELIEVE the so-called rational thoughts, especially on an emotional, not just intellectual, level. And some of it is pretty oversimplistic, like the shame-attacking exersises where you do embarrassing things on purpose; for someone with deep rooted shame issues this makes about as much sense as curing broken bones by breaking a few more. Cecilia
Posted by Cecilia on January 24, 2002, at 4:32:09
In reply to Re: David Burns is a psychiatrist , posted by Lisa01 on January 23, 2002, at 15:13:36
> > Clearly Burns is a psychiatrist, not a psychologist. I have his latest updated "Feeling Good" and while Im not a big fan of any kind of talk therapy, I found the updated drugs section in the second half of the book to be OUTSTANDING. In fact, the drugs section of "Feeling Good" is worth the price of the book IMO. Its written in plain English and is clear, concise, useful information about psychiatry drugs used to treat depression. I would rely on this information anyday. One thing I like about Burns is he obviously does not believe in overmedicating his patients and this is clearly obvious in his drugs section of Feeling Good.
> >
> > His drug information is first class info.
> >
> > Old School
>
> I was quite sure that he could not have prescribed drugs as a psychologist--I believe only M.D.'s and psychiatrists only have this 'power'--and he talks extensively in the book about his prescribing experience with the various drugs and the feedback from his patients.
>
> I would also point out that I did not take the dosage advise from the book alone but also from my family physician, who thought that beginning on the 10 mg. dose would be best. He has since approved a move to twice daily with a close watch on side effects (I still get dizzy and disoriented following the afternoon dose, but am waiting this out hoping for the benefits!)
>
> LisaDoes anyone know if anything happened to Dr. Burns? I used to read his web site (feelinggood.com) in which he would personally answer readers questions, but he stopped writing in it after Sep. 11 and now his web site has disappeared altogether. Dr. Burns is indeed a psychiatrist, but makes it clear in his web site that he has little faith in medication and believes CBT to be much more effective. I guess CBT works well for some people, but I`ve never figured how you make yourself BELIEVE the so-called rational thoughts, especially on an emotional, not just intellectual, level. And some of it is pretty oversimplistic, like the shame-attacking exersises where you do embarrassing things on purpose; for someone with deep rooted shame issues this makes about as much sense as curing broken bones by breaking a few more. Cecilia
Posted by OldSchool on January 24, 2002, at 10:30:56
In reply to Re: David Burns , posted by Cecilia on January 24, 2002, at 3:50:02
>
> Does anyone know if anything happened to Dr. Burns? I used to read his web site (feelinggood.com) in which he would personally answer readers questions, but he stopped writing in it after Sep. 11 and now his web site has disappeared altogether. Dr. Burns is indeed a psychiatrist, but makes it clear in his web site that he has little faith in medication and believes CBT to be much more effective. I guess CBT works well for some people, but I`ve never figured how you make yourself BELIEVE the so-called rational thoughts, especially on an emotional, not just intellectual, level. And some of it is pretty oversimplistic, like the shame-attacking exersises where you do embarrassing things on purpose; for someone with deep rooted shame issues this makes about as much sense as curing broken bones by breaking a few more. Cecilia
I have his book Feeling Good. I dont agree with much of the stuff in it. He criticizes the idea of depression having a chemical imbalance root cause, but then goes onto giving rave reviews of MAOIs. MAOIs are the most potent antidepressants available. What gives with that? What a hypocrite. Its obvious Burns is another idiot who has this mindblock many psychology buffs have to the basic fact that all of your thoughts, moods, feelings, perceptions, etc. are brain based. Everything starts in your brain.He also admits bipolar disorder is heavily biological and genetic, but denies depression is biological. LOL
Old School
Posted by Elizabeth on January 24, 2002, at 12:59:33
In reply to Re: David Burns is a psychiatrist , posted by OldSchool on January 23, 2002, at 14:33:08
> The above information is totally incorrect. I have David Burns's book "Feeling Good" right in front of me and it clearly says "David Burns, MD." His credentials are the following according to the book. "Clinical Associate Professor of Psychiatry and Behavioral Sciences, Stanford University School of Medicine."
