Johns Hopkins Health Alerts - Depression and Anxiety

Antidepressant Medication "Poop Out"

Wed, 11 Nov 2009 06:00:00 CST

A reader from Roswell, Georgia asks: “I have been taking 20 mg/day of Celexa (citalopram) for about a year and a half for depression. It was the first medication I tried, and it worked great. For the past two months or so, however, I haven't been feeling great. I have been sleeping a lot, crying a lot, and feeling antisocial. Is it possible for Celexa to "poop out" and just stop working over time? Should I talk to my doctor about increasing my dosage or changing medications? Or maybe this bout with depression is just extra bad and I should tough it out?” Here’s our advice.

Antidepressant tachyphylaxis -- known less formally as the "poop out" effect -- was first described in 1984 when researchers observed that some patients experienced relapse of mood symptoms on antidepressants that had previously been effective therapies. There is some suggestion that serotonin reuptake inhibitors, or SSRIs, such as Celexa, are more prone to tachyphylaxis than other antidepressants, such as tricyclic medications like nortriptyline and serotonin norepinephrine reuptake inhibitors (SNRIs) like Effexor.

When antidepressants appear to "poop out," there are four options available to the physician and patient. The first is to increase the medication dosage in an effort to boost the antidepressant effect, assuming the maximum dose is not already prescribed. For example, the maximum dose of Celexa is 60 mg daily. A common pattern with SSRIs is for there to be an initial response to a lower dose that is not sustained, requiring titration over time to higher doses. Increasing the dosage alone may be sufficient to jumpstart recovery.

The second option is to switch antidepressant medications, either to another medication within the same class or to a different class. This method has the benefit of simplicity, in that it continues to be a single medication regimen.

The third and fourth options involve augmentation of the current antidepressant, either with the addition of a second antidepressant or a non-antidepressant augmentation drug. If a second antidepressant is chosen, it is common to add a medication with a different mechanism of action. For example, if someone is already taking an SSRI, the physician might add a tricyclic antidepressant. Non-antidepressant augmentation strategies include lithium, low-dose atypical neuroleptics such as Zyprexa or Risperdal, thyroid hormone, the blood pressure medication Pindolol, or the anti-anxiety drug Buspar (buspirone).

Bottom line: In most cases like yours, the simplest intervention is to increase the dosage of the antidepressant medication you're already taking, particularly because it has been effective in the past and you're not currently taking the maximum dosage. The key to successful treatment of depression is ongoing communication between you and your physician and not settling for partial recovery or resigning oneself to "toughing it out."

What's Minor About Minor Depression?

Wed, 21 Oct 2009 06:00:00 CDT

A reader from Landmark, SC asks: My husband's primary care physician told him he has "minor depression." I understand what major depression is, but what is minor depression? Johns Hopkins answers.

Minor depression is not a formal psychiatric diagnosis. That being said, the term may indicate several possibilities. Minor depression may be used to describe a depressive episode that does not meet the formal diagnostic criteria for major depressive disorder.

Major depressive disorder consists of at least one episode of major depression, which by definition must entail at least five out of nine of the following signs and symptoms for a minimum of two weeks: depressed mood, diminished interest in all, guilty feelings, low energy, poor concentration, sleep disturbances, appetite disturbances, psychomotor agitation or retardation, and suicidality.

In addition, to qualify as a major depressive episode, one of the five criteria must be depressed mood. Lastly, there must be impairment of functioning in social or occupational spheres. If all of these criteria are not met, a patient might be described as having a "minor depression."

Minor depression might also be used to classify an episode of depression in which the signs and symptoms are present but not very severe. For example, your husband may have mild symptoms of sleep, appetite, and concentration disturbance that result in taking longer to complete tasks at work. However, if he is still able to get his work done in a reasonable amount of time and the other aspects of depression are mild, it would be difficult to give a diagnosis of major depressive disorder.

Minor depression could also be meant to describe dysthymia, which consists of a depressed mood for more days than not over a two-year time period. In addition, the individual should have two additional symptoms of depression, such as hopelessness, poor self esteem, and sleep, appetite, or concentration disturbance, to receive a diagnosis of dysthymia.

