Saturday, September 29, 2007

JCP: Family Intervention Overcomes Poop-out

Your taking an antidepressant for major depression, but after a year or two it seems to wear off; what some call SSRI Poop-out. A recent article in the Journal of Clinical Psychiatry finds that a family intervention approach to this problem is more effective than increasing the dose of the antidepressant.

Can anyone educate us about the "McMaster model"?

Family Intervention Approach to Loss of Clinical Effect During Long-Term Antidepressant Treatment: A Pilot Study

Background: The return of depressive symptoms during maintenance antidepressant treatment is a common phenomenon, but has attracted very limited research attention. The aims of this investigation were to explore the feasibility of a family intervention approach to loss of clinical effect during long-term antidepressant therapy and to compare this approach with dose increase.

Method: Twenty outpatients with recurrent major depressive disorder (diagnosed using Research Diagnostic Criteria, i.e., patients were at their third or greater episode of major depressive disorder, with the immediately preceding episode being no more than 2.5 years before the onset of the episode which led to antidepressant treatment) who lived with a partner and relapsed while taking antidepressant drugs were randomly assigned to (1) family intervention approach according to the McMaster Model and maintenance of the antidepressant drug at the same dosage or (2) dose increase and clinical management. A 1-year follow-up was performed. The study was conducted from January 2002 to December 2004.

Results: Seven of 10 patients responded to an increased dosage; all but 1 relapsed again on that dosage during follow-up. Seven of 10 patients responded to family intervention, but only 1 relapsed during follow-up. The difference in relapse was significant (p < .05). Conclusions: The data suggest that application of a family intervention approach is feasible when there is a loss of clinical effect during long-term antidepressant treatment, and this approach may carry long-term benefits. The results need to be confirmed by large-scale controlled studies but should alert the physician to explore the psychosocial correlates of loss of clinical effect.

(J Clin Psychiatry 2007;68:1348-1351)


Anonymous said...

Dear Shrink Rap,

I really like how your blogroll is arranged by length of title. That's cool.


Anonymous said...

McMaster is a university in Hamilton, Ontario Canada. The name comes from there. The model was developed in the 1970's. Family systems approach. McMaster's med school uses a very holistic approach, or at least they did. Their psych dept would be part of the med school so it is not surprising that they would develop a model based on problem centered systems theory. Then again, systems theory was very popular in many places at the time. Want some old books?(Until solution focused therapy became all the rage later on). Now we live in the age of "there is a medication for everything". This flows from the popularity of the brain based disease model.
The M model has been studied quite a bit, and used quite a bit. It has it's flaws as do all models, but it goes beyond the let's do drug and individual psychotherapy approach to include the family. If you have a family and you have depression, they either help contribute to the depression in the first place and/or they are affected by the depression so there is an interaction between the individual and family functioning. That isn't much different from the studies that were done that looked at patients with schizophrenia and discovered that they fared worse when around their high EE families vs ones with low EE.

Anonymous said...

Sounds rather like a placebo effect rather than a medical treatment effect, yes?


Anonymous said...

That is assuming that the only valid treatment would be drug.

Rach said...

Just to follow up on Anony's comments - McMaster's Med school uses PBL to teach their students, so it's not surprising that this is something that would come from their research - as Anon said, it's very much a holistic, and multi-disciplinary approach, to healthcare.

Also, was wondering (and Roy, could you comment), if this type of research would hold true for Mood Stabilizing meds, or are there too many other factors that come into play in order for the theory to hold true? In my own opinion, I would argue, with all other things being equal and stable, yes it's possible for mood-stabilizers to poop out if a pt's external environment triggers the onset of symptomatology - or at least, that's my own experience.

Anonymous said...

I just don't know what to say about this post. Poop-out is pretty common on SSRI's. I've always thought of it as some type of receptor sensitivity or illness break through. I tell patients it will get better-- that we either need to lower the meds or raise the meds (if it's receptor sensitivity and you lower/stop the meds for a while, your receptors should re=sensitize, no?). So far, 15 years of this, NO ONE has taken me up on my offer to lower/stop the meds, everyone wants an Increase. And everyone (don't ask for numbers) get better with an increase in the SSRI that had been working. I can't imagine the conversation now being: we can lower the dose, raise the dose, or you can go to family therapy. What if the patient doesn't have a family? What if the family can't make it? What if the family agrees to go then logistics prevent regular therapy sessions? My guess is these people were eliminated from the study. Can't wait to read it. I'll probably still just raise the dose of SSRI.

I'm google ad-ed out. We're aiming for a Shrink Rappers go shopping for audio equipment trip, hopefully tomorrow. And thanks for your offer Lily, save your money for those expensive shrinks and meds!

Roy said...

Yay, thanks. It's one of the settings on

Others, I'm somewhat familiar with McMaster philosophy, but if I had to initiate a program based on it, I wouldn't know how to start. The specifics. Is there a cookbook?

Rach, I can't say I see true poop-out, or tachphylaxis, with mood stabilizers, especially because they tend to have a therapeutic level window, and I do not see people who used to require a lithium level of 0.6 now requiring a 0.9. Just my 2 cents.

