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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
15
Cancer of the Prostate. SYMPTOMS.
July 15, 2009 | Leave a Comment
Cancer of the Prostate
Cancer of the prostate, or adenocarcinoma of the prostate, as it is technically called, is a malignant growth occurring
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Norman Schwartzkopf and President Fran4ols Mitterand - but they are unlikely to realise just how common it is clomid and progesterone cream .
This is surprising because it is, in fact, the most common type of cancer in men in Britain celebrex and percocet . It is also the second most
common cause of death from cancer in men, after lung cancer generic to viagra . According to the Imperial Cancer Research Fund, it kills
nearly 10,000 men a year in Britain, which is four times as many men as women who die from cervical cancer taking luvox and paxil . Some 14,000
new cases of prostate cancer are diagnosed each year in Britain effexor xr no pres . But ask the average man in the street where his prostate
gland is, and the chances are he won’t be able to tell you fetal exposure to dilantin .
A DISEASE OF OLD AGE
Prostate cancer most often occurs in the elderly, though it does sometimes develop in middle age bupropion tab 300mg xl . More precisely, it is
most common in men over the age of 55, and becomes increasingly common as a man gets older raman caffeine . Nearly all deaths caused by
prostate cancer occur in men over the age of 65, while half of all cases occur in men over the age of 75 medication digoxin . Peak age is
between 70 and 80 clotrimazole betamethasone dermatitis ear .
People worry that cancer of the prostate seems to be on the increase, but this is not necessarily as sinister a prospect
as may at first appear blood clots developed while on warfarin . More screening is being done, which is bound to reveal an increase in figures dyspepsia effexor xr 300 . And it is, in any
case, more characteristically a disease of old age than any other cancer wellbutrin stimulant effects . As there are more and more elderly people in
the population today, it is not surprising that prostate cancer has become correspondingly more common too ibuprofen and tylox .
SURVIVAL RATES
The question in the mind of any man who is reading this will probably be: If I get prostate cancer, what are my chances
of survival?
The answer to this vexed question is not a simple or an obvious one caffeine breastfeeding coke . This is because it depends on so many things:
• How old you are warfarin testing kits .
• The state of your overall health, prostate apart first try sucess stories using clomid .
• At what stage the cancer was discovered singulair aerator 780 .
In a man over the age of 70, the survival rate is about 50 per cent prilosec infant . It is higher in a younger man - the younger he is,
the greater his chances of survival paxil lawyers san diego . His chances are also higher if the cancer was detected early on in its growth duracell lithium manganese batteries rc .
WHAT CAUSES IT?
The exact cause of prostate cancer remains a mystery, though the male hormone testosterone appears to have some
involvement lithium polymer battery pv use . Quite what that is, though, is not certain testosterone shot women .
Certain risk factors have, however, been identified breast cancer risperdal . Firstly, and like a great many cancers, cancer of the prostate is
known to run in families mobic 15 mg infomation . If a close relative - say, a brother or father - has cancer of the prostate, a man’s risk of’
developing the disease seems to be nearly three times greater than that of a man who does not have any family history of
the disease phenergan black box warning . If a man has more than one relative with prostate cancer - say, a grandfather or uncle as well as a brother
or father - his chances of developing the disease are as many as six times greater than that of a man who does not have
any family history of the disease evista buy online .
There do, however, seem to be other factors involved brain shiver symptoms from withdrawal effexor . Diet is one of these mrsa osteomyelitis vacomycin efficacy zyvox efficacy . The typical UK diet, for example - which is
usually low in green vegetables, fruit and pulses and high in animal fats in the form of meat and dairy products - may
well be a contributing factor lithium manganese battery charging .
According to the Cancer Research Campaign, black American men have the highest incidence of prostate cancer, with some 50
per cent more cases than in the US white male population soma muscle relax . This is probably because they have a higher than usual level of
testosterone prednisone how fast does it work .