In summary, mild depression is not a formal diagnosis, but may include a subthreshold major depressive episode or chronic depressive symptoms. Depending on the particulars of the case, psychotherapy and possibly pharmacotherapy may be beneficial. Evaluation by a psychiatrist would be helpful in guiding your husband's treatment.

Insomnia: Nature or Nurture?

Wed, 09 Sep 2009 06:00:00 CDT

According to the American Academy of Sleep Medicine, about one-third of adults have symptoms of insomnia, the most common sleep disorder. In fact, insomnia is so common that many sufferers wonder if it could be inherited. Here’s what the research on insomnia and family ties shows.

From what we know so far, it looks like insomnia may very well run in families, just like diabetes and heart disease.

A study published last year in the journal Sleep reported that people who have experienced bouts of insomnia -- difficulty falling asleep and staying asleep or waking up too early -- are more likely than good sleepers to have a close relative with the condition.

About 12–15% of the population has chronic insomnia -- sleep problems that last a month or longer. In the largest study to date to evaluate insomnia and its family ties, 953 adults age 18 to 83 were surveyed multiple times about their sleep habits and the sleep habits of their parents, siblings, and children.

Just over half of the people who took the survey were classified as good sleepers, i.e., they did not report sleep complaints. About 33% experienced occasional symptoms of insomnia. Nearly 16% met all the criteria for the sleep disorder.

Participants who experienced past and current bouts of insomnia were significantly more likely than good sleepers (39.1% vs. 29%) to note that one or more family members also had experienced sleep problems.

Bottom line: So are genetics or relatives who behaviorally pass on bad sleep habits to blame? Probably a little of both. There is some evidence from smaller studies, including one that looked at twins, suggesting a genetic factor. That said, researchers are still a long way off from identifying a clear genetic marker for insomnia. There is also some evidence of a learned insomnia effect, i.e., people with bad sleep habits tend to transmit them to their children.

Pristiq: A New SNRI for Depression

Wed, 19 Aug 2009 06:00:00 CDT

Dr. Karen L. Swartz, Director of the Johns Hopkins Mood Disorders Center, answers a reader’s question about the therapeutic benefits of Pristiq, a new antidepressant: I am currently on Effexor (venlafaxine), which has a similar generic name, so I'm wondering how Pristiq differs from Effexor and other SNRIs? Chester, VT

Dr. Swartz: Pristiq (desvenlafaxine succinate) is an antidepressant in the serotonin and norepinephrine reuptake inhibtor (SNRI) class of drugs. Pristiq is indeed very closely related to Effexor (venlafaxine hydrochloride) chemically. In fact, it is metabolic byproduct of Effexor. Pristiq, like Effexor XR, is dosed once daily.

What is reported to be different about Pristiq is that the antidepressant medication can be started at a dose high enough to potentially be therapeutic. One of the great challenges with antidepressants is that, for almost all of them, they need to be started at low doses and slowly increased to a potentially therapeutic dose. Since it is impossible to predict which antidepressant will be effective for a given person, the time spent adjusting the dose can be very frustrating, especially if the antidepressant dose not eventually help.

For Pristiq, it is recommended to start with a dose of 50 mg daily, which is also typical maintenance dosage. This guideline is based on two things: data showing inconsistent improvement with dosage increments and the finding that patients are generally able to tolerate 50 mg daily as a starting dose.

Pristiq has been shown to be safe at higher doses, but a decision to increase dosage should be made in collaboration with the your psychiatrist and/or primary care physician.

Pristiq, Effexor, and other SNRI's such as Cymbalta have not proven markedly different in their effectiveness. (For that matter, there is not strong evidence that any particular antidepressant or class of antidepressants is superior to another for everyone.) For this reason, if someone is doing well on Effexor, it would be wise to consider staying on that medication rather than switching to another SNRI, including Pristiq.

Clue to the Cause of Depression in Older Men

Wed, 29 Jul 2009 06:00:00 CDT

Women are more likely than men to have depression -- that is, until age 65, when the numbers become almost equal. Why? It may have to do with the drop in testosterone levels in older men, according to recent research reported in Archives of General Psychiatry (Volume 65, page 283).