Well, then he doesn't have any excuse, if he did indeed claim that 20 mg of Parnate should be enough for all or most patients. 20 mg of Parnate is a very modest dose, although it may of course be adequate for a few people.
You of all people should know that just because someone is a psychiatrist, that doesn't mean they know what they're talking about! (Not that Burns doesn't know what he's talking about; all I know is that he's wrong about this particular thing.)
-elizabeth
Posted by Elizabeth on January 24, 2002, at 13:07:37
In reply to Re: David Burns is a psychiatrist , posted by Lisa01 on January 23, 2002, at 15:13:36
> I was quite sure that he could not have prescribed drugs as a psychologist--I believe only M.D.'s and psychiatrists only have this 'power'--and he talks extensively in the book about his prescribing experience with the various drugs and the feedback from his patients.
That's right, psychologists can't prescribe drugs (thank goodness). A psychiatrist is an M.D. and as such can prescribe. I haven't read the book; I was going on memory from a discussion about it a very long time ago on Usenet! Sorry about that.
> I would also point out that I did not take the dosage advise from the book alone but also from my family physician, who thought that beginning on the 10 mg. dose would be best.
*Beginning*, sure. That doesn't mean that 10 mg is an effective dose! The 20 mg you're taking is also seldom enough. It is a good idea to increase it slowly (assuming your depression is not serious enough that you need to get to a target dose ASAP) since you seem to be sensitive to the side effects. A good *starting* dose isn't the same as an *effective* dose -- many people have to start at 5 mg/day of Paxil, for example. You might be lucky and find that 20 mg/day is enough Parnate for you, but I wouldn't count on it. You might go back and read Burns again -- I'm guessing that he didn't say that 20 mg is generally a sufficient dose.
-elizabeth
Posted by Lisa01 on January 24, 2002, at 13:14:45
In reply to Re: David Burns and Parnate » Lisa01, posted by Elizabeth on January 24, 2002, at 13:07:37
You might go back and read Burns again -- I'm guessing that he didn't say that 20 mg is generally a sufficient dose.
Hi Elizabeth--thanks for all your input. Burns does say that he will sometimes go to 30 mg. Parnate but very rarely to 40 or more. He emphasized that many respond so well to 10 or 20 that they do not need to go any higher. I was hoping to be one of those people. One thing that is unclear in Burns is how long to give it at 20 mg before determining you need more (my fam. phys. says 2 weeks). At this point I don't even notice partial benefits which makes me wonder if it just needs more time...Lisa
Posted by Elizabeth on January 24, 2002, at 13:24:48
In reply to Re: David Burns , posted by OldSchool on January 24, 2002, at 10:30:56
> I have his book Feeling Good. I dont agree with much of the stuff in it.
I agree, and I'm surprised to hear that you have the book. Any particular reason you got it?
> He criticizes the idea of depression having a chemical imbalance root cause, but then goes onto giving rave reviews of MAOIs. MAOIs are the most potent antidepressants available.
Well, if they are the best ADs, maybe it just means he thinks the other ADs are weak and don't do much. (BTW, I'm guessing that you mean the *strongest* or most *effective*. Potency just means the effective dose is low -- so Parnate is more potent than Nardil, and Paxil is more potent than Zoloft, but MAOIs and other ADs can't really be compared in potency since they do different things.)
> What gives with that? What a hypocrite. Its obvious Burns is another idiot who has this mindblock many psychology buffs have to the basic fact that all of your thoughts, moods, feelings, perceptions, etc. are brain based. Everything starts in your brain.
A lot of people seem to have a hard time grasping this idea. Anyway, that must be why I thought Burns was a psychologist, because he's such a CBT cultist.
