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Depression. Diagnosis, Treatment and FAQ.
July 16, 2009 | Leave a Comment
DEPRESSION
• Report suicidal thoughts to a health professional
• Ask your doctor if fluoxetine (generic) is appropriate for you
• Discuss bupropion if sexual side effects from fluoxetine become a problem
• Consider cognitive behavioral therapy
• Try vigorous exercise 5 days a week
• Spend time outside in the sun or get a bright light
• Add fish oil to your dietary regimen
• Ask your doctor if St. John’s wort would be safe
• Inquire about Emsam when other treatments fail
Almost everyone knows what it’s like to feel sad. Losing a pet, a friend, or a loved one is devastating. Being fired or getting a divorce can send you into a tailspin. An accident or a serious disease affects not only the physical body but also the psyche. Fora while there is little pleasure to be had in life. It can be as if darkness has settled into your bones and sucked the joy right out of the marrow.
Most of us eventually recover from the boulders that are dropped on us. But some people never manage to dig themselves out of a hole. According to the National Institute of Mental Health, major depression affects about 15 million people each year. One in five of us will experience some form of depression sometime during our lifetime. 175
When the fog descends, people may forget what it’s like to feel happy. Sleep becomes next to impossible–or all you want to do. Food loses its appeal and its flavor. Those with major depression often have a low energy level; they find it hard to mobilize themselves to finish projects or visit friends or family. They feel gloomy and down in the dumps for weeks or even months. They doubt their abilities and feel pessimistic much of the time. Just remembering simple things becomes an overwhelming challenge. They may experience thoughts of suicide—a hallmark of major depression.
Such a mood disorder requires professional help immediately. Let us repeat that. If any of the symptoms below apply
SIGNS OF DEPRESSION
• Feeling sad, gloomy, or “empty” for more than a few weeks
• Feeling hopeless
• Feeling helpless or worthless
• Insomnia, early-morning wakening, or persistently sleeping too much
• Feeling worn-down, fatigued, or like you’re moving in slow motion
• Loss of appetite: eating because it’s necessary rather than because the food tastes good and satisfies hunger
• Loss of interest in sex
• Restlessness or agitation, pacing the floor
• Difficulty with concentration and with remembering simple things; indecisiveness
• Physical complaints such as headache or pain that don’t get better when treated
• Thoughts of death or suicide to you or someone you care about, seek highly qualified assistance right now! Digging out from a depression should never pull
be a do-it-yourself project. You cannot puyourself up by the bootstraps or tough it out on your own. Chronic depression increases the risk for heart disease, stroke, diabetes, and other serious conditions and must not be ignored. The suggestions we will
widiscuss in this chapter are meant to supplement whatever your health professional may offer you in the way of help.
The Good Old Days
As remarkable as this may sound, some people actually coped surprisingly well with depression 50 to 100 years ago. They intuitively knew that there were some strategies that worked. For one thing, they looked around for someone to talk to. It might have been a pastor, a friend, a neighbor, or a relative. If they could afford it, they went to a psychologist or psychiatrist for counseling. Just talking things out sometimes seemed to help.
People also exercised. It might have been a physically exhausting task like chopping wood, hoeing a field or hiking through the woods. In those days, people spent more time outdoors working hard and walking from here to there. Nowadays we go from the air-conditioned comfort of our house or apartment to the air-conditioned comfort of a car, bus, or train to the air-conditioned comfort of an office or mall. We rarely spend time outside in the sun, and the only “workout” we get is at the gym or health club.
Oh yes, there was one more thing. In the good old days, especially during the winter, mothers made their kids swallow a spoonful of cod liver oil. It was never clear exactly what cod liver oil was good for, but mothers seemed to know that fish oil had beneficial properties. It was just “good for you,” no matter how bad it tasted.
Well, it turns out that virtually all of those quaint old strategies have now been proven helpful against depression. As you will learn shortly, research has shown that fish oil, exercise, light exposure, and cognitive behavioral therapy are surprisingly effective in dealing with depression.
Drug Therapy
Fifty years ago “talking therapy” was considered essential in the treatment of depression. Psychologists and psychiatrists saw lots of patients who suffered from mild to moderate depression. But during the 1970s biological psychiatry took off. The medical profession embraced the theory that depression was primarily caused by an imbalance of chemicals in the brain. Many health professionals adopted the belief that a depressed person only needed antidepressant medication to normalize brain biochemistry. All you had to do was “feed your head” the right chemicals and the depression would disappear.
During those heady days many patients were given tricyclic antidepressants to soothe their troubled psyches. Medications like amitriptyline (Elavil), desipramine (Norpramin, Pertofrane), doxepin (Adapin, Sinequan), imipramine (Janimine, Tofranil), and nortriptyline (Aventyl, Pamelor) were prescribed in huge numbers. Never mind that such drugs caused drowsiness, fatigue, constipation, dry mouth, dental problems, weight gain, blurred vision, urinary difficulties, dizziness, disturbed concentration, impaired memory, mental confusion, sexual dysfunction, and impotence.
Although these medications did help many people get out of the depths of despair, the side effects were sometimes as depressing as the depression itself. Imagine what it would be like to put on 30 or 40 pounds, feel mentally cloudy and constipated most of the time, and have no sex life. But insurance companies liked these medications. It seemed far more cost-effective to have an internist or a family practice doctor prescribe an antidepressant than to approve a lengthy series of counseling sessions with a psychologist or psychiatrist.
Then along came Prozac (fluoxetine). In 1987 when it was introduced, this antidepressant hardly made a splash. First-year sales were just barely respectable, but more than doubled in the second year. By the third year, Americans spent more on Prozac than on all other antidepressants combined. Everyone seemed to fall in love with Prozac—physicians, pharmacists, patients, and, most of all, the big payers (insurance companies and HMOs).
Prozac—a selective serotonin reuptake inhibitor, or SSRI—was so successful because it got great PR, and because it seemed to have fewer side effects than traditional tricyclic antidepressants. At least it was less likely to cause sedation, dizziness, constipation, or dry mouth. It also was more effective—or at least that was the impression among physicians and patients. There were never any data to support that belief, but that didn’t stop the media blitz. Prozac even made the cover of Newsweek and Time magazines. Once people decided it was the new wonder drug, other pharmaceutical manufacturers were desperate to get in the game. The race was on.