The incidence of depression is higher in older adults. The National Institute of Mental Health's Epidemiologic Catchment Area Study, which focuses on several major geographical areas, estimated that at least one million of the nation's 31 million people age 65 and older suffer from major depression, and an additional five million have depressive symptoms that are severe enough to require treatment. Now a study in the Archives of General Psychiatry sheds light on a possible cause for the increase in depression in older men.

The study included nearly 4,000 men ages 71 to 89 who were given questionnaires about their health, underwent evaluation for depression and cognitive problems, and gave blood samples to determine their testosterone levels.

Five percent of participants had depression at the start of the study. The men were then grouped into five categories based on testosterone levels; researchers found that those in the lowest quintile were significantly more likely to be depressed than those in the highest quintile -- even after adjusting for other depression risk factors such as education level, body mass index, other physical illnesses, and cognitive function.

Testosterone binds to many receptors in the body, including those in the central nervous system, which may explain this potential link between the hormone and depression. However, clinical trials are needed to determine whether testosterone supplementation may be helpful for older men with depression.

How Pets Comfort Us

Wed, 27 May 2009 06:00:00 CDT

Pets are more than just furry friends and loyal companions. Yes, they tug at our heartstrings, but they also improve our health, both mental and physical, helping us to live longer and happier lives.

Studies over the past 25 years have shown that stroking a dog or cat can lower blood pressure and heart rate and boost levels of the mood-related brain chemicals serotonin and dopamine. Heart attack sufferers recover more quickly and survive longer when they have a pet at home, and children who are exposed to pets early in life may have a reduced risk of allergies and asthma.

For people with disabilities, pets can offer a lifeline to a more normal existence: guiding the blind, hearing for the deaf, and performing tasks for those who can't do for themselves. Dogs and cats -- even a tankful of fish -- calm frazzled nerves and ease anxiety and depression, according to research. In one study, pets seemed to temper some of the psychological stress of being a caregiver to someone who is ill or suffering from dementia.

Studies performed in nursing homes and hospitals have proven that the elderly in particular can benefit from the companionship of a dog or cat. Having a pet to care for helps fill the long, sometimes aimless hours and reminds seniors to nurture themselves just as they are caring for their pets.

In one study, researchers found that quiet time with a dog made nursing home residents in St. Louis feel less lonely, more so even than visits with both a dog and other residents. The study enrolled 37 nursing home residents with high scores on a loneliness scale who were interested in receiving weekly half-hour visits from dogs. Half of the study subjects had dog-only visits. The other half shared the dog with other nursing home residents. Both groups said they felt less lonely after the canine visit, but the decrease in loneliness was much more significant among those who had the dogs all to themselves.

Bottom line: Why do pets make us feel better? One reason is that pets alter our behavior -- when they are near, we tend to calm down and speak more slowly and softly. All types of animals offer distractions from the worries of the day, because we naturally shift our attention to them when they are around. Pets also provide an opportunity to touch and stroke another living thing, which has been shown to be of value to our mental and physical health.

Depression and Your Health

Wed, 08 Jul 2009 06:00:00 CDT

Depression clearly has a harmful effect on physical health, although the biological reasons for the link between body and mind are unclear. Whatever the reasons, over the past 20 years, it has become evident that depression after a heart attack is much more than an "understandable emotional reaction" to a stressful, life-changing event -- it is profoundly dangerous, raising a person's chances of having a second, fatal heart attack.

More recently, researchers have studied the flip side of the equation -- the question of whether someone with depression is at increased risk for developing coronary heart disease (CHD) down the line. Indeed, prospective studies show that people who had no CHD but were depressed when the studies began were more likely to develop or die of heart disease. Depression also aggravates chronic illnesses such as diabetes, arthritis, back problems, and asthma, leading to more work absences, disability, and doctor visits.

Now results from a large Norwegian study suggests that depression increases the risk of death from most other major diseases, including stroke, respiratory illnesses, cancer, multiple sclerosis, and Parkinson's disease. It is also associated with accidental deaths.

Researchers gathered baseline information on physical and mental health for 61,349 Norwegian men and women, average age 48, and then noted the number of deaths and their causes during an average follow-up of nearly 4.5 years. Participants who had significant depression (2,866) had a higher risk of dying of most major causes of death, even after adjusting for age, medical conditions, and physical complaints at the study's outset.