The number of sexual partners a man has had may have a link with the development of prostate cancer, though this has not
been proved prevacid how long . In particular, the wart virus (human papilloma virus), which is usually sexually transmitted, may increase a
man’s chances of developing cancer of the prostate, in much the same way as it predisposes a woman to developing cancer
of the cervix maker of zoloft .
SYMPTOMS
Very often there are, unfortunately, no early signs of prostate cancer casodex pharmacy . which makes its early detection very difficult overnight generic viagra american express .
The great majority - up to 90 per cent - of cancers begin on the outside of the prostate, which means that they do not
usually obstruct urinary flow in the early stages of the disease, and can therefore go unnoticed for some time effects of metoprolol succ er .
And they can remain undetected for some time because prostate cancer is very slow in spreading amoxicillin trying to conceive . It may be as long as four
years before the cancer has doubled in size, and this, too, makes its early diagnosis very difficult unless people have
routine screening for the disease soft drink caffeine amounts .
In its later stages, however, prostate cancer has similar symptoms to those of an enlarged prostate clindamycin pharmacophore . It is not unusual,
in fact, for a man who is being investigated for an enlarged prostate to have cancer diagnosed wikipedia metronidazole . That is not intended to
be alarmist, however, and any man who is being investigated for an enlarged prostate should not panic fluticasone propionate high blood pressure . An enlarged
prostate is ten times more common than prostate cancer, so the odds are greatly in your favour - it’s just that the two
conditions do have similar symptoms allegra breedlove harry potter . As has already been discussed (see Chapter 5), the symptoms of an enlarged prostate
are:
• A weak, sluggish urinary stream, which may be particularly noticeable first thing in the morning; you may notice
this as a thin stream, or you may not be able to urinate as high or as far as you used to tetracycline uti mg achromycin .
• Difficulty in starting the flow of urine, known as hesitancy date cialis was released by fda .
• A tendency to stop and start urinating, known as an intermittent flow testosterone propionate or cypionate .
• The feeling that you haven’t quite emptied your bladder and that there is more to come tetracycline hydrochloride cas .
• Straining to pass water baclofen uses .
• Incontinence - this is not an inevitable part of old age, it is a sign that there is something wrong zovirax 5 .
• Dribbling of urine coin lithium batteries .
• Urinary retention cipro 500 mg .
• Pain or discomfort on passing water, known as dysuria what does flagyl do .
• Blood in the urine, known as haematuria diltia xt 240mg sode effects stoping .
• The need to rush urgently to the toilet to pass water relieve cymbalta withdrawal symptoms .
• Increasingly frequent need to pass water - perhaps as often as every two hours who use zyrtec .
• Having to get up in the night to pass water fexofenadine hcl 180 mg tab .
• The need to push or strain to pass water photograph of omeprazole 20mg .
• Blood in the semen, known as haemospermia terbinafine 250mg tablet .
There may, however, be no urinary symptoms at all prazosin maximum dosage . The first sign of the disease may be from secondary growths, or
metastases, of the cancer, which are most commonly in the bones side effects of cardizem cd . Prostate cancer has a tendency to spread to the bones,
and this happens in a high proportion of cases risks of coumadin .
Symptoms of cancer of the bone:
• Pain in the bone, which is often worse at night celecoxib poland .
• Bone tenderness no perscription buy for azithromycin .
• Brittle bones, which may suddenly break without any injury medications oxytrol dis 3.9 mg 24 .
• Fatigue generic didronel .
• Loss of appetite nursing standing orders for coumadin .
• Weight loss levothyroxine nausea dizziness .
• Anaemia apris birth control .
Bone cancer
A malignant growth in the bone can be primary, in which case it originates in the bone itself: or secondary, in which
case it has spread from cancer elsewhere in the body avandia and congestive heart failure . Secondary bone cancer, or metastatic cancer, is more common than
primary bone cancer, and prostate cancer is one of the cancers that spreads readily to the bone codeine allergy tramadol .
Bone metastases occur most commonly in:
• The spine diet for coumadin patient .
• The ribs neurontin withdrawal .
• The hips lexapro help to purchase medicine .
• The pelvis dose gabapentin pain .