Dinah, I think it is consistent with the recent Brown University study (which I will blog about as well), which John Grohol wrote about:

Researchers believe a new study helps explain why some antidepressants seem to lose their effectiveness after being used for six months to a year.
The answer is that the medications were never effective in the first place; rather the benefit individuals received while taking the drugs came from a placebo response (a positive medical response to taking a placebo as if it were an active medication.).
The study by Rhode Island Hospital researchers was published in the August issue of the Journal of Clinical Psychiatry.

Anonymous said...

Very logical, but what if the patient had no water and couldn't take a pill? HMMM. Oh yeah, forgot about the yummy SLs. make more of those. Family therapy sure can suck, no doubt about that, and it is true that many people do not have families r would refuse to go to family therapy.I do think that levels of social support can have an impact which is probably what is measured here. We have all been conditioned to believe that the answer lies in drugs and more drugs. Drugs have a place and this culture is the place to find them.

Sarebear said...

This is interesting.

I was put on 150mg Effexor back in the fall of 2001, and it was effective, although I thought so many of my other symptoms were "me" that it's difficult to look back and say what may have been mania contributing to being able to do stuff, and what part of it was the drug.

It definitely had a positive effect on the depression, though. I had no clue about anxiety disorders/bipolar, as I thought all those things were me (For example, I didn't know there was anything odd about worrying about a fire starting in the wall everytime I plugged something in in the kitchen; I just thought that was me.)

1 month after starting the drug, hubby got laid off work as they closed the plant. With severence pay, we were able to keep up another two months of the med and then I stopped, cold turkey (ouch). We eventually had to move in w/my parents due to the recession (and 300 other people all in the same field looking for jobs in that same field at the same time, ugh, and positions in it were few).

About 2-1/4 years ago, my first psychiatrist started me up on Effexor, as well as starting Lamictal. By the end of that summer (he was suspended at the time, I saw a lady doc subbing) she doubled it to 300, saying that when you stop it, you often need a higher dose when you go back on it again.

I have no idea if this is poop out. I also wonder if it has pooped out in the last year or so (not that I'm asking you guys a clinical question, I'm not.) But there's so much going on with me at the mo it's hard to tell anything anyway. Stress is not a good thing, and I'm under alot of it, so I s'pose that doesn't help the med either.

I found the family aspect of this study/post interesting, although with the usual pang inside of, "Damn, this wouldn't work for me, my family support system is nil, anyway (they say they do, but it's hot air (hubby not included in that, for the most part.))"

I wish there'd be some studies on what people with little to no support system can do cause it seems to me like alot of the stuff that's helpful for people like me, is dependent in large part on a support system.

DOH! (Ok, I sound a little . . . sour, resignedly peeved about it, but can you blame me? lol.)

I'll be looking forward to your post, Roy, on the placebo issue. That is very interesting; if a sugar pill can have a placebo effect, it stands to reason (to me, anyway) that any pill could have a placebo effect. At some times, in some situations, with some people.

That about some's it up, don'tcha think? hee.

(Clink I'm getting into Prison Break, starting w/season 1; It's all your fault ;^) )

Anonymous said...

is poop-out something that keeps happening... say for example every 2 or 3 years... FOREVER? is there a point where it generally stops happening? i mean, what are the looooong-term studies showing?

Anonymous said...

i am especially impressed by the ad :"borderline behandling" that leads to a site in Denmark or so it seems. something is rotten in denmark but it is good to know that they know how to behandle their borderlines.

Anonymous said...

"Your" taking an antidepressant? Are you for real?

Anonymous said...

What, you want shrinks to study spelling and grammar?

Anonymous said...

I don’t understand. This is taking the complete common sense approach of:
1. More and more studies showing that antidepressants do not work any better than “active placebos” (in other words Placebos that cause the side effects SSRIs do ex dry mouth)
2. More Studies coming out of the horrible withdrawal symptoms from coming off antidepressants, which again, speaking “common sense” will lead me to believe these drugs, are creating some sort of brain change, and from the looks of it a damaging brain change.
3. You speak of SSRI Poop-out, isn’t this concerning to anyone???? Brain damage??
IT’s more like a bleep in the screen for you guys, “yeah, the antidepressants are causing some sort of “receptor sensitivity” “ aka brain damage or “illness break through” that the drugs are supposed to be preventing/treating ?!?!
4. To me this reads that the Risks do outweigh any benefit these drugs can provide.

As someone who came to a “shrink” for help for anxiety after having my first son AND THEN losing five years of my life allowing docs to “find the right combination” I can attest it is NOT WORTH IT. Today I am drug free and the major depression I was suffering coincidently disappeared when I began to taper of these drugs.

So did my High White Blood levels, High Blood Pressure, High Blood Sugars, Irregular Periods, and Low End Thyroid Hormones.

Unless you can explain exactly what a med is doing you are only experimenting on humans. God Bless the ones who find relieve in these drugs all power to them. But the rate and ease these drugs are given out makes me think Doctors do not take into account the dangers of them.

For example, High blood pressure, as a woman in her 30’s with a family history of heart disease would mean a drastic life reduction for me. But relying on COMMON SENSE knowing I have never suffered from this before would indicate it was the meds. But my doctor never heard of this before…… couldn’t be the meds.