In contrast, a diagnosis of anxiety did not increase the risk of death. However, coexisting anxiety-depression appeared to raise the risk of accidental death and suicide. The researchers theorize that depression may increase the risk of death by directly affecting the cardiovascular and nervous systems. In addition, depression may lead to poor health habits, such as smoking, alcohol abuse, and a sedentary lifestyle, and may affect people's ability to follow treatment regimens. Results reported in the journal Psychosomatic Medicine (volume 69, page 323).

How We Grieve

Wed, 06 May 2009 06:00:00 CDT

Sometimes we experience huge changes in our lives, such as the death of a loved one. These events can cause intense emotional anguish, and grieving during such life changes is a normal and healthy, if painful, process. A recent study from the Journal of the American Medical Association sheds new light on the grieving process.

Grieving often produces a wide range of feelings. The psychological process itself is a means for the mind to adjust, over time, to the acute sorrow of a loss. Grieving also allows us to accept the finality of the loss, to experience a full range of feelings as a result of the loss, and to adjust to our changed lives. The end of grieving does not entail forgetting; rather, it usually comes with the acceptance of our loss.

A recent study published in the Journal of the American Medical Association (Volume 297, page 716) says that the dominant emotional responses for most people after the death of a loved one are acceptance and yearning for the deceased -- not disbelief, as proposed by the traditional stage theory of grief. While the predominant initial reaction is disbelief for those whose loss is due to a sudden, traumatic death, the same is not true for those who lose someone after an extended illness.

Investigators analyzed data on 233 people participating in the Yale Bereavement Study who had lost a spouse (84%) or an adult child, parent, or sibling (16%). They found that disbelief peaked at one month post-loss and then declined. Yearning peaked at four months post-loss, anger at five months post-loss, and depression at six months post-loss. Acceptance of the loss increased throughout the three-year observation period. At all stages, acceptance was greater than disbelief, yearning, anger, or depression. Likewise, yearning was greater than disbelief, anger, or depression, while depression was greater than anger.

Individuals who continue to have negative emotions or experience depression beyond six months after their loss may be having a difficult time adjusting and could benefit from further psychological evaluation.

What is PTSD?

Wed, 15 Apr 2009 06:00:00 CDT

In a recent issue of The Johns Hopkins Depression and Anxiety Bulletin, Dr. O. J. Bienvenu, associate professor of psychiatry at Johns Hopkins, talked about post-traumatic stress disorder or PTSD – an increasingly common condition.

Q. What is the difference between a normal reaction to a traumatic event and PTSD?

A. Individuals can experience a wide array of reactions to a traumatic event, ranging from relatively mild to severe emotional responses that create major disruptions in a person's life. It is important to remember that most emotional and behavioral responses are normal reactions to an abnormal event. It is very common for people to experience anxiety, fear, shock, and grief, as well as emotional numbness and personal or social disconnection for several weeks.

For most people, the emotional and behavioral responses to a trauma gradually diminish over time. It is often helpful to speak with family and loved ones about what happened, express one's feelings about the event, and get support from trusted friends and colleagues and perhaps a mental health professional. For some people exposed to trauma, disturbing symptoms can persist or even worsen, developing into the syndrome known as PTSD. A syndrome is a constellation of symptoms that consistently occur together and thereby define a condition.

The symptoms that define PTSD must last at least one month for a diagnosis of PTSD and may include:

Recurrent, intrusive, distressing dreams and memories of the trauma

A sudden sense that the event is recurring; experiencing flashbacks

Extreme distress when confronted with events that symbolize or resemble the trauma

Attempting to avoid thoughts, feelings, and activities associated with the event

Inability to remember important aspects of the trauma

Markedly diminished interest in important activities

Feelings of detachment and estrangement from loved ones

A sense of a foreshortened future

Insomnia

Extreme irritability

Inability to concentrate

Hyper vigilance or an exaggerated startle response

Q. How do you define "trauma"?

A. The Diagnostic and Statistical Manual of Mental Disorders DSM-IV (Fourth ed.) -- the primary guidebook in the U.S. for classifying and diagnosing mental disorders --defines a traumatic experience as one that involves a threat of death or serious injury and inspires intense fear, helplessness, or horror. The victim may experience the trauma directly, witness it first hand, or be confronted with it in some other way.