Out of curiosity, have you tried CBT or other talk therapy, and if so what did you think of it? (My experience with CBT was much like Cecilia's.)
> He also admits bipolar disorder is heavily biological and genetic, but denies depression is biological. LOL
So he buys the idea of a biological basis for some mental disorders, but denies that depression is one of them, huh? Personally I've never heard of *anyone* with serious depression who was cured by CBT.
Yes, the brain gets sensory input from external experiences, and in the long term these experiences affect what we call "personality," but whether or not a major depressive episode will occur is largely predetermined, probably at least in part by genetics. (There may be other factors, such as autoimmune conditions.) So I don't think that people with depression that has recurred for more than a couple times are likely to benefit from personality or behavior modification (the supposed effect of CBT).
-elizabeth
Posted by OldSchool on January 24, 2002, at 14:25:44
In reply to Re: David Burns is a psychiatrist » OldSchool, posted by Elizabeth on January 24, 2002, at 12:59:33
> > The above information is totally incorrect. I have David Burns's book "Feeling Good" right in front of me and it clearly says "David Burns, MD." His credentials are the following according to the book. "Clinical Associate Professor of Psychiatry and Behavioral Sciences, Stanford University School of Medicine."
>
> Well, then he doesn't have any excuse, if he did indeed claim that 20 mg of Parnate should be enough for all or most patients. 20 mg of Parnate is a very modest dose, although it may of course be adequate for a few people.
>
> You of all people should know that just because someone is a psychiatrist, that doesn't mean they know what they're talking about! (Not that Burns doesn't know what he's talking about; all I know is that he's wrong about this particular thing.)
>
> -elizabethElizabeth, I agree Burns is biased against meds. Thats obvious from his book. I read in his book that he prefers to "keep the dosage low." I know thats BS. He also criticizes SSRIs, in favor of the older tricyclics. That is BS as well, as the SSRIs are much cleaner drugs with fewer side effects.
All that being said, Burns's book is worth reading. Some of the things he says about meds is true, while some of it is junk. I have the ability to discern the junk from the good stuff.
I dont think CBT, nor any other talk therapy gets to the "root" of severe mental illness.
Old School
Posted by OldSchool on January 24, 2002, at 14:35:19
In reply to Re: David Burns » OldSchool, posted by Elizabeth on January 24, 2002, at 13:24:48
> > I have his book Feeling Good. I dont agree with much of the stuff in it.
>
> I agree, and I'm surprised to hear that you have the book. Any particular reason you got it?Because I read some stuff saying that CBT can be useful for refractory depression. I was skeptical and still am. However I wanted to read the book, which I havent done yet. I have read parts of the meds section in it though. Plus Ive had such a hard time tolerating meds in the last year that I figured I better start doing some things in case someday all I can tolerate is ECT. Although I think the experience with Amantadine recently has explained a lot...it totally "loosened me up" and I found I could add drugs while on Amantadine easily.
> > He criticizes the idea of depression having a chemical imbalance root cause, but then goes onto giving rave reviews of MAOIs. MAOIs are the most potent antidepressants available.
>
> Well, if they are the best ADs, maybe it just means he thinks the other ADs are weak and don't do much. (BTW, I'm guessing that you mean the *strongest* or most *effective*. Potency just means the effective dose is low -- so Parnate is more potent than Nardil, and Paxil is more potent than Zoloft, but MAOIs and other ADs can't really be compared in potency since they do different things.)I think the guy is just full of it to a large extent, although I still liked some of what he writes especially about meds. He believes in being cautious with meds and I agree with that.
>
> > What gives with that? What a hypocrite. Its obvious Burns is another idiot who has this mindblock many psychology buffs have to the basic fact that all of your thoughts, moods, feelings, perceptions, etc. are brain based. Everything starts in your brain.
>
> A lot of people seem to have a hard time grasping this idea. Anyway, that must be why I thought Burns was a psychologist, because he's such a CBT cultist.
