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I came across a recent video looking at anxiety and drugs by the makers of penny arcade. Penny arcade is a webcomic, mostly revolving around computer gaming. The authors, Jerry Holkins and Mike Krahulik were recently named in the time 100. It’s a sizable video, so apologies for people on slower internet connections, but I found it to be a particularly interesting look at mental illness.

I liked their discussion of how mental illness can be unique. For them mental illness wasn’t about being boring, looking out of a window, seeing the world in bland colours, with nothing to look forward to. They make the point that people respond in different ways, and for them it was telling jokes, responding with humour. Those of you who have read the comic will be aware of Mike and Jerry’s unique sense of humour.

And related to this, they discuss the fear that medication would have caused them to their lose their creativity, their craziness, fearing that mental illness is what makes them have their ability to write webcomics. Mike tells us that he wouldn’t have stuck with anti-depressants if the drugs took away his creativity and made things different. But, as he found out, through drugs he could feel better, while still retaining his creativity, and was still able to ‘be crazy’.

Near the end there was an interesting discussion involving illegal drugs. Jerry saw illegal drugs as similar to medical drugs, and a legitimate way to deal with life, while Mike, having seen his brother overdose was opposed to illegal drugs. I tend to agree with Mike. People with mental illness sometimes self-medicate recreational drugs (including alcohol) because they seem to help in the short term. However, this can create a dependence on the substance, as the substance can quickly become all that the user knows that will make them feel better. Eventually substances need to be taken just to feel normal, which creates a whole other set of problems. Recreational drugs may seem to help in the short term, but it’s probably better to find a longer term solution to the problem.

Overall I found the video to be heartwarming, a frank and friendly discussion of a difficult topic. It was good to hear how they looked out for each other, and how they want to help others by sharing about a personal topic.

Anti-depressant drugs can be one way to deal with depression. One issue with anti-depressants is that there is not one anti-depressant that is effective for everyone. While many may find relief with the first anti-depressant, others need to ‘shop around’ for the right anti-depressant, and still others don’t find one that works for them. Add to this the delay – a number of weeks – between when anti-depressant therapy begins, and when you can tell if it effective, and the process can rather frustrating.

In the future this delay may be minimized. One article on psychcentral describes how brain waves were measured in a study to detect individuals responses to a couple of anti-depressants, with 74% accuracy, much higher than other methods. A recent article in the journal psychophamacology reports that fMRI – a technique using magnetic fields to examine which parts of the brain are active – can be used to predict how likely people with anxiety disorders are to respond to anti-depressants (anxiety disorders and depression are linked, so it’s thought fMRI could be used in a similar way with depression).

If such technologies became widespread it would make finding the right anti-depressant easier. But for now, we have to taking it one day at a time, making sure we have a healthy lifestyle and diet. And as always, it’s good to be supported, to have someone to go when you really need to.

The Irish Times has an article on St John’s Wort. St John’s Wort is a herbal remedy that has been quite popular in the treatment of depression. Interestingly, in some countries, for example Ireland and Germany, preparations of St John’s Wort are prescribed by Doctors to treat mild depression. In Germany, St John’s Wort extracts are prescribed more than other anti-depressant medications.

A recent review found that extracts of St John’s Wort were effective in treating major depression, having similar efficacy to standard antidepressants. There were also indications that St John’s Wort has fewer side effects. However, the authors noted there was a difference in the results from studies from German and Non-German speaking countries, which could mean some studies from German speaking countries were overoptimistic. Alternatively, it could be due to better administration of St John’s Wort in German speaking countries.

The mechanism by which St John’s Wort has this effect is currently unknown. There is some indication that some components – hyperforin and hypericin – may block serotonin re uptake, achieving a similar effect to conventional SSRIs. However, an extract of St John’s Wort without hyperforin still has antidepressant effects. St John’s Wort contains a number of different compounds, and this makes it difficult to establish which compounds are responsible for it’s effects.

It should be noted that St John’s Wort interacts with many drugs. For example, St John’s Wort can cause Serotonin Syndrome when taken with other antidepressants, presumably because both effect Serotonin. Also, St John’s Wort can interact with drugs that act on different parts of the body. This occurs when drug metabolism is altered – St John’s Wort can increase the rate which the body processes the drug, and so decrease the amount of active drug left in the body. For example, St John’s Wort can cause oral contraceptives to be ineffective. (A list of interactions is on wikipedia). For this reason, it is recommended that St John’s Wort should be only be taken after consultation with your Doctor.

So, St John’s Wort is a herbal antidepressant that can be effective in treating depression, and with less side effects. However, as with most medications, it is not advisable to take St John’s Wort without consulting your Doctor -especially if you are on other medications.

A recent study (cited here) questions whether drug trials assessing antidepressants relate to the people who actually use them. Such trials often involve individuals with more severe depression, who don’t have any other comorbidities. The problem is this isn’t often who the drugs end up getting prescribed for:

After assessing 2,855 patients treated with citalopram, a commonly prescribed selective serotonin reuptake inhibitor for mood disorders, study authors concluded that fewer than one in four, or 22.2 percent, of the patients met the usual criteria for inclusion in phase III antidepressant trials.

So hopefully this research will lead to more trials being done on a more representative sample, so people can be more informed about how effective different drugs are for a more general population. The lesson for Doctors – and anyone looking up research – is to be aware of who are in the drug trials, and whether this is generalizable to other people. Because antidepressants are effective for some people, but it’s important to know who those people are.

December 2019
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