The phrase "confronted with it in some other way" is somewhat controversial. It allows many kinds of events to "qualify" as traumatic; i.e., merely hearing about a traumatic event could be considered "being confronted with it."

Not all traumas are alike, and people's reactions to trauma vary greatly. The most common traumatic events that trigger PTSD include violent personal assaults such as rape or mugging, military combat, accidents, and human-caused or natural disasters (e.g., the attacks of 9/11 and Hurricane Katrina).

Dr. Swartz Talks About Situational Depression

Wed, 11 Feb 2009 06:00:00 CST

Q. How would you suggest people deal with situational depression? If a person is depressed because of world events or because he or she is going through a divorce or has been fired, is the person treated differently than someone who is depressed without any specific cause?

A. I hear this question quite often and think it's extremely important to point out the similarity between depression and other medical conditions such as asthma. An asthma attack may be triggered by something in the environment (such as allergens from house dust mites and pets) but may also occur with no obvious trigger. Either way, you treat the attack the same way. Depression is no different.

Major depression is characterized by a constellation of symptoms: low mood (including sadness or apathy), changes in sleep patterns, decreased level of interest in formerly pleasurable activities, feelings of self-criticism or guilt, decreased energy, decreased concentration, changes in appetite, the sensation of feeling sluggish or mentally slowed down, and possibly thoughts of dying or actively harming oneself. These symptoms may be triggered by some outside influence or life event or may seemingly occur out of the blue, without specific cause.

Once a person has been diagnosed as having depression, it is the severity of the symptoms that determines the course of action, not whether it is "situational" or "endogenous" (biological).

If a person has mild to moderate depression, the physician and the patient may choose together to begin with psychotherapy alone. This may take the form of cognitive-behavioral therapy, interpersonal therapy, or psychoanalysis. If the person does not improve, or worsens, the physician may suggest a trial of medication.

Of course, once a person is stable, factors that caused depression in the first place become more important. It is necessary to identify triggers and attempt to change them or modify one's response to them in the future to decrease the likelihood of relapse. It is also imperative to recognize that once a person experiences a major depressive episode, the rate of relapse is relatively high and in no way reflects a failure or commentary on the strength of the sufferer. Some people will never experience relapse of their depression.

Either way, identifying the signs and symptoms of depression and getting into treatment early can significantly decrease the length of the depressive episode. Untreated episodes last, on average, six months, while treated episodes last approximately three months. If someone has had a previous episode of major depression and knows that he or she is facing a potential trigger, it is helpful to begin speaking with a therapist or physician right away for help in responding to that trigger.

Is Your Depression Triggered By Stress?

Wed, 25 Mar 2009 06:00:00 CST

Each issue of our popular Johns Hopkins Depression and Anxiety Bulletin contains Grand Rounds, a lively question and answer section. Here's a question from a subscriber in New York.

Q. If your depression is triggered by stress, should it be treated with medication?

A. The relationship between mood disorders and stress is complicated, but we do know that they are closely interconnected. Stressful events can potentially cause changes in brain chemistry that predispose people to depression and anxiety.

It is also possible that some people's brain chemistry is already vulnerable to depression, and a stressful event -- such as the death of a loved one, moving to a new town, or losing a job -- triggers a depressive episode.

An acutely stressful event or chronic stress may spark depression by prompting feelings of helplessness and negative self-talk, especially if an individual has experienced major depression in the past.

The issue of whether medication is needed for stress-induced depression is also complex. No one should automatically be prescribed antidepressants for any problem. Your doctor should perform a physical examination and ask about your symptoms and medical history before recommending a course of treatment. In many cases, antidepressants have a crucial role in treating depression triggered by stress.

Cognitive-behavioral therapy (CBT) may also help in cases of stress-induced depression. A Canadian study showed that people who recovered from a major depressive episode through medication were more likely to fall back into negative thought patterns than people who had treated depression with CBT. The ability to recognize dysfunctional thinking and disengage from such thoughts can be a valuable tool.

Men and the Blues

Wed, 21 Jan 2009 06:00:00 CST

Is depression really less common in men than in women? Researchers are beginning to wonder. In fact, some experts believe that depression may actually be just as common in men as in women but is often overlooked because of its different symptoms.