>
> Out of curiosity, have you tried CBT or other talk therapy, and if so what did you think of it? (My experience with CBT was much like Cecilia's.)Nope Ive never been in any therapy. The closest to therapy Ive ever been in was my offline support group...it was kind of like a real informal, loose group therapy session. Very informal which I like.
>
> > He also admits bipolar disorder is heavily biological and genetic, but denies depression is biological. LOL
>
> So he buys the idea of a biological basis for some mental disorders, but denies that depression is one of them, huh? Personally I've never heard of *anyone* with serious depression who was cured by CBT.
>Yep...thats exactly what he does. He says bipolar is clearly biological and genetic but rejects these ideas for regular depression. He says many people with bipolar will need to be on lifetime medication, but those with depression "rarely require lifetime drugs." In other words, the guy is an idiot.
> Yes, the brain gets sensory input from external experiences, and in the long term these experiences affect what we call "personality," but whether or not a major depressive episode will occur is largely predetermined, probably at least in part by genetics. (There may be other factors, such as autoimmune conditions.) So I don't think that people with depression that has recurred for more than a couple times are likely to benefit from personality or behavior modification (the supposed effect of CBT).
Me either. This stuff is largely pure neurology in my opinion. Its your brain and CNS. Sometimes the endocrine system has something to do with it or as you mentioned the autoimmune system.
Old School
Posted by Emme on January 24, 2002, at 16:10:59
In reply to Re: David Burns, posted by OldSchool on January 24, 2002, at 14:35:19
Hi Folks,
Funny this thread should come up. I'm partway through the book. I personally find a lot that's objectionable and a lot that's good (besides the thorough medicine listing at the end). First of all, I don't think we should disregard the usefulness of CBT. *Every* human being, mood disordered or not, can use a reality check now and then. To me, CBT is just a formalized system of being aware of how your thoughts and reactions relate to what may or may not actually be going on. When I look at his descriptions of cognitive distortions, I see myself so clearly in some of them. While I'm not big into writing it all down, it doesn't hurt to have my awareness raised. My therapists have used some aspects of CBT (though not in the rigid cultlike manner as Burns prescribes). Although it's certainly not enough to manage my illness without meds, I can't say it hasn't been helpful.
Do I think CBT has or can "cure" my serious mood disorder? No! I *know* that I need careful psychopharmacologic management. Do I think there's a genetic component to my illness? My family history says absolutely. And I can't process any CBT while severly depressed - the meds have to bring me up a bit. I suspect my illness is more "biologically" based than "psychologically" (if we're gonna draw a line between the brain and the mind). But hey, any adjunct tool that can help me manage better can't hurt. I just don't expect CBT to be the magic key.
On the negative side: I do agree the book and techniques have an almost cultlike feel to them. I totally agree that it's ridiculous that he says bipolar is genetic and depression is not. It also sounds a bit hard to believe when he says he has cured suicidal patients in incredibly short periods of time. And that he's rarely had a patient need onoging drug treatment beyond a year or so. I also worry that all his glowing stories might make people who've had CBT feel like failures if they haven't had resounding success with CBT. I worry that the book might encourage folks to abandon their medicine without appropriate discussions and oversight from their doctors, or to not recognize when they need to really think about starting meds. Yeah, I know he puts in caveats about when to call in a professional and all that. But I think his anti-drug stance poses possible dangers.
Oh, and the guy's way too long winded (unlike this post :) He could've made his points in a quarter of the space and his writing style irritates me - he writes as if his audience is a bunch of third-graders. How annoying.
Emme
Posted by Rick on January 24, 2002, at 19:19:43
In reply to Re: David Burns, posted by Emme on January 24, 2002, at 16:10:59
I probably shouldn't reprint an entire editorial here (the one I printed a snippet of in another post), but it may add some historical perspective to the Burns discussion. (Although it does veer off in a different direction.)
If I understand what folks are saying, Burns is suggesting that unipolar depression in general is what used to be called exogenous depression, i.e. caused by life events (vs. chemistry) and thus treatable only with talk.