It wasn’t long before the wannabes started showing up, trying to claim a piece of the Prozac pie. Today the competitors include bupropion (Wellbutrin), citalopram (Celexa), duloxetine (Cymbalta), escitalopram (Lexapro), nefazodone (Serzone), paroxetine (Paxil), sertraline (Zoloft), and venlafaxine (Effexor). Almost 190 million prescriptions are written for these antidepressants each year, with sales exceeding $12 billion. 176
Such coeds are being prescribed enthusiastically for a wide range of other health problems, too. The pharmaceutical industry has promoted some of these antidepressants for conditions such as obsessive-compulsive disorder, panic attacks, hot flashes, premenstrual distress, nervousness, and shyness (”social anxiety disorder”).
Almost from the beginning, though, these drugs have been controversial. In the original clinical trial for Prozac, 15 percent of patients in the study dropped out because they felt worse instead of better—a statistic that was not widely publicized. Anxiety, insomnia, restlessness, nausea, and tremors caused distress for some people. There also was a high incidence of sexual dysfunction with the SSRIs. But the real controversy has always swirled around whether Prozac and similar compounds could trigger thoughts of suicide or homicide in some people.
Antidepressants and Suicide
In 1988, we received a letter from a grieving physician. His daughter had been prescribed Prozac for an eating disorder; a month later she took her er life by hanging herself. This oph- thalmologist was convinced that Prozac had contributed to her tragic death. At the time, we discounted this story—which we now regret—and told him that depressed people sometimes take desperate action and may try to harm themselves when they start treatment. Later, he responded that his daughter had never been depressed, nor had she been acting like a person who planned to take her life.
In 1990 an article appeared in the American Journal of Psychiatry describing a half-dozen patients who developed “intense violent suicidal preoccupation after 2 to 7 weeks of fluoxetine treatment.”177 This report stirred up quite a lot of concern, but many psychiatrists downplayed the connection. When we asked the drug company and the FDA about this report, we were told that depressed people sometimes commit suicide and that the drug was not to blame.
Over the last 18 years we have heard of many other instances in which people became preoccupied with harming themselves or others after starting on an antidepressant. A man taking Zoloft awoke in the middle of the night with a strong urge to kill himself. A woman reported wild thoughts on Prozac about ramming her car into other cars and getting a gun to kill an irritating co-worker. Another woman told us that she experienced an overwhelming urge to open her car door and jump-out of the vehicle while it was going at 50 miles an hour down the highway.
My son Mike was prescribed Paxil for depression while he was a graduate teaching assistant at New Mexico State University. Around day 13 he slipped into a mood that I had never seen before. He never came out of it. Four days later he shot himself in the temple with a.2? rifle. He had taken Paxil for 17 days.
I hold the FDA and GlaxoSmithKline (maker of Paxil) responsible for my son’s suicide. No one should ever have to look at a son or daughter’s tombstone!
Whenever we discussed our concerns with psychiatrists, drug companies, or FDA officials, we were told that such events were purely coincidental. Our federal watchdog insisted that the medicines could not have been responsible for such tragic outcomes. But when British drug regulators began warning physicians that SSRI-type medications might trigger suicidal thoughts, agitation, and self-injury in young patients, the whole ball of yarn began to come unraveled.
Eventually, an FDA staffer, Andrew Mosholder, MD, MPH, was given the task of analyzing 22 studies. His conclusion: “Short-term pediatric trials of antidepressant drugs demonstrate an increased rate of suicidal events with active drug compared to placebo.” He also said that there is not adequate information to tell if antidepressants other than Prozac are effective for children.
FDA JULY 1, 2005, PUBLIC HEALTH ADVISORY
• Adults being treated with antidepressant medicines, particularly those being treated for depression, should be watched closely for worsening of depression and for increased suicidal thinking or behavior.
• Close observation of adults may be especially important when antidepressant medications are started for the first time or when doses for the specific drugs prescribed have been changed.
• Adults whose symptoms worsen while being treated with antidepressants, including an increase in suicidal thinking or behavior, should be evaluated by their health-care professional.
The idea that drugs designed to fight depression and prevent suicide could potentially make things worse for some kids seemed to shock FDA officials to the core. Initially, Dr. Mosholder was muzzled. Eventually, though, the data convinced even the FDA hardliners. Belatedly, the agency issued warnings about suicidal thinking and antidepressants.
These cautions came far too late to prevent many terrible tragedies over nearly 2 decades. As difficult as it has been for psychiatrists and FDA officials to contemplate, people taking SSRI-type antidepressants are sometimes preoccupied with thoughts of suicide or homicide. Harvard psychiatrist Joseph Glenmullen,’ MD, has criticized the makers of SSRI-type antidepressants for delaying adequate warnings.”‘ The maker of Effexor XR added “homicidal ideation” to its label years after the drug was introduced. The company considers this a very rare adverse event and does not believe the drug can be causally linked to actual homicides. But there have been a number of high-profile violent events associated with antidepressants. Causal or not, this controversy continues to simmer.
The entire SSRI-suicide story strikes us as mishandled. Just as with the Vioxx (rofecoxib) scandal, it has seemed to us that FDA officials have been more intent on protecting the pharmaceutical companies’ profits than the public health.
To add even more confusion to this already sordid affair, the reputation these drugs have enjoyed as being highly effective against depression is now suspect. Remember that placebo-controlled trials are the gold standard that everyone is supposed to adhere to. Drug companies are required to show that their expensive antidepressants are significantly superior to a placebo. But an “analysis of 96 antidepressant trials between 1979 and 1996 showed that in 52 percent of them, the effect of the antidepressant could not be distinguished from that of placebo. ,179 In other words, “more than half of all recent clinical trials of commonly used antidepressants failed to show statistical superiority for the drug over placebo.”180
That, dear reader, is almost beyond belief. It suggests that either placebos—sugar pills—are amazingly effective in relieving depression or that current antidepressants are not all that impressive.
Another overview of many clinical trials concludes that the latter is the case. It goes even further and suggests that “recent meta-analyses show selective serotonin reuptake inhibitors have no clinically meaningful advantage over placebo…. Antidepressants have not been convincingly shown to affect the long-term outcome of depression or suicide rates.”181 Of course, this kind of analysis relies on the statistical manipulation and combining of many smaller studies. As compelling as the conclusions may be, they do not substitute for really big, well-conducted trials.