Rather than feeling sad, weepy, worthless, or guilty, as women usually do, men are more inclined to get angry and irritable, feel an increasing loss of control over their lives, take greater risks, become more aggressive, and complain about problems at work. But the consequences of depression in men -- and of not being diagnosed and treated -- can be even more dangerous than for women.

Tragically, men are four times more likely than women to commit suicide. And while depression is associated with a greater risk of coronary heart disease in both genders, a study in the Archives of Internal Medicine shows that only depressed men, not depressed women, suffer a higher death rate from heart disease.

Researchers believe that men are more vulnerable than women to stressful life changes that can trigger depression, such as divorce, loss of a spouse, unemployment, or retirement. All too often, men fail to get treatment because they may not recognize the symptoms of depression or, even if they notice something is wrong, they can't admit they have a problem for fear of being perceived as "weak" or "dependent."

Typically, when men try to cope with depression on their own, they often become argumentative and combative, withdraw from relationships, engage in dangerous sports or unprotected sex with multiple partners, and self-medicate with alcohol or drugs. Ultimately, these risky behaviors only make the condition much worse.

The stigma surrounding depression is lessening in this country, even for men, as researchers are learning about the physical basis for depression -- it's not a sign of weakness, but rather a brain disorder that can be treated. Because of the change in thinking, men are slowly coming around to the idea that it's okay to get help for a mental illness. So if you've noticed that you're feeling more irritable or withdrawn than usual, be sure to tell your primary care doctor about it. He or she can perform tests to check for illnesses that could be causing depression, assess whether your medications are a contributing factor, and evaluate the need for antidepressant medication or psychotherapy.

Bottom line on men and depression: Assistance is readily available in a variety of treatments that can help manage depression and make you feel better. The good news is that men who receive treatment respond as well as women do to medication and psychotherapy. There is no disgrace in seeking help -- and no one except you and your doctor needs to know you're doing so. The only shame is in letting outdated notions about depression and masculinity stop you from taking advantage of the support that is available.

Spinning Out of Control With GAD

Wed, 31 Dec 2008 06:00:00 CST

Generalized anxiety disorder (GAD) is characterized by excessive, recurrent, and prolonged anxiety and worrying. People with generalized anxiety disorder typically agonize over everyday concerns, such as job responsibilities, finances, health, or family well-being or even such minor matters as household chores, car repairs, being late for appointments, or personal appearance. The focus of anxiety may shift frequently from one concern to another, and sensations may vary from mild tension and nervousness to feelings of dread.

Generalized anxiety disorder affects 6.8 million adults (3.1% of adult Americans) each year. Although people with generalized anxiety disorder know that the intensity, duration, and frequency of their anxiety and worry are out of proportion to the actual likelihood or impact of the feared event, they still have difficulty controlling their emotions.

Perpetual anxiety may impair concentration, memory, and decision-making ability, decrease attention span, and lead to a loss of confidence. Normal activities, such as working, socializing with friends, and maintaining intimate relationships, may become difficult or even impossible.

Generalized anxiety disorder may also produce a range of physical symptoms, including heart palpitations, restlessness, sweating, headaches, and nausea. Some generalized anxiety disorder sufferers, not realizing that generalized anxiety disorder is a treatable illness, become accustomed to their condition and assume that it is normal to feel on edge all the time. But the constant anxiety can lead to alcohol or drug abuse. The physical symptoms of generalized anxiety disorder, along with alcohol or drug abuse, are often what finally compel a person to seek treatment.

Despite its more chronic course, generalized anxiety disorder responds better to treatment than does panic disorder. Psychotherapy helps many people, either by itself or in combination with medication. In addition, relaxation techniques, such as deep breathing exercises or meditation, may relieve symptoms of generalized anxiety disorder.

The antidepressant medications duloxetine (Cymbalta), escitalopram (Lexapro), Paxil, and Effexor are FDA approved for the treatment of generalized anxiety disorder, but other serotonin and norepinephrine reuptake inhibitors, SSRIs, tricyclics, benzodiazepines, and BuSpar are also commonly used to treat generalized anxiety disorder.

Treatment Alternatives For Depression and Anxiety

Wed, 10 Dec 2008 06:00:00 CST

In this Health Alert, Dr. Karen L. Swartz, Director of the Mood Disorders Clinic at Johns Hopkins, answers a patient's question: What can I do, in addition to medication and therapy, to alleviate depression and anxiety?