From
Medscape Mental Health
Medscape Psychopharmacology Today
Endogenous Versus Exogenous: Still Not the IssueThomas AM Kramer, MD
[Medscape Mental Health 7(1), 2002. © 2002 Medscape, Inc.]
Many readers may recall a time during the early 1980s when it was believed to be important to classify depression as either endogenous or exogenous. The idea was that there was a difference between depression precipitated by life events, called exogenous depression, and depression that was inherent to the patients' physiology, referred to as endogenous depression. The theory was that patients with exogenous depression did not respond to antidepressants -- ie, tricyclic antidepressants or monoamine oxidase inhibitors (MAOIs) -- because, presumably, their depression was not a function of their physiology but rather a reaction to their life situation. As such, they required treatment with some form of talking therapy. This theory, as it was promoted at the time, not only made the distinction between endogenous and exogenous depression based on symptoms (ie, did they or did they not have vegetative symptoms of depression), but also by assumed etiology. Thus, it was believed that depression precipitated by the loss of a loved one or any other grief-inducing event would not respond to antidepressants because it was exogenous, ie, not physiological.
In retrospect, this rather dualist approach to depression seemed to imply that only some behaviors had anything to do with the chemistry of the brain, but other behaviors were somehow exempt. All of this thinking came, to a certain extent, from the discovery of monoamine neurotransmitters and their role in depression. Since antidepressants seemed to increase the amount of norepinephrine, serotonin, and perhaps dopamine by making more neurotransmitters seemingly available, it made sense at the time to understand depression as a deficit of these neurotransmitters. Ignoring the fact that the effect of these drugs on the neurotransmitters was virtually immediate, their effect on the patient took considerably longer. The assumption was that the depressed patients clearly needed more of something, and the neurotransmitters were the best candidate at the time. It was hard to believe, then, that life events could change fundamental biochemistry. We now are fairly certain -- armed with new knowledge from various studies about dietary manipulation, blood and CSF level monitoring, and other sophisticated methodology -- that the deficit model of neurotransmitters is considerably more simplistic than whatever the reality of the pathophysiology of depression is.
Much more recently, we came up with a new application of the semantic distinction between endogenous and exogenous. In spite of the data that question the validity of a deficit paradigm, we continue to think of psychopharmacology as somehow having an effect on some sort of balance. One often hears patients parroting this idea by referring to themselves as having a chemical imbalance. As we strive to somehow rebalance that imbalance, we struggle to conceive of exactly what it is that is out of balance. Throughout most of the history of the treatment of depression, we have done this with reuptake blockers, which ostensibly increase the amount of neurotransmitter available to the outside of the neuron by blocking reuptake. These drugs, by the semantic distinction described above, would be exogenous, ie, they are not something that the body naturally produces but are ingested to achieve an impact on the balance of neurotransmitters.
More recently, we have begun to get interested in the use of endogenous compounds, ie, hormones or other substances that are naturally produced by the body, in the treatment of depression. The idea is that if we administer substances that the body already has, but perhaps doesn't have enough of, this may treat the depression. Recent studies have shown that estrogen supplementation, growth hormone, and even secretin, which is used in the treatment of autism, may have beneficial effects in depressed patients. The idea here is once again to rebalance an imbalance by giving the actual substance that the body may be in deficit of. This brings about interesting discussions concerning the actual definition of a drug and whether it is somehow better or safer to give, as treatment, substances that are already found within the body.
This kind of work can be misleading or deceiving. Virtually every medical disorder that results from having too little of a hormone has a companion disorder that is a result of too much of that same hormone. In addition, it is often impossible to deliver a naturally occurring neurotransmitter or hormone to its target in all cases.