The largest and most definitive study of depression and antidepressant medications was a $35 million project, funded by the National Institutes of Health, called the STAR*D (Sequenced Treatment Alternatives to Relieve Depression) trial. This was no drug company whitewash. This was your tax money at work. What made this research so valuable was that the investigators looked at actual recovery from depression (”remission”), not just some symptom improvement. Recovery is, after all, what depressed patients really care about.
The antidepressants used in the STAR*D trial were bupropion SR (Wellbutrin SR), citalopram (Celexa), sertraline (Zoloft), and venlafaxine XR (Effexor XR). When the long-awaited results were published in the New England Journal of Medicine (March 2006), they were surprisingly disappointing.
About one-fourth of the patients achieved real remission, regardless of the type of antidepressant that was taken.182 What makes this so discouraging is that these patients got optimal treatment. They received intense evaluation and a level of care not usually available to the average patient. If the depressed folks in this study had been treated in a more typical manner, “the remission rate probably would have been significantly lower—perhaps even in the single digits.”183 That’s abysmal.
If there is any good news that came out of the STAR*D research, it is that when a different antidepressant medication was substituted after initial treatment failure, about one in three patients finally did achieve remission. 1114, 181 What this means is that antidepressants actually do what they are supposed to do (cure depression) about half the time. Depending upon your perspective, that means the glass is either half full or half empty.
We are happy to learn that 50 percent of the patients in this trial got better. But even under these ideal conditions, half did not, regardless of the type of medicine used. That means that an awful lot of people are suffering drug side effects without benefit. And since there were no placebo controls in STAR*D, we have no idea how many folks might have improved if they had received sugar pills instead of drugs.
So how can you determine which antidepressant is best for you? In truth, it is extremely difficult for physicians and patients to make clear decisions about safety and effectiveness when it comes to these medications. Despite all the hype from the drug companies, it is hard to prove that one type of antidepressant is better than another one.186
Newer drugs like Cymbalta affect both serotonin and another neurotransmitter called norepinephrine (hence their name serotonin/norepinephrine reuptake inhibitors, or SNRIs). This dual action is supposed to make such drugs more effective. It has certainly driven up the cost. A single Cymbalta pill can cost between $3 and $4. A Wall Street Journal review reported that when Cymbalta was compared head-tohead with venlafaxine (Effexor), an older drug in this class, “Cymbalta wasn’t significantly different from Effexor in treating depression.”187
The bottom line is that there are no “best choices” when it comes to these kinds of antidepressants. All these drugs are roughly similar in effectiveness, and all have the potential to cause serious adverse reactions for some people. Anyone who experiences anxiety, agitation, irritability, and especially thoughts of violence toward himself or others should contact a health professional immediately!
Watch Out for Withdrawal!
There is one other complication associated with these antidepressants that is rarely discussed. Sudden discontinuation of drugs like Effexor, Paxil, Serzone, and Zoloft may cause unexpected symptoms. We have heard from many patients that they experienced dizziness, nausea, insomnia, headaches, nervousness, sweating, shakiness (like a bad hangover), weakness, visual disturbances, and an inability to concentrate. One reader called the problem “Paxil Head,” like having your head stuck in a blender.
I take Zoloft, and have tried to stop taking it several times. Each time I stop I experience a-very strange thing. Doctors, nurses, and pharmacists dismiss me like I’m a nut case, but I swear this is true. I get electrical shocklike sensations in my head and become extremely dizzy. I absolutely know this is associated with not taking Zoloft. Not 2 hours after I resume taking it again the symptoms, which are overwhelming, disappear completely. I would like to get off of this drug but have no idea how to do so, especially when I cannot function without it and no one recognizes I’m having any trouble. They just think I’m crazy.
What is so sad about this particular problem is that no one really knows how common withdrawal symptoms are. There are, as far as we can tell, few good guidelines for helping people overcome this complication. So we do not know how long people will experience dizziness, shocklike sensations, or nausea after they stop a drug like Zoloft. Drug companies are not particularly interested in developing protocols for discontinuing SSRI/SNRI-type medications, since they would then need to admit they have a problem on their hands. That means that patients and physicians are on their own.
Gradual tapering over several weeks may be necessary. We have heard from some doctors that they switch patients over to fluoxetine and then taper it very slowly. That’s because Prozac lingers in the body and may be less likely to trigger withdrawal symptoms *** Fluoxetine (Prozac)
Fluoxetine is a stand-in for all SSRI-type drugs. Although there are subtle variations between medications in this class, there are more similarities than differences.
Side effects: Headache, nausea, dizziness, diarrhea, nervousness, anxiety, and insomnia are relatively common and may affect up to one-fourth of the patients who take SSRI-type medications. Some people may experience drowsiness or dizziness. Delayed ejaculation, inability to achieve orgasm, and decreased sexual desire are common complications of this entire class of drugs. Less frequent problems may include decreased appetite, indigestion, sweating, mania, dry mouth, heart palpitations, tremor, chills, constipation, blurred vision, memory problems, confusion, rash, and joint pains. Blood sugar control or thyroid function may be altered. Seizures, while uncommon, have been reported in roughly 0.1 to 0.2 percent of patients, an incidence comparable to that seen with older antidepressants. Any thoughts of suicide or violence must be reported to a physician immediately)
Downside: SSRI-type medications like Prozac can interact with many other drugs. Make sure your physician and pharmacist double-check to verify that any other medicine, herb, or dietary supplement you take is safe with your antidepressant.
Cost: Approximately $130 to $140 for a month’s supply of Prozac. Generic fluoxetine costs $16 to $20 for the same amount.
Despite all the controversy, we still think Prozac is worthy of consideration, especially since it is less likely to precipitate withdrawal symptoms when discontinued. And we are not convinced that other SSRI/SNRIs are more effective. Many people benefit dramatically from this or another SSRI or SNRI. Prozac is now available generically as fluoxetine, so the cost factor is less problematic. We’re not convinced, though, that all generic fluoxetine is created equal. Some patients report therapeutic failures on this generic (see Generic Drug Quandary for details).