• The upper legs promethazine routes of administration .
• The skull is bactrim effective for diverticulitis .
Secondary bone cancers from the prostate often respond well to hormonal treatment, including oestrogen or hypothalamic
hormones premarin price . Sometimes the most effective treatment may be by removal of the testes, or adrenal glands drink alcohol with fluoxetine capsules . The administration
of a radioactive isotope such as Metastron is used to relieve pain from bone cancer isosorbide dinitrate cream .
Jul
15
The Prostate in Sexual Activity.
July 15, 2009 | Leave a Comment
The Prostate in Sexual Activity
The prostate is part of the male reproductive system and supplies part of the seminal fluid viagra and oxycodone . It is not essential for the
man’s sexuality, though, nor even for his ability to reproduce ezetimibe simvastatin lawsuit .
When a man’s prostate is removed, male sexuality is not normally affected ripped fuel testosterone booster . His sex drive is intact, and his ability to
achieve and maintain an erection is unchanged caffeine free pepsi one .
SEMINAL FLUID
Sperm makes up only a small part of the seminal (laid asprin ec 8 . In fact most of the fluid you ejaculate isn’t sperm at all seroquel negative side effects . Most
of the fluid consists mainly of secretions from a number of glands promethazine hcl and codeine phosphate syrup . The largest of these glands is the prostate lithium hydrated .
‘The various secretions from these glands probably serve the purpose of providing the sperm with a greater motility after
they have been ejaculated, which stimulates their activity and enables them to move towards the egg get rid of caffeine jitters .
It is thought by some people that the prostate also has a lot to do with the feeling that an orgasm gives you boniva model . When a man
has an orgasm, sperm fluid from the seminal vesicles and the secretions from the prostate all mix together as semen at
the top of the urethra, just below the bladder xanax and zyrtec . A man gets an intensely pleasurable sensation when the semen floods down
the urethra into the penis erythromycin in dogs . He also gets a pleasurable feeling when the semen squirts out of the penis and into the tight
region of a woman’s vagina casa allegra rockport tx . The prostate gland can be felt, as a man’s orgasm proceeds, to contract i-liythmically, which
some people believe to be very much an integral part of the pleasure he experiences on orgasm side effects celexa long term use .
What prostate fluid contains
• Water penicillin and bismuth .
• Salts steroid and benzoyl peroxide .
• Minerals labetalol for treating pregnancy induced hypertension .
• Proteins azithromycin and eating .
• Antibodies lamictal and libido .
• Enzymes prevacid for toddlers .
• Citric acid wellbutrin withdraw .
• Fats buy domain fioricet tramadol .
• Prostaglandins, which are hormone-like chemicals omeprazole sa 20mg .
PROSTATIC DISEASE
Prostatic disease can have an effect not only on the urinary system, but also on the reproductive system seroquel prescription . The male
reproductive and urinary systems are, of course, closely linked, if only because they share the same exit route - the
penis - or, to be more exact, the urethra which runs through the centre of the penis testosterone normal range .
The prostate gland is the site at which the male sex hormone testosterone, which is made by the testicles, is broken
down clomid and robitussin . It is here that it then forms another hormone called dihydrotestosterone (DHT) abilify rx . The conversion is controlled by an
enzyme called 5-alphareductase biaxin side effects in children .
Ina study conducted by Imperato-McGinley (Science, 1974), the males in an obscure tribe in the Dominican Republic are
deficient in 5-alpha-reductase and are often mistaken for girls until they reach puberty enalapril and muscle pain . Until then, they have a very
small penis and scrotum, which suddenly enlarge at puberty, along with the development of a deep voice angiomyolipoma finasteride . These males only
ever develop a very small prostate gland, they never go bald, and they do not suffer from acne check the price on plavix medicine .
It is this genetic deficiency in 5-alpha-reductase that has enabled researchers to comprehend the role played by
dihydrotestosterone in the enlargement of the prostate gland lamictal 2006 .
Testosterone
As well as prostate enlargement, the male hormone testosterone also has several other effects on the male body digoxin level after digibind pharmacokinetics .
