Dr. Charles Raison is an American psychiatrist and professor of psychiatry at the University of Wisconsin-Madison School of Medicine and Public Health as well as the Mary Sue and Mike Shannon Chair for Healthy Minds, Children & Families and Professor with the School of Human Ecology in Madison, Wisconsin.
I've dealt with depression in my life. My body temperature also seems to run hot; in fact my wife Kate has nicknamed me "the baked potato." My guest today says that there may be a connection between those two things. His name is Charles Raison, he's a psychiatrist, professor of psychiatry, and the co-author of The New Mind-Body Science of Depression. We begin our conversation with why Charles thinks it's important to ask the question, "Does Major Depression even exist?" and what we do and don't know about what causes depression. We then turn to the emerging theory that physical inflammation may play a role in depression; Charles describes what inflammation is, and why the body may become inflamed and physically hotter not only in response to physical illness, but psychological stress as well. We then discuss the paradoxical finding that short-term exposure to inflammation in the form of exercise or sitting in a sauna can reduce long-term inflammation, and how hot you probably have to get in a sauna for it to have antidepressant effects. We also talk about how intermittent fasting may have a beneficial effect on inflammation, before turning to whether taking anti-inflammatory drugs could also help, and why you might want to get a blood test to see if your body's inflamed. We end our conversation with Charles' thoughts on how to figure out the right treatment for depression for each individual. Get the show notes at aom.is/inflammationdepression.
In this masterclass, Charles L. Raison, MD, returns to the MDedge Psychcast to discuss the risks and benefits of antidepressants. He previously appeared on the Psychcast in episodes 15 and 16. Dr. Raison is Mary Sue and Mike Shannon Chair for Healthy Minds, Children & Families and professor, School of Human Ecology, and professor, department of psychiatry, School of Medicine and Public Health, University of Wisconsin-Madison. Later, Renee Kohanski, MD, discusses the need for psychiatrists to take care of and nourish their communities. Show Notes by Jacqueline Posada, MD, consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. Treatment with antidepressants The STAR-D trial, a large effectiveness trial (n = 4,000), looked at the effect of SSRIs and other medications for the treatment of depression. As an effectiveness trial, STAR-D looked at “real” patients with comorbidities (as opposed to efficacy trials, which use “perfect patients” with no comorbidities to minimize confounding effects). Only 30% of patients went into complete remission with first step of treatment with an SSRI (citalopram) at the highest tolerated dose. Almost 50% experienced a response (a 50% reduction in symptoms of depression on standardized scale). Cynicism and hope for antidepressants To obtain Food and Drug Administration approval, a medication requires two positive studies (showing that the drug beats placebo), and on average, an SSRI requires five to seven studies to get the two positive studies. A meta-analysis of negative SSRI studies that were “filed away” found only a 1.8-point difference on Hamilton Depression Rating Scale score between SSRI vs placebo. The difference between SSRI and placebo in treatment disappeared among patients who were less depressed. Geddes et al., presented a more balanced view in a published meta-analysis of 522 trials that included more than 100,000 patients. Antidepressants had a modest benefit, compared with placebo. In head-to-head studies, some antidepressants were better than others, such as amitriptyline, escitalopram, mirtazapine, paroxetine, venlafaxine, and vortioxetine.  Predictors of response Poor response to antidepressants: Presence of comorbid anxiety disorder, failure of first or subsequent antidepressant trials. Within STAR-D, among those who failed three treatment steps, only 13% responded to the next treatment. Good response to antidepressants: An acute response to an antidepressant predicts long-term response. A 20% or greater improvement within 2 weeks of treatment resulted in a higher chance of remission, compared with those who don’t initially respond, who then had a less than 5% chance of remission. Are antidepressants good for everyone? The difference between active antidepressants and placebo is small. A latent growth curve analysis of placebo vs. antidepressants for depression showed that there are two separate trajectories with antidepressants: 70% will respond and are vastly improved, while 30% actually do worse. A National Institute of Mental Health study from 1980s randomized patients to two types of psychotherapy vs. tricyclic antidepressants (TCAs) vs. waitlist control group. Treatment took place for 16 weeks, and patients were followed for 18 months. People who went into remission on TCAs were more likely to relapse than those who went into remission on psychotherapy. Epidemiological Catchment Area (ECA) trial: Prospective data of 92 people from the total 3,500 in the study. Of the 92 with a first major depressive episode, 50% had a second major depressive episode. Of those who were treated into complete remission, even after 5 years, more than 50% had a relapse of their depression. Conclusion: Relapse of depression is common when patients come off antidepressants To stay well, a patient with depression should continue to receive an antidepressant. Clinicians must ask: Do the antidepressants increase the risk of relapse of depression? Depression is a disabling disease, so treatment is necessary. But clinicians should question for whom and when antidepressants should be used. References Turner EH et al. Selective publication of antidepressant trials and its influence on apparent efficacy. N Engl J Med. 2008;358:352-60. Cipriani A et al. Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: A systematic review and network meta-analysis. Lancet. 2018 Apr 7:391(10128):1357-66. Penninx BW et al. Two-year course of depressive and anxiety disorders: Results from the Netherlands study of depression and anxiety (NESDA). J Affect Disord. 2011 Sep;133(1-2):76-85. Perlman K et al. A systematic meta-review of predictors of antidepressant treatment outcome in major depressive disorder. J Affect Disord. 2019 Jan 15;243:503-15. For more MDedge Podcasts go to mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgePsych        
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Creator Details

Birthdate
Dec 26th, 1957
Location
Atlanta, Georgia, United States of America
Episode Count
2
Podcast Count
2
Total Airtime
1 hour, 25 minutes