One intriguing example of this was the development of gabapentin. Gabapentin is a biologically derived compound that was developed with a very simple idea. Many of the drugs that we use to treat epilepsy are active in the gamma-aminobutyric acid (GABA) system. The idea was that if we could somehow give the patient GABA, instead of drugs that accentuate the GABA system, we would somehow have a better, purer response. There was only one problem with this idea: GABA does not cross the blood-brain barrier. All of the GABA that is in the brain was manufactured there. In order to give the brain a dose of GABA, you would either have to inject it directly into the brain, a procedure that most patients would object to if it were done on a regular basis, or modify the GABA molecule in some way that would maintain its action but allow it to cross the blood-brain barrier. That clever thing was done; a pentin ring was attached to GABA, and thus gabapentin was born. It works quite well, and everyone was happy until someone actually conducted studies of gabapentin receptor binding. What they discovered was that gabapentin had absolutely no interest in GABA receptors or any GABA circuitry, but seemed to be very interested in the glutamate system, where it turns out all of its actions take place. In other words, the drug's efficacy had nothing to do with the ideas behind its development. I have been told this story informally, and I have no idea if it is actually true, but it illustrates the point I am trying to make quite nicely.
I propose a reframing of the paradigms that we use for psychopharmacology and its relationship to neurotransmitters. Neurotransmitters slosh around the body, and specifically inside the brain, in relatively constant amounts. The drugs that we give, even MAOIs, do not really affect the number of neurotransmitters in the body very much. What these drugs do is affect receptors. Instead of being concerned about the effect of norepinephrine and serotonin, we really need to redefine our concept of psychopharmacology as receptor drugs. Saying, for example, that selective serotonin reuptake inhibitors (SSRIs) treat depression by increasing serotonin is like saying that a boat sinking on the ocean needs to have reduced water levels. The water is there and all around. To fix the boat you need to plug the holes. That will be a great deal more effective than worrying about decreasing the overall amount of water in the system.
SSRIs affect the serotonin transporters in cell membranes; they do not necessarily affect the overall level of serotonin. There is no deficit or surplus of serotonin; there are cells with impaired ability to have certain levels of serotonin on either side of their membranes. If serotonergic drugs really did affect serotonin overall, they would cause absolutely horrible GI side effects, since the gut has considerably more serotonin and serotonergic neurons than the brain has. This is also why different patients get better on different SSRIs. These agents may all block serotonin reuptake, but each is structurally distinct and thus may bind differently to serotonin transporters, depending on the patient. Similarly, dopamine blockers that are used to treat psychosis do not affect dopamine as much as they lower the sensitivity of certain cells to dopamine by blocking some of their receptors. This has no effect on the total volume of dopamine. It is even more likely that some drugs that appear to work by serotonin receptor blockade actually work by shunting the serotonin moving around from one receptor group to another. In other words, if a certain class of serotonin receptors is completely blocked, the serotonin has no choice but to bind to other receptors.
For years we have struggled to attribute fluctuations in neurotransmitters to drugs' mechanisms of action. Once we begin to conceive of drugs as affecting receptors, things generally seem to make more sense. Even the hormonal treatments described above have their effects at the actual receptors on the cells. Newer exciting treatments, such as the use of corticotrophin-releasing factor antagonists to treat depression and anxiety, and the most recent work, involving the noncontroversial use of a controversial compound, RU486, for the treatment of depression, are aimed at antagonizing hormonal receptors. Why should we concern ourselves with receptors? Because of Willie Sutton's law. Sutton, the noted bank robber, when asked why he robbed all those banks, replied, "Because that's where the money is."
Disclaimer
The opinions expressed are those of Dr. Kramer and do not reflect those of the American Board of Psychiatry & Neurology or the Directors of the ABPN.
--------------------------------------------------------------------------------Thomas AM Kramer, MD, is Clinical Associate Professor of Psychiatry, Northwestern University, Chicago and Deputy Executive Vice President of the American Board of Psychiatry and Neurology.