These include the following:
• The growth of the penis how viagra works in the body .
• The growth of testes body resisting coumadin .
• The production of sperm
• A deeper voice amiodarone and thyroid function .
• The growth of facial and body hair preventative risperdal .
• The male sex drive cialis generic pills .
• Bone growth hair loss information propecia propecia .
• Strength pseudoephedrine hydrochloride .
• Acne erythema multiforme bupropion .
• Baldness
A MAN’S GREATEST FEARS
One of man’s greatest fears on seeing a urologist and considering the prospect of a prostatectomy is what effect this
will have on his sexuality allegra gomez . The idea of having any sexual organ tampered with by a surgeon is very frightening for most
men, who worry that it may have a deleterious effect on their sex lives allegra hotel golden sands .
Many men are so frightened that their prostate problems will affect their sex lives, particularly if they have to have an
operation, that they put off going to the doctor gastroparesis caused by prozac . And even when they do eventually go to the doctor, they may be too
embarrassed to discuss sexual matters generic cialis viagra caverta buy online . Sex is something that all too many men find difficult -if not impossible - to talk
about with their doctor zyprexa and parkinson’s disease symptoms .
But this is foolish ibuprofen therapy for dogs . It is only by talking the matter over with their doctor that they will find their fears were
groundless and that they can therefore be reassured naproxen while pregnant .
The doctor’s role
To make matters worse, some doctors and urologists are sometimes insensitive on this subject metformin side effects sleeping problems . It is quite wrong of them
to assume that their patients are too old to be interested in sex tocicity of ibuprofen . Sex can play an important role in the lives of many
rnen until well into old age, and they should treat their fears as real and serious lexapro concerta interactions .
A inan who is due to have a prostatectomy should not just fret about this in secret, he should talk to his doctors about
it - his GP, his consultant, his surgeon gabapentin 100mg tablets picture . Most importantly, the doctor should respect his fears, and him for coming to
air them with him bupropion hcl sulfa .
It’s not easy for any man to do this, and if he succeeds in overcoming his reluctance to do so, the doctor should
recognise what that has cost him altace blood pressure medicine side effects . If the doctor reacts badly, it might have catastrophic effects: it might just send him
scuttling back to his burrow, his pride injured, and he might never be able to take the risk again asprin and alzhiemer .
Only when both doctor and patient can talk about this calmly, sensibly, realistically, will the patient be reassured that
it will have no effect on his sexuality - neither on his libido, nor his ability to obtain or maintain an erection, nor
on his performance lexapro morning or night .
Retrograde ejaculation
What it may well do, however, is cause him to be infertile after the operation (see Chapters 7 and 
dostinex and bodybuilding .
Even a man who has no intention of becoming a father again may find the idea of losing his potential to be a father very
distressing cube carisoprodol . A man may find this emasculating, as if it were questioning his manhood methotrexate liver cancer . He’s only lost his ability to
procreate, not his sexuality, but this can have a devastating effect on him angle closure glaucoma from topamax . This is reminiscent of a woman who regrets
the loss of her womb after a hysterectomy, even though she is beyond childbearing, and feels she has lost her femininity prevacid 15 mg .
A doctor should have the sensitivity to talk to his patient about this dilantin and keppra combined . Only with patience and understanding can he help
him come to terms with his feelings of fear and loss following beverages originally contained lithium salts .
Retrograde ejaculation will not make a man impotent, nor - in most cases - will it prevent him from having orgasms heart attacks and plavix . It
will, however, make the sensation of orgasm a different one - and, in all honesty, probably not as good a one aldactone pharmacia . Some
women, too, are disappointed by the new feeling of a ‘dry’ climax in their male partner terazosin diarrhea .
These changes in a man’s sexuality should be addressed beforehand metformin surgery . He should be told what to expect toprol side affects . A sensitive doctor
will also help a couple come to terms with their new-found sexuality lithium orotate alzheimer’s .