Since there is no way to predict whether someone will ben-Bupropion (Wellbutrin)
This antidepressant is less likely to interfere with sexuality and may even be helpful for people who have experienced diminished libido. It is also available generically, so there is a cost savings. People tend to feel energized rather than sluggish when taking bupropion.
Side effects: Common complaints include insomnia, dry mouth, anxiety or agitation, headache, nausea, and dizziness. Less common adverse reactions that we are aware of include mania, seizures, irregular heart rhythms, skin rash, hallucinations, paranoia, high blood pressure, and migraine.
Downside: Bupropion can interact with many other medications. Make sure your physician and pharmacist double-check to verify that any other medicine, herb, or dietary supplement you take is safe with your antidepressant. Any thoughts of suicide or violence must be reported to a physician immediately!
Cost: Approximately $130 to $150 for a month’s supply of brand-name Wellbutrin SR; generic bupropion SR runs roughly $60 to $70 for a similar amount.
efit more from one antidepressant than another, this is mostly a process of trial and error. It may take 4 to 6 weeks to begin to see improvement, so it is important to give each medication a fair trial. If no success is achieved after a few drugs in the same class are tried, then it may be time to move on to another category.
Bupropion (Wellbutrin) may offer certain advantages over other SSRI-type drugs. For one thing, it is far less likely to interfere with sexuality. Some have even reported that it restores libido.
Some people do benefit from old-fashioned tricyclic-type antidepressants such as desipramine, imipramine, and nortriptyline. For people who become agitated or anxious on an SSRI/SNRI or find that bupropion keeps them wide awake, tricyclics may offer an acceptable alternative.
There is also a completely different kind of antidepressant that comes as a skin patch (Emsam). We will discuss it at the end of this chapter.
Nondrug Therapy: Back to the Future
At the beginning of this chapter we suggested some old-fashioned approaches to treating depression that might be worth reconsidering. We were referring to seemingly archaic practices such as counseling, exercise, and fish oil. Surprisingly, there is some scientific support for these quaint concepts.
Talking Therapy
In our rush-rush world, people rarely take time to talk anymore. The idea that someone could actually sit down for an hour or so and discuss the issues that are causing distress seems outdated. Insurance companies and “mangled care organizations” may not be thrilled at the prospect of paying a psychologist or psychiatrist $100 to $200 a week to do counseling for several months. The bean counters seem to prefer paying for prescription drugs indefinitely. What is so bizarre about this ass-backwards approach is that psychotherapy can enhance the effectiveness of medications and can be stopped once it has been successful. That seems cost-effective to us.
For those in the know, cognitive behavioral therapy, interpersonal therapy, and problem-solving therapy are surprisingly effective for mild to moderate depression. 188 Cognitive behavioral therapy (CBT) got traction in the 1970s. In a nutshell, this therapy works on the premise that depression arises from dysfunctional thoughts and beliefs. We are all influenced by our early learning experiences. When those thought processes
Cognitive Behavioral Therapy
The results of well-conducted research suggest that cognitive behavioral therapy (CBT) is as effective as antidepressants in treating depression. The benefits are long lasting and we don’t know of any serious side effects to talking therapy.
Downside: Such treatment can be expensive and it requires an experienced psychotherapist. Identifying someone who has the requisite expertise may not be that easy.
Cost: Approximately $1.00 to $200 per session. This is highly variable depending upon the practitioner’s skill. level and are dysfunctional, they can be triggered by situations later in life and produce depression and other psychiatric symptoms. The trick here is to have skilled therapists help patients identify and challenge negative automatic thoughts so that behavior can be changed.”‘
One study found that “cognitive therapy can be as effective as medications for the initial treatment of moderate to severe major depression but this degree of effectiveness may depend on a high level of therapist experience or expertise.”" Another study found that “cognitive therapy has an enduring effect that extends beyond the end of treatment. It seems to be as effective as keeping patients on medication.”"‘
Exercise
As effective as talking therapy may be for depression, exercise may also be beneficial. Investigators have known for decades that aerobic exercise can improve mood and outlook. Recent research backs this up. A review confirms that exercise can benefit mental health, helpiy to alleviate depression as well as improve physical health.’ According to Canadian reviewers, there is “irrefutable evidence” that physical activity can be effective against depression. 193
One study was dubbed DOSE, for Depression Outcomes Study of Exercise. Men and women between 20 and 45 years of age with mild to moderate depression were asked to exercise for various amounts of time ranging up to 30 minutes of moderate-intensity movement almost every day of the week. That allowed the investigators to compare the “dose response” from exercise. They found that low-intensity exercise was no better than pla- cebo, but high-intensity exercise was an effective treatment
Light
To give your exercise a jump start, go outside and get a little sun on your face. There is growing evidence that light therapy can be beneficial against depression. One eminent psychiatrist reviewed the literature, expecting to find that the research was awful and the therapy didn’t work. Instead, after reviewing the data objectively, he came to the conclusion that phototherapy was “comparable to what has been described in the clinical literature for conventional medications to treat depression. The findings are as strong or as striking.”195,196
Bright light therapy is helpful not only for seasonal af-fective disorder (SAD), which frequently occurs during the winter, but also for depression that occurs at any time of the year. There is evidence that light can enhance the effects of exercise as well as the antidepressant action of medications like citalopram (Celexa).197,’9′
Fish Oil
Grandma might have been right that cod liver oil is good for your mind as well as your body. She may not have had the benefit of randomized, placebo-controlled trials, but we do. Most of them show that fish oil can be helpful against depression. 199 We’re hoping that there will be more studies in the future to determine the best dose of DHA and EPA, the main fatty acids in fish oil. We’re not thrilled with cod liver oil, per se. These days you can obtain pharmaceutical-grade fish oil that does not have the excessive levels of vitamin A you often find in cod liver oil. Too much vitamin A is bad for your bones.
St. John’s Wort
The medical community has had a very hard time grappling with research suggesting that an herb might be as good as an antidepressant like fluoxetine (Prozac) for relieving depression. Nevertheless, there have been dozens of clinical trials demonstrating that St. John’s wort can be effective in treating mild to moderate depression .200 In some studies, St. John’s wort works as well as prescription antidepressants, and it usually has fewer -troublesome side effects.