Posted by Elizabeth on January 25, 2002, at 1:13:25
In reply to Re: David Burns and Parnate, posted by Lisa01 on January 24, 2002, at 13:14:45
> Burns does say that he will sometimes go to 30 mg. Parnate but very rarely to 40 or more. He emphasized that many respond so well to 10 or 20 that they do not need to go any higher. I was hoping to be one of those people. One thing that is unclear in Burns is how long to give it at 20 mg before determining you need more (my fam. phys. says 2 weeks).
A general rule that I find helpful: your doctor should always overrule what you read in a book!
It is certainly true that you may need to raise the dose (and I doubt that 20 mg/day is a sufficient dose of Parnate for most people; chances are you will need to raise it). I think that you should wait if you're having trouble tolerating it, though -- don't rush it unless your situation is truly urgent. Most side effects will dissipate with time.
-elizabeth
Posted by Cecilia on January 25, 2002, at 2:56:47
In reply to Re: David Burns, posted by Emme on January 24, 2002, at 16:10:59
> Hi Folks,
>
> Funny this thread should come up. I'm partway through the book. I personally find a lot that's objectionable and a lot that's good (besides the thorough medicine listing at the end). First of all, I don't think we should disregard the usefulness of CBT. *Every* human being, mood disordered or not, can use a reality check now and then. To me, CBT is just a formalized system of being aware of how your thoughts and reactions relate to what may or may not actually be going on. When I look at his descriptions of cognitive distortions, I see myself so clearly in some of them. While I'm not big into writing it all down, it doesn't hurt to have my awareness raised. My therapists have used some aspects of CBT (though not in the rigid cultlike manner as Burns prescribes). Although it's certainly not enough to manage my illness without meds, I can't say it hasn't been helpful.
>
> Do I think CBT has or can "cure" my serious mood disorder? No! I *know* that I need careful psychopharmacologic management. Do I think there's a genetic component to my illness? My family history says absolutely. And I can't process any CBT while severly depressed - the meds have to bring me up a bit. I suspect my illness is more "biologically" based than "psychologically" (if we're gonna draw a line between the brain and the mind). But hey, any adjunct tool that can help me manage better can't hurt. I just don't expect CBT to be the magic key.
>
> On the negative side: I do agree the book and techniques have an almost cultlike feel to them. I totally agree that it's ridiculous that he says bipolar is genetic and depression is not. It also sounds a bit hard to believe when he says he has cured suicidal patients in incredibly short periods of time. And that he's rarely had a patient need onoging drug treatment beyond a year or so. I also worry that all his glowing stories might make people who've had CBT feel like failures if they haven't had resounding success with CBT. I worry that the book might encourage folks to abandon their medicine without appropriate discussions and oversight from their doctors, or to not recognize when they need to really think about starting meds. Yeah, I know he puts in caveats about when to call in a professional and all that. But I think his anti-drug stance poses possible dangers.
>
> Oh, and the guy's way too long winded (unlike this post :) He could've made his points in a quarter of the space and his writing style irritates me - he writes as if his audience is a bunch of third-graders. How annoying.
>
> EmmeYes, I definitely feel there`s a sort of "blame the patient" attitude about CBT. He talks a lot about doing homework; if you don`t get better it`s because you haven`t done your homework. And his dramatic success stories do indeed make me feel worse about myself, though I seem to have that problem with all self help books. Cecilia
Posted by Blue Cheer 1 on January 25, 2002, at 5:39:48
In reply to Re: David Burns, posted by Emme on January 24, 2002, at 16:10:59
> Hi Folks,
>
> Funny this thread should come up. I'm partway through the book. I personally find a lot that's objectionable and a lot that's good (besides the thorough medicine listing at the end). First of all, I don't think we should disregard the usefulness of CBT. *Every* human being, mood disordered or not, can use a reality check now and then. To me, CBT is just a formalized system of being aware of how your thoughts and reactions relate to what may or may not actually be going on. When I look at his descriptions of cognitive distortions, I see myself so clearly in some of them. While I'm not big into writing it all down, it doesn't hurt to have my awareness raised. My therapists have used some aspects of CBT (though not in the rigid cultlike manner as Burns prescribes). Although it's certainly not enough to manage my illness without meds, I can't say it hasn't been helpful.