Impotence
It is possible, though by no means certain - nor even common -that prostatectomy may cause impotence tramadol al english . Some men are
frightened that it might have this effect, probably because they have heard tales of the old perineal prostate operation
(which is hardly ever done nowadays) or the radical prostatectomy in which the entire prostate, including the capsule in
which it is enclosed, is removed (sometimes performed for prostate cancer) kamagra leverans stockholm . In both these operations, the nerves
supplying the penis were sometimes cut, which led to a man’s impotentence hydroxyzine hcl 10 . 11′ these operations are done today, it is
usually -though not always - possible to avoid cutting these nerves diflucan cipro . The problem of impotence is therefore unlikely but
it may arise can minocycline cause weight gain .
If a man is very frightened that the operation may lead to impotence, he may actually experience a kind of psychological
impotence afterwards board carisoprodol direc dynu net href . This underlines how important it is for a man to be reassured before the operation propecia medica . If a
psychological problem does occur, a counsellor or sex therapist should be able to deal with it lamictal cause hair loss .
An excuse to avoid sex
In spite of all the evidence that prostate surgery has no effect at all on a man’s sexuality (other than retrograde
ejaculation), it does occasionally seem to happen which works better motrin or darvocet . An obvious explanation for this is that some men may use surgery as an
excuse to avoid sex, which they had stopped enjoying ages ago anyway demadex 1 mg . Occasionally, if a man is not in very good health,
a prostate operation - which is, after all, a major operation requiring a long convalescence period - may be enough to
push his sexuality over the edge ranitidine drug class .
Generally, though, most men do not have any problems with their sex lives after the operation can zyrtec raise blood pressure . In fact, a man may
actually find that his sex life has greatly improved since he had his prostatectomy, if only because he now has full
control of his bladder adderal prozac combination .
AN EROGENOUS ZONE
Some people believe that the prostate gland is a highly erogenous zone and that awareness of this can greatly heighten a
man’s sexual pleasure breastfeeding levoxyl cranio .
Many sex therapists consider that the man’s prostate gland is the equivalent to a woman’s G-spot compazine suppository . In fact the female
G-spot and the male prostate gland are located in very much the same position heart problems and imitrex .
In order to find a man’s prostate gland, proceed in the following way:
• With the man lying face down on the bed, with a couple of pillows under his hips, insert a well-lubricated finger
into his rectum, palm facing downwards cyclosporine opthalmic .
• You should feel his prostate as a firm mass, about the size of a large chestnut diflucan safety . Stroke it with your fingers reaction to wellbutrin .
• Be guided by what he tells you erythromycin op oin fougera . This should feel very pleasurable and produce intense sexual sensations soma listening . Ask him
how it feels, and do what he likes best zyprexa lilly can you break .
• Keep on stroking his prostate until he ejaculates how does brethine stop labor . Many men ejaculate while this is being done without ever
having an erection depo provera health risks .
• An alternative position to this is with the man on his back and his legs drawn right up hydrochlorothiazide and depression . In this position, the prostate
can be felt on the front wall of the rectum nexium ec .
A woman’s objections
Some women object to doing this to their lover because they are frightened that it will be messy over night tramadol . It may be, but the
lower part of the rectum is usually empty anyway, so there should not be a problem ramipril slows .
One way of dealing with this is for the woman to use a latex finger stall, which is available from the chemist to cover a
finger that has an open wound on it how do i purchace viagra . This is intended to keep the finger waterproof side effect nightmares paroxetine .
Whatever you use - a naked finger or a finger with a finger stall -you should wash it carefully afterwards lovastatin anger effects . The anus is a
breeding ground for bacteria, and it pays to be careful about hygiene prevacid sexual side affects .
Some women are frightened that they might hurt their lover when they do this does white chocolate have caffeine . It is true that the anal area is very
sensitive and they should therefore always be careful tetracycline dose acne . They should, in particular, make sure that they do not have a
sharp or jagged nail on the finger they use to do this cymbalta night sweats .
They should be careful, too, not do this if they have any open cuts on the finger used, in case of the transmission of
HIV or hepatitis B mixing imitrex with crack cocaine .