St. John’s wort has long been prescribed in Europe for treating depression and other mood disorders. Although there are studies showing that the extract is not better than placebo, there are several showing that it works at least as well as prescription antidepressants. Most trials indicate that St. John’s wort appears to be safe and well tolerated, perhaps better tolerated than a pharmaceutical antidepressant.
The way St. John’s wort acts to relieve depression is not known. Scientists don’t even know which of its many constituents might be responsible for the activity. This makes it hard to select an extract appropriately. Only standardized extracts, preferably ones that have been tested and found effective, should be used. Three standardized products that have been tested in Germany are available here. The brand names are Kira, Movana, and Perika.
St. John’s Wort (Hypericum perfornow)
Some people may find that St. John’s wort is an effective antidepressant. As long as it is taken under medical supervision and caution is exercised regarding drug interactions, we think it is worth consideration.
Side effects: Side effects are uncommon and usually mild. Unlike many prescription antidepressants, St. John’s wort does not cause sexual dysfunction. Digestive upset has been reported. Allergic reactions are possible.
Downside: St. John’s wort can cause photosensitization, making the skin and the eyes vulnerable to damage from sunlight. St. John’s wort interacts dangerously with a wide range of prescription medications. Ask your pharmacist or your doctor to check on this possibility if you contemplate taking St. John’s wort together with any other medicine.
Cost: Approximately $15 to $20 a month for Kira brand
The Selegiline (Emsam) Patch
The latest and most interesting chapter in antidepressant therapy involves a prescription skin patch containing the drug selegiline (Emsam). ‘Ibis transdermal medication works in a completely different manner from most current antidepressants. It is called a monoamine oxidase inhibitor (MAGI). Such drugs were among the first antidepressants ever developed. But they lost their luster because of a potentially deadly. interaction with many foods, beverages, and drugs. The “cheese effect,” as it came to be known, could cause extremely high blood pressure when a person taking a medication like Marplan or Parnate ate an aged cheese such as cheddar. This could result in a stroke.
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Q. What can you tell me about selegiline? The vet prescribed it for my elderly dog. She had been very agitated, pacing for hours at a time (sometimes 12 or 15 hours straight!). She would pace until she dropped from exhaustion, sleep for half a day, then get up and start pacing again. She was also drooling excessively, dig-ging compulsively, deliberately knocking things over, and urinating in the house whenever I left.
My vet said these are all symptoms of senile dementia in dogs. I think it was precipitated by the death of my other dog. They had been together for more than 12 years and she just couldn’t handle being alone.
Several days after she started on selegiline all those behaviors stopped completely. It was amazing. She started acting like herself again. After seeing how much it helped my dog, I would definitely take it myself. Do they ever prescribe it for people with memory problems?
A. Our veterinary consultant, Andrea Frost, DVM, says that selegiline can be helpful for dogs with the canine equivalent of senile dementia. When an old dog gets lost in his own house or becomes incontinent because he can’t remember to ask to go out, quality of life for the owner, if not for the dog, has really declined.
Not every dog has as dramatic a response as yours, but selegiline can help buy some old dogs a little more quality time with their human families.
Selegiline is used in human medicine to treat people with Parkinson’s disease and depression. It has been studied against Alzheimer’s disease with mixed results.
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The good news is that this new-generation MAGI is far less likely to cause such problems. In the lowest-dose skin patch, there is no food prohibition. When people take higher doses (9 or 12 milligrams), however, they do have to be careful about foods containing tyramine (beef liver, blue cheese, bologna, Brie, broad beans, Camembert, cheddar, Chianti, chicken liver, draft beer, miso soup, Parmesan cheese, pepperoni, salami, sauerkraut, and yeast extract) because their blood pressure could rise dangerously high.
Emsam should not be combined with other antidepressants or St. John’s wort. It is crucial to check with your pharmacist and your physician before combining any other medication when you are using Emsam.
In double-blind trials, scientists determined that Emsam is significantly more effective than placebo. The most common side effects include irritation where the patch is applied to the skin, rash, indigestion, headache, insomnia, diarrhea, dry mouth, and dizziness when standing up suddenly. Sexual side effects appear to be uncommon. Anyone who experiences thoughts of suicide while using this patch should contact the prescribing physician immediately.
Conclusions
If there is one lesson you should learn from this book it is that everyone responds differently to various treatments. That is as true for relieving depression as for lowering cholesterol or controlling diabetes. Some people find that Prozac is an absolute miracle, lifting them from the despair of lifelong depression. Others find it makes them irritable, jittery, and incredibly uncomfortable. There is no good way to predict how any individual will react, so the best advice we can give is to stay vigilant.
If you start to feel better on an antidepressant, that’s great. If you experience no improvement or get worse, contact your health-care professional immediately and seek alternatives. In some cases, combining several approaches such as vigorous exercise, fish oil, and light therapy may be as effective as prescription medicine.
• Depression can take the wind out of your sails. Do not expect that you will be able to pull yourself together on your own. Seek help from friends, family, and qualified professionals.
• Antidepressants can be very helpful for some people. There is no clear evidence that one is superior to another. Trial and error may be the only way to tell which one will produce the best results for you.
• Suicidal thoughts are now recognized as a potential complication of virtually all antidepressant therapy. Family and friends should be especially vigilant during the first few weeks of treatment and whenever your dosage is changed.
Jul
16
Dandruff Problem. Dandruff Treatment Drugs
July 16, 2009 | Leave a Comment
DANDRUFF
• Soak the scalp with Listerine original-formula (amber► mouthwash
• Smear some Vicks VapoRub on itchy spots
• Make an herbal rinse with sage or rosemary ***
• Slather yogurt on the scalp
• Use a dilute vinegar rinse after washing the hair ****
• Rotate dandruff shampoos to maintain effectiveness
• Shampoo with Nizoral A-D ****
Dandruff may be dastardly, but in general, it is not a serious medical condition. Though people who have it may by frustrated by it, or even desperate for relief, doctors don’t get too excited when they see it. The flakes are not life threatening. They never require surgery. They are not contagious and, unlike flatulence, they don’t drive others away. But a bad case of dandruff makes people self-conscious, and thanks to decades of advertising, may even carry a social stigma.
