“Antiviral therapy may be a powerful tool in the fight against SEID”. Dr. Thomas Henderson

Doctors on Missions

Dr. Thomas Henderson and Dr. William Pridgen are on similar missions. They’re both asserting doctors in their respective fields are missing the boat.

progress

When a piece slamming CBT/GET and proposing antiviral shows up on Psychiatry Advisor things are starting to change

Henderson, a psychiatrist, asserts herpesviruses are a major issue in misdiagnosed chronic fatigue syndrome adolescents and patients. Dr. William Pridgen, a surgeon, proposes antivirals and anti-inflammatories are knocking down herpesvirus infections in people with fibromyalgia. They’re bucking strong headwinds for sure, but their message is getting out there, and it’s getting into surprising places.

Psychiatry journals are the last place you’d think to find an article denouncing CBT and GET and embracing antiviral therapies. Thomas Henderson just penned an opinion piece titled The Role of Antiviral Therapy in Chronic Fatigue Treatment in Psychiatry Advisor doing just that, though.  When the Psychiatry Advisor’s editorial board (all MD’s) starts giving the OK to pieces like that you’ve got to think things are starting to change.

Henderson’s is the second article examining ME/CFS from a biological perspective to appear on a mainstream psychology publication in the last six months…

Wrong Diagnosis

The IOM report may be continuing to open doors. Henderson begins his piece stating

“Perhaps the most important evolutionary step was the clear message delivered on page 15 of the introduction: CFS/ME is underdiagnosed and misunderstood.”  (Underlines present in article.)

Henderson then goes on to tell them just how off the doctors in his field are.  Despite the fact that many of the adolescents in his practice do not meet the criteria for major depression, many had been diagnosed with it – and unsuccessfully treated with antidepressants. (Talk about a “basket-case definition”. How many people with all types of difficult to diagnose disorders get thrown into the depression basket at some point?)

puzzled doctor

Henderson hopes some psychiatrists will re-examine their diagnoses.

Henderson noted that all his adolescent patients experienced high rates of fatigue, exertion induced malaise, brain fog, unrefreshing sleep and impaired academic performance. That constellation of symptoms is not commonly found in depression.

Back in 2005, Lenny Jason showed  that people with ME/CFS experience significantly more

  • post-exertional malaise (PEM)
  • unrefreshing sleep
  • more fatigued
  • more confusion and disorientation
  • more shortness of breath

than people with major depression. While that may not be news to the ME/CFS community, it surely is news to the psychiatry community.

Improved Results

In the Psychiatry Advisor piece Henderson reported that 92% of his adolescent patients responded not just well but very well. Many of their symptoms resolved with long-term antiviral use (valtrex 1000 mg 2 x’s a day – 6 months). Vigor scores group-wide quadrupled.  Five out of the seven adolescents who’d dropped out of school returned. 

It was a small case-series study, but the results snuffed those of the PACE trial. In the Pace Trial – a huge unblinded study with significant methodological problems of its own (biased scoring) – a ten percent decrease in fatigue was considered significant progress.

Henderson stated he’s getting similar results in the 200 plus adult ME/CFS patients he’s seen, and cited Lerner’s studies showing efficacy as well. Montoya’s small placebo-controlled, double-blinded valcyte study of ME/CFS patients with high EBV and HHV-6 titers was not as successful. It did find, though, that the longer the patients were on Valcyte the better they did.

Henderson’s figures seem high to me, but they undergird the need for large, rigorous studies examining the effectiveness of antivirals in these disorders. Montoya has called for just those. In a recent CDC call he suggested that this field of inquiry is still, almost thirty years later, being poisoned by the after effects of that small, three-month, unsuccessful Straus aciclovir trial in 1988.

Evidence keeps accumulating, however, that Montoya and Henderson and those proposing antiviral and/or immunomodulatory therapies in ME/CFS and related disorders may be on the right track

Antivirals and Immunomodulators?

Antivirals may be doing more than just impacting viruses. Montoya suggested that the immunomodulatory shift  (to Th1 functioning) he observed might be more important than the impact the drug had on the viruses themselves. That’s an intriguing suggestion given a recent finding that ganciclovir – a Valcyte prodrug- is a potent microglial and neuroinflammation inhibitor.

immune system

As they kill invaders some antivirals may be shifting the immune response as well

As Hornig recently noted most pathogens require a immune dysfunction or weakness to exploit. If ME/CFS or parts of it are pathogen or immune-based, then immunomodulatory treatments that return the immune response to normal may be the best long-term answer.

The immune system is so complex, though, that simply characterizing what a normal, healthy immune system looks like is beyond us at this point. Work on that is underway at Stanford and other institutions. Thankfully, Mark Davis – who is now engaged in what may be the largest ME/CFS study ever –  is including chronic fatigue syndrome in that work.

Shift Occurring

An article appearing just a couple of days after Henderson’s piece on Psychiatry Advisor indicates the psychiatry field is getting the message as well.

In “How Neuroinflammation May Play a Role in Mood Disorders“, Dr. Roger McIntyre argues that the hypothesis guiding most drug development for mood disorders over the past fifty years has been played out.  The monoamine hypothesis proposed that alterations in neurotransmitters causes mood disorders. It’s had its successes, but many patients are still symptomatic, and a significant subset don’t respond at all.

Citing a ” highly replicated body of evidence” gathered over the past twenty years, McIntyre asserts that neuroinflammation plays a role in a significant set of those with mood disorders. They include the patients Henderson reports he is successfully treating – people with treatment-resistant depression – as well people with early life trauma and people with obesity associated depression and others.

Immune Mood Connection Growing

The immune/neuroimmune connection with many of the symptoms associated with ME/CFS and depression is clearly growing. The association of early life trauma with the later development of autoimmune and cardiovascular diseases points a finger at immune activation and inflammation. Immune upregulation has been linked with depression, lack of enjoyment and cognitive problems.  Inflammation induced activation of the kynurenine pathway has been shown to reduce neurotransmitter levels.

Some SSRI antidepressants have anti-inflammatory effects.  We’ll soon be presenting a story on Health Rising of a person with ME/CFS whose mood and energy improved dramatically while on a prescription anti-inflammatory.

Finally, McIntyre notes that many non-pharmacological approaches that have proven helpful in depression such as mindfulness-based therapy, aerobic exercise, dietary modification, sleep/ chronobiological normalization have anti-inflammatory effects.

All depression is not associated with inflammation, but a good chunk of it, perhaps 30 percent, appears to be.  With high rates of mood disorders found in ME/CFS/FM one wonders if the percentage of inflammation induced mood problems are very high indeed in these diseases.

Changes in the Wind

doors opening FM

Some doors are showing signs of opening

Options are opening up. The conceptions of ME/CFS/FM and depression in the psychiatric world appear to be slowly changing. With so many ME/CFS and FM patients getting dumped off at a psychiatrists office at some point, Henderson’s opinion piece may be a crack in the door in just the right place.

Psychiatrists and pyschologists are in the business of helping people. They must be tired of running into a dead end with their treatment-resistant patients.  Hopefully Henderson’s opinion piece will point some of them in a direction that proves fruitful for them and their patients.

Meanwhile, McIntyre’s piece suggests that Henderson and Montoya and others looking to the immune system for answers for symptoms like fatigue, brain-fog, mood changes and sleep problems may be in the right place as well.

If you’ve tried any of the antivirals mentioned in this blog please share your experiences in Health Rising’s new Treatment Review section for Valtrex here and Valcyte here.

 

 

 

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