>
> Do I think CBT has or can "cure" my serious mood disorder? No! I *know* that I need careful psychopharmacologic management. Do I think there's a genetic component to my illness? My family history says absolutely. And I can't process any CBT while severly depressed - the meds have to bring me up a bit. I suspect my illness is more "biologically" based than "psychologically" (if we're gonna draw a line between the brain and the mind). But hey, any adjunct tool that can help me manage better can't hurt. I just don't expect CBT to be the magic key.
>
> On the negative side: I do agree the book and techniques have an almost cultlike feel to them. I totally agree that it's ridiculous that he says bipolar is genetic and depression is not. It also sounds a bit hard to believe when he says he has cured suicidal patients in incredibly short periods of time. And that he's rarely had a patient need onoging drug treatment beyond a year or so. I also worry that all his glowing stories might make people who've had CBT feel like failures if they haven't had resounding success with CBT. I worry that the book might encourage folks to abandon their medicine without appropriate discussions and oversight from their doctors, or to not recognize when they need to really think about starting meds. Yeah, I know he puts in caveats about when to call in a professional and all that. But I think his anti-drug stance poses possible dangers.
>
> Oh, and the guy's way too long winded (unlike this post :) He could've made his points in a quarter of the space and his writing style irritates me - he writes as if his audience is a bunch of third-graders. How annoying.
>
> EmmeI see Dr. Burn's as more of an opportunist than anything else. Essentially, he took the ideas of Aaron Beck, M.D. (father of congitive therapy) and ran with them. He did his psychiatry residency at the Philadelphia VAMC and gave the hospital an undeserved black eye when he described (in his preface if memory serves me) a patient he passed on the elevator there who was returning from his 18th shock treatment, and was yelling "I want to die." I haven't looked at Feeling Good since it was first published, but I think he claimed that it was at this point when he decided there 'must be another way' (to treat depression). In any case, I know psychiatrists who remember him well, and he routinely used drugs in his practice.
I don't care about his drug recommendations since he's not a psychopharmacologist.
I've tried manualized CT/CBT before, but it's of no value if you're in a state of depression that makes it impossible to carry out the "homework assignments" that are part of the therapy. For those who are experiencing mild to moderate depression, I think it's an excellent adjunct to medications.
Blue
Posted by Lisa01 on January 25, 2002, at 7:42:10
In reply to Re: David Burns, posted by Blue Cheer 1 on January 25, 2002, at 5:39:48
> I've tried manualized CT/CBT before, but it's of no value if you're in a state of depression that makes it impossible to carry out the "homework assignments" that are part of the therapy. For those who are experiencing mild to moderate depression, I think it's an excellent adjunct to medications.
>
> BlueI see that most of you are referring to CBT in the context of depression. I am inclined to agree that depression is likely more brain-based than mind-based (for lack of more scientific terminology). My personal demon is SP, and I do think there is--for me anywhere--a direct correlation between my thoughts ("I'm going to blow it" , "Everyone can see how nervous I am") and how anxious I become. I also know I am pre-disposed to social anxiety in that I had several early traumatic experiences with performance situations and have, I believe, come to dread them based on that. I think that I need meds at least temporarily until I can learn to 'correct' the way I look at performance situations, because my fears are overblown in terms of--and this is something Burns talks about--extremity and likelihood (I'm not using his terminology here)i.e. the outcome is not usually as bad as I anticipate and sometimes the situation I dread most does not even occur (e.g. someone asking a question I cannot answer at a presentation). I don't think CBT can be written off, or seen as a cure-all either. A combination of both meds and some kind of therapy can be more helpful for some than meds alone.
Anyone out there had luck with CBT for SP?
Lisa
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