Skin cells die and are sloughed off every day, all over the body. But on the scalp, they may clump together and form flakes that stick in the hair or fall to the shoulders, and are unpleasantly visible on a black polo shirt. If the flakes are especially large and numerous and the scalp is particularly itchy and red, a dermatologist might identify the problem as seborrheic der-matitis. This condition may also affect the face. In some people, patches of skin on the forehead (including the eyebrows), the sides of the nose, and the chin seem to be especially susceptible to developing reddish, itchy scales.
I fought dandruff for 30 years. Even my eyebrows itched I only bought light-colored clothing that wouldn’t show flakes.
My dermatologist recommended various shampoos that didn’t work. When I changed doctors, my new doctor said my -dandruff” was a yeast infection. She recommended Nizoral shampoo. I only have to use it about once a month and I have no more flakes or itching.
I know this story isn’t as dramatic as finding a cure for cancer, but solving an annoyance like this is truly liberating.
Dermatologists usually distinguish between dandruff and seborrheic dermatitis, but researchers now believe that both conditions can be traced to the skin’s reaction to yeast that lives on its surface. This fungus, Malassezia globo and related species, sets up housekeeping, especially where the skin is secreting oil&’66 The fungus then produces oils of its own, which irritate the skin.” The resulting reaction is the excessive flaking typical of dandruff or the redness and itching on the scalp and face that characterize seborrheic dermatitis. Presumably, the big difference between dandruff and seborrheic dermatitis is the amount of irritation that results.
Malassezia yeast normally inhabit the skin; nobody seems to know exactly why some people are more irritated by Wassezia by-products than others. It might have something to do with hormones, or diet, or the activity of the immune system. Because dermatologists don’t know how to change individual susceptibility, the basic approach has been just to kill off as many of the yeastie beasties as is practical without hurting the scalp. This not only makes sense, it actually works most of the time. And it also explains why some dandruff shampoos seem to lose effectiveness over time. Presumably, the yeast can develop resistance.
Once in a while, people taking an oral anti-fungal drug for another problem report that it gets rid of their dandruff. But even for super-dandruff (aka seborrheic dermatitis of the scalp), an oral antifungal is too big a cannon to consider seriously. Why risk potentially serious side effects over dandruff?
Q. I had dandruff for more than 20 years and tried all sorts of medicated shampoos with no success. About 2 years ago I got a fungus under the nail of my big toe. My podiatrist put me on Lamisil, a pill a day for 3 months.
While I was taking it, my dandruff cleared up and quit itching. The Lamisil did not get rid of my nail fungus, but it seems to have cured the dandruff.
A. We’re not surprised to learn that the antifungal medicine you took for your nail infection cleared up your dandruff. Dermatologists think that dandruff is caused, in part, by yeast. Antifungal medicines could eliminate the yeast.
0 * 0
Home Remedies for Dandruff
Anyone who has had dandruff knows that ordinary shampooing, while it may help for a little while, just doesn’t make much difference. But a lot of people have discovered some rather interesting home remedies that can be helpful. We’ve collected a few that are low cost and low risk, even though there is not much evidence that they work more than occasionally. Use your own common sense in selecting those that seem worth a try.
Herbal Products
What would you think of putting mouthwash in your hair? It may not be the first thing that comes to mind, but quite a few people assure us that Listerine (the amber-colored original formula) can banish dandruff. We first heard this idea from a man who said his veterinarian recommended a mixture of Listerine and baby oil to treat itchy “hot spots” that caused his dog to keep licking its coat. It worked well for the dog, so he experimented on himself! We caution animal lovers to check with your own vet before trying this at home. And we would be especially wary about trying anything of this sort on cats, since they groom themselves so assiduously.
Q. Have you ever heard of using Listerine for dandruff? Someone told me he heard it on the radio.
A. A gentleman called in to our public radio show with an amazing story about Listerine mixed with baby oil. His veterinarian had recommended this combination for relieving itchy spots on his Dobermans and horses. He found that it worked and tried it for his own dandruff. He told us that it gets rid of dandruff in 2 to 3 days.
0 0 0
In the early 20th century and throughout the World War II era, Listerine was actually promoted as a dandruff treatment. Presumably the company dropped that claim when the FDA demanded proof. It’s not too far-fetched to believe, though. Listerine contains a number of herbal oils that have antifungal action, such as thymol, eucalyptol, and menthol. These ingredients might work together to knock down Malassezia and thus control flaking. The alcohol in Listerine might also have some antifungal action.
I have suffered from severe dandruff all of my life, and nothing helped I tried washing my hair with Listerine, and have been dandruff free since. It’s nothing short of a miracle cure.
The ingredient list for Listerine overlaps quite a bit with the list for another familiar old-fashioned product, Vicks VapoRub. Vicks contains camphor, thymol, menthol, eucalyptus oil, turpentine oil, cedarleaf oil, and nutmeg oil. Although Vicks is not promoted as working against fungus, many people find it helpful in fighting nail fungus, which is notoriously difficult to treat. Others report that it can be effective for the red, itchy flakes of seborrheic dermatitis on the face or behind the ears.
The drawback to using Vicks against dandruff is that the base is petroleum jelly. Washing this goo out of hair could be a real challenge!
People have tried a lot of different techniques to get petrolatum out of hair. The one technique that appears to be most Original Listerine contains a mixture of herbal oils with anti-fungal action. Currently, it is not promoted as a dandruff cure, but it was once marketed for this purpose. Wet the scalp well with Listerine and leave it on for 5 minutes before shampooing.
Downside: May sting on application. Mouthwash aroma might linger after shampooing.
Cost: Approximately $8 to $10 for a 11/2-liter bottle (around 150 per treatment)
reliable, and easiest, is to work mineral oil into the glop to “cut” it and then wash that out with shampoo or with Dawn dish detergent. It may take several latherings. Some folks are willing to try this treatment repeatedly, but many find that once is enough to convince them to try another method.
* * 0
Q. I’ve been suffering with scaly dandruff for 3 years. I’ve spent an enormous amount of money on medicines prescribed by the dermatologist, but none is a cure.
Last year I read in your column about people treating fungus-infected toenails with Vicks VapoRub. I thought I would try it for my problem. A bottle of Vicks cost me just over $5.
The Vicks softened those itchy scales and in just 2 weeks I have no more nasty flakes. Thank you for helping people like me on a low income.
A. We’ve never heard of using Vicks VapoRub against dandruff. This condition has been linked to yeast on the scalp, however, and is treated with antifungal shampoo.