Dr. Swartz answers: Many lifestyle changes can help lessen depression and anxiety symptoms. To start, a healthy diet can contribute to good mental health. A low level of omega-3 fatty acids, found in fatty fish such as tuna and salmon, has been associated with depression, so eating more of these fish may help improve your mood.

Studies have also shown that low levels of the B vitamin folate are linked to depression and may prevent people from responding optimally to antidepressants. Supplements at doses of 400–800 mcg can be of benefit -- although you should ask your doctor before trying any supplements to be sure they won't interact with medications you're taking. Getting adequate sleep is also important to reduce depression: People who don't get enough rest tend to be irritable and moody, which can trigger major depressive episodes.

Finally, exercise is a key ingredient of a comprehensive program for depression and anxiety. Even though it can be difficult to motivate yourself to be physically active when you're feeling sad and lethargic, studies show that even taking a short, 10-minute walk may improve your mood and life depression.

Mind-body exercises such as yoga may be particularly beneficial because they force you to breathe deeply, circulating oxygen to all parts of your body and potentially releasing endorphins that may help you feel better and more invigorated.

Managing Your Weight on Antidepressants

Wed, 29 Oct 2008 06:00:00 CST

While recovery from mood disorders such as anxiety and depression can be lifesaving, weight gain often can be an unwanted side effect of treatment for many people. In this Health Alert, Johns Hopkins provides nine practical strategies to head off unwanted weight gain.

Psychiatric medications including antidepressants, mood stabilizers, and antipsychotics may increase weight by stimulating the appetite or slowing the body's metabolism, and that gain can range from minimal (a few pounds) to significant (up to 50 pounds).

Such rapid weight gain may increase the risk of many health conditions associated with being overweight, such as high blood pressure, diabetes, heart disease, arthritis, and some types of cancer. Despite the fact that many psychiatric medications have weight gain as a side effect, that does not mean it's a fait accompli. Be aware of the potential for weight gain and follow these strategies to head off extra pounds:

Weight Loss Strategy 1: Weigh yourself weekly and keep a diary of your weight so you can notice small increases quickly and take steps to counter further gains. Also keep a food diary for an accurate gauge of how much you're really eating on a daily basis.

Weight Loss Strategy 2: Avoid or limit high-calorie, high-fat foods.

Weight Loss Strategy 3: Eat smaller portions -- and smaller meals and snacks overall.

Weight Loss Strategy 4: Don't keep large quantities of junk foods in your home. If you need to snack, choose healthy foods such as fresh fruit or vegetables or unbuttered popcorn.

Weight Loss Strategy 5: Eat slowly. Many people eat too quickly -- the brain needs about 20 minutes to recognize that the stomach is full , so if you eat too fast, you'll be apt to consume more calories than you need to satisfy your hunger.

Weight Loss Strategy 6: Don't skip meals. Going for long periods of time without food only serves to make you hungrier in the long term and more likely to overeat once you do eat.

Weight Loss Strategy 7: Exercise every day to counteract any extra calories you're consuming and give a boost to your metabolism. Try resistance training and aerobic exercise. To build muscle, lift weights or use resistance machines three times a week.

Weight Loss Strategy 8: Drink frequently. Hunger is one of the symptoms of dehydration, so quench your thirst with calorie-free beverages such as water, seltzer, diet soda, and decaffeinated coffee and tea.

Weight Loss Strategy 9: If all else fails, talk to your healthcare provider about switching to a medication that is less likely to cause weight gain or adding another one that might help avoid weight gain. Don't stop taking your medication without discussing it with your doctor, as your depression or anxiety may return or you may experience withdrawal side effects.

Antidepressants and Personality Changes

Wed, 08 Oct 2008 06:00:00 CDT

If you take antidepressant medication, you may wonder: Will medication change my personality or who I am? In this Health Alert, Dr. Karen L. Swartz, Director of the Mood Disorders Clinic at Johns Hopkins, answers this important question that's on the minds of many patients.

Dr. Swartz answers: Antidepressant and antianxiety medications don't alter your personality, but they may change your interactions with others. For example, depending on your initial symptoms, they may make you feel less anxious, sad, moody, irritable, or lethargic. That can help you get along with others better and be more productive and engaged in life.