The essential oils in Vicks are reported to have some activity against fungus. We’re glad to hear it worked for you, but we wonder: How did you wash the Vicks out?
We heard from one individual who was experimenting with coloring her hair naturally. She made an herbal tea out of sage (but did not tell us how she made it). Then she used the sage tea as a rinse after each shampoo. To her astonishment, she realized that her dandruff had disappeared. Being of a scientific turn of mind, she stopped using the sage tea rinse. Sure enough, her dandruff came right back. She was very pleased to have found an inexpensive way to treat dandruff.,
0 * 0
Q. I used to rinse my hair with a decoction I made from rosemary plants that I grew in my herb garden.
My hair tends to be the “fly-away” sort, but rosemary made it manageable and also eliminated dandruff. It made my hair smell nice, too. Growing the rosemary myself made my hair rinse a renewable resource that came from my own yard and saved me money.
A. Rosemary has a reputation as being good for hair, so we are not surprised that your home remedy is helpful. *Some people are sensitive to rosemary oil, however, and may develop a rash.
0 0 *
One of the important components of rosemary oil is camphor (along with cineole, alpha-pinene, and limonene). It also contains rosmarinic acid and carnosol. Sage, on the other hand, contains thujone, cineole, and rosmarinic acid.”‘ If you plan to try one of these herbal teas as a scalp rinse, use a teaspoon of dried herb for a generous cup (8 or 9 ounces) of hot water. Steep sage tea for 5 minutes before straining; let rosemary tea steep for 15 minutes. If you have fresh herbs from the garden, use a tablespoon of fresh leaves for your cup of tea. Let it cool before pouring it over your scalp so you won’t scald your scalp by accident.
Kitchen Magic
People can be quite ingenious when they are faced with a problem like dandruff, so it’s little wonder that some folks have tried putting common foods on the scalp. One herbal au-After washing the hair, rinse with a tea made of sage or rosemary leaves.169
Downside: Some people may have an allergic skin reaction. To be safe, test a spot on your inner arm the day before you plan to use it on your scalp.
Cost: Varies. Using rosemary or sage from the garden is free. Buying herbs in bulk results in a cost of about 50 per dose.
thor recommends smearing yogurt onto the scalp after shampooing, allowing it to sit for 15 minutes, and then washing it oUt.170 Don’t use just any yogurt, though. It should be a type with active cultures (read the label). Yogurt is fairly acidic, and that may make the skin less appealing to fungus. Then again, perhaps those live cultures do their own bit to discourage yeast. We have not tried this remedy and don’t know how well it would work.
All my life I have used dilute vinegar to rinse my hair after shampooing. It works well against dandruff and you can also use it on your feet to stop odor. Best of all, ih; cheap!
We have heard from a number of people who use vinegar as a rinse after shampooing. Some insist upon apple cider vinegar, while others go with inexpensive white vinegar. Like yogurt, vinegar is acidic. Acid disrupts the environment for many fungi that live on human skin. It stands to reason that it would also work against Malassezia.
In fact, when the problem is a fungal infection of the ear that makes it itch, one ear-nose-and-throat specialist recommends a solution made of one part white vinegar to five parts tepid water. The ear is flushed gently three times a day, and the fungus usually responds. Such a dilution might work as a scalp rinse. Then again, it is possible that a solution as strong as one part vinegar to two or three parts water would not be too harsh for the scalp.
One other food that could be used against dandruff could make you very popular with Pooh and other fictional bears. Honey, it turns out, is active against Malassezia yeast.171 This It may take a little experimentation to find the right dilution. One partminegar to fiveparts waterwould be safe, but might not be strong enough. One,part vinegar to,one part water Would probably.be strong enough to fight the fungus, but it might also sting the. scalp. Apply the rinse after shampooing, let it stay. on the scalp for 5minutes, then rinse it with dear water to get rid of the vinegar aroma.
Side effect: Possible skin irritation
Downside: Without the final water rinse, you might smell like a pickle.
Cost: About. $1 per quart
might be a lot more convenient to use against seborrheic dermatitis on the face than on the scalp to treat dandruff. But if one were feeling brave, or extra-sweet, it would be possible to mix honey with water, apply it to the scalp for 10 or 15 minutes, and then wash it off. Honey probably wouldn’t be much messier than yogurt, though it certainly would be more expensive than vinegar.
Over-the-Counter Remedies
Dandruff shampoos are readily available, and most are backed up by research showing that they affect yeast on the scalp and reduce flaking and itching. Keep in mind, though, that Malassezia may develop resistance to shampoos they are exposed to on a regular basis. As a result, it makes sense to rotate the type of medicated shampoo you use every month or two.
You might start, for example, with a shampoo such as Head & Shoulders, Pert Plus for dandruff, or Suave Dandruff 2 in 1 that contains zinc pyrithione. Research has shown that zinc pyrithione kills Malassezia and other fungi,”‘ which is why these shampoos are usually effective for dandruff. After 6 weeks or so, though, you should switch to an entirely different category of dandruff shampoo.
A medicated shampoo like Nizoral A-D, which contains ketoconazole, would be one option. This antifungal drug also kills Malassezia and has some anti-inflammatory action as well. 173 This shampoo is to be used twice a week at first, then only as often as necessary once the flakes are under control. Keep the suds away from the eyes, of course, but you can use Nizoral to wash any skin affected by fungus (patches of seborrheic dermatitis, jock itch, athlete’s foot, and the like).
Selenium sulfide is yet another antifungal ingredient. It is found in Selsun Blue, Glo-Sel, and Exsel shampoos.
There are two other categories of dandruff shampoo. One contains coal tar (a category that includes Denorex, Ionil T Plus, Neutrogena T/Sal, and Zetar). This ingredient acts against flaking and helps quell itching as well. The other contains salicylate acid and sulfur, which loosen the flakes and help them break into smaller (and thus less visible) pieces. These are shampoos such as Meted, Pernox, and Sebulex.
It surely doesn’t make sense to try all of these medicated shampoos, or even all of the various categories. Switching back and forth among three different categories would probably be just fine. The idea is simply not to let Malassezia get too accustomed to whatever it is you are using.
Give any dandruff shampoo enough time to fight the fungus. That is, after first washing off the surface dirt with any shampoo you please, lather up the medicated shampoo and leave it on for at least 5 minutes. This is harder than it sounds. After all, you may not want to waste water in the shower, but standing around wet and shivering for 5 minutes is also not appealing. You’ll have to use your ingenuity to solve this problem, but if you can, you’ll find the dandruff shampoo is far more effective. Here’s a hint: Shampoo first, then wash the rest of your body while you let the suds sink in.
arjiJ A - D
This shampoo contains the antifungal drug ketoconazole. (Make sure you buy the medicated shampoo. Nonmedicated Nizoral A-D is also available, but it won’t fight dandruff.) Nizoral shampoo is also available by prescription at twice the strength (2 percent).
Side effects: Rash, allergic reaction. To be safe, test a spot on your inner arm before you use it on your scalp.
Downside: Relatively expensive
Cost: Approximately 80o to $1.30 per wash When you are done washing your hair, resist the urge to blow it dry, at least once in a while. Hair dryers are hard on the scalp and seem to make flaking worse.
Prescription Shampoos
A stronger formulation of Nizoral shampoo is available by prescription. Doctors have a couple of other prescription possibilities as well, in case the other options aren’t effective enough. One of these is Loprox shampoo (ciclopirox). This antifungal agent also has some anti-inflammatory activity, which is useful when skin is itchy and red.”‘ Needless to say, a prescription shampoo is more expensive than the nonprescription approaches. No head-to-head studies have been done to compare it and find out if it is also more effective.
Conclusions
Dandruff and seborrheic dermatitis both seem to result from a-reaction to yeast that normally live on the skin. Scientists don’t know why some people react while others do not, nor are they sure why Malassezia yeast seems to grow more vigorously on some people’s skin than on others’. But research has shown that making life hard for the yeast usually controls the flaking and itching that are so bothersome. If any of these remedies make matters worse, stop the treatment right away and give your skin time to recover before you try anything else. When in doubt, check with a dermatologist!
• Drench the scalp with Listerine original (amber) mouthwash before shampooing. The herbal oils and alcohol in Listerine discourage the growth of yeast on the scalp.
• Smear some Vicks VapoRub on itchy, red, scaly spots. It contains many of the same antifungal herbal oils as Listerine. It can be very difficult to remove Vicks from hair, though.
• Brew some herbal tea with sage or rosemary. Use it as a rinse after shampooing your hair.
• Slather yogurt containing live cultures on the scalp. Leave it for 15 minutes before shampooing it out. Unlike the petrolatum in Vicks VapoRub, yogurt should be fairly easy to wash out.
• Make a rinse with vinegar diluted at least two to one in water. Some people prefer apple cider vinegar, while others use the cheapest white vinegar.
• Switch from one type of dandruff shampoo to another every 6 to 8 weeks. Don’t give Malassezia a chance to adapt.
• Try using Nizoral A-D shampoo twice a week, then cut back and use it only as often as needed to keep flaking under control.
• If none of this helps, check with your doctor. Perhaps your condition is not ordinary dandruff.
*A prescription shampoo such as Loprox may help when other measures have failed.
Jul
15
PROSTATE PROBLEMS. WHERE IS PROSTATE GLAND LOCATED?
July 15, 2009 | Leave a Comment
1 What is the Prostate Gland?
This is one case where small is definitely not beautiful! A tiny gland which causes enormous problems, the prostate is
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Other than the usual proviso of leading as healthy a life as possible (see Chapter 10), there’s not a great deal you can
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and misery what is asprin in medicine . What started as a tiny part of your body that you didn’t even know you had, let alone where it was or what it
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treatment of prostate problems has come on by leaps and bounds can tramadol effect bladder control . There have been several advances in drug therapy, not to
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The latest and most attention-grabbing advance, though, is research in London which has shown that the prostate can now
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The prostate gland is a tiny part of the male body, about the size of a chestnut, yet it can cause a disproportionately
large number of problems moxifloxacin side effects . The great majority of these problems are irritating and inconvenient, and can have a dramatic
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The prostate is not just one gland sulfamethoxazole trimethoprim description . It is, in fact, a complex gland, consisting of millions of tiny glands, lined with
cells that secrete fluids, which empty into tens of thousands of tubules and ducts, and eventually into the urethra
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The prostate gland is involved in the reproductive process, in that prostate secretions in semen are important providers
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PROSTATE PROBLEMS
According to the World Health Organization (WHO), as many as 80 per cent of men are likely to experience prostate
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It may come as a surprise to you that, in spite of these alarming statistics, there are very few men who know anything at
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According to a recent MORI poll, only 32 per cent of men in the UK know anything about their prostate gland at all prozac and mania . Yet
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The animal kingdom
Most male animals have some kind of prostate gland, but animal prostate glands differ greatly from human prostate glands viagra abu dhabi .
Most mammalian non-human prostates are very different from human ones generic to asacol . Some animals actually have not one gland, but two
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IN IGNORANCE
Most men will probably have heard it mentioned in the news tapering zoloft to start lexapro . They will have heard about famous sufferers of prostate
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But by the time they reach their 50s, their 60s, and still more their 70s, the prostate will probably have taken on a
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Given this unpalatable fact, it makes sense for men to get to know a bit about their prostate gland and what can happen
to it ibuprofen and lactation . A man who has some understanding of his body, his symptoms and what they mean will be equipped to ask his doctor
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No man can afford to ignore his prostate gland canadian pharmacy meloxicam fexofenadine .
The origins of the word
The Greek words from which the word ‘prostate’ was derived by 16th-century French surgeon Ambroise Pare suggest that it
played the role of ‘doorkeeper’ to the bladder cialis cheap visa .
WHERE IT IS LOCATED
The prostate is located just below the bladder and in front of the rectum cymbalta symptons .
It encircles the outlet of the bladder, which is called the urethra, in rather the same way as the cuff encircles the arm
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WHAT IT LOOKS LIKE
The prostate gland is small and solid, about the size and shape of a large chestnut clonidine in neuropathic pain . It weighs only a few grams at birth,
when it is about the size of a garden pea, and then gains weight as it becomes larger through adolescence clomiphene citrate and my immune system . Its weight in
an adult man is about 20g tetracycline lawsuits . It measures between 1 and 11/2 inches in width accutane and unborn baby .