The medications don't artificially make you go from sad to happy; rather, they correct the chemical imbalance that, in turn, has thrown your emotional reactions out of balance. You should still be able to experience mood changes.

Sometimes, individuals taking antidepressant medication experience a sense of numbness, apathy, or dulling of moods. This side effect is not a goal of the medication. It may mean that your depression has been partially treated and the dull mood will lift with time, or that you need to adjust your dosage.

It could also mean that this particular medication is not the right one for you, and switching to another medication might produce better results. You also may not have received the correct diagnosis: For instance, you may have been diagnosed with depression when you are actually suffering from bipolar disorder, which requires a different approach to treatment. That's why it's imperative to be aware of your moods. If you feel like you're just not yourself when you're taking a medication, be sure to discuss it with your doctor.

Can Taking an Antidepressant Make Me Suicidal?

Wed, 17 Sep 2008 06:00:00 CDT

Suicide attempts or suicidal thoughts are common symptoms of depression, and the risk of suicide may increase as depression begins to respond to treatment because the person might regain just enough energy and motivation to follow through on a suicidal urge. This discussion addresses the question: Can Taking an Antidepressant Make Me Suicidal?

Whether antidepressants raise suicide risk has been a hotly contested issue since the U.S. Food and Drug Administration (FDA) issued black-box warnings that they could increase suicide risk in children and teenagers, then extended the risk to adults. On the other hand, suicide remains a risk of untreated depression, and research suggests that SSRIs decrease suicide risk by improving symptoms, while the increased use of fluoxetine (Prozac) in the United States has been linked with a lower suicide rate.

The risk of antidepressants increasing suicidal thoughts in those with severe depression appears to occur during the first few treatment weeks or when changing the dose. At this time, when the medications might not yet be having an effect, depression and suicidal thoughts may worsen. Also, when some individuals begin to respond to the medication, they may have just enough energy and motivation to commit suicide. In addition, people with bipolar disorder who have been misdiagnosed with depression and given antidepressants may be at greater risk for suicide.

A good strategy is to stay in close contact with your healthcare provider, family, and friends when you start on an antidepressant or if your dose is adjusted so that they will notice any warning signs if your symptoms worsen. It’s always a good idea, too, to engage in some form of talk therapy, which has been shown to enhance the effectiveness of antidepressants.

Talking About Social Phobia

Wed, 16 Jul 2008 06:00:00 CDT

In this excerpt from a recent Depression and Anxiety Bulletin, psychiatrist Emily A. Bost-Baxeter, M.D. explains social phobia and discusses treatments.

Q. Where do you draw the line between shyness and social phobia? I get overwhelmed with anxiety in many social situations. It has affected my career and my ability to socialize and date. I am wondering whether medication could help me. I'd appreciate your input. Seattle, WA

A. A phobia, in general, is an irrational, intense, persistent fear of an object or a situation. Social phobia, also called social anxiety disorder, involves an irrational, intense, persistent fear of social situations in which embarrassment can occur. Individuals with social phobia are overwhelmingly concerned about being watched or judged by others and are exceedingly anxious and self-conscious in social situations. This anxiety frequently produces physical symptoms including sweating, blushing, nausea, shortness of breath, racing heart, and panic attacks, which often make the individual even more self-conscious.

Treatment for social phobia involves medication and psychotherapy. Medication management ranges from antidepressants (especially serotonin reuptake inhibitors, such as Paxil, Zoloft, and Effexor, which are used to reduce anxiety in general) to medications used specifically for stressful, social situations (benzodiazepines). Beta blockers, a type of blood pressure medication, are helpful in reducing the physical symptoms of anxiety by lowering heart rate and decreasing blushing. Reducing these physical symptoms helps patients to feel less self conscious.

Psychotherapy, particularly cognitive behavioral therapy, is as important as medication management for the treatment of social phobia. Cognitive behavioral techniques specifically aimed to help social phobia include relaxation training, gradual exposure to feared situations, and cognitive talk therapy, in which an individual learns to replace fearful thoughts with more realistic thoughts.

An evaluation by a primary care physician or a psychiatrist is necessary to exclude medical illnesses that can cause anxiety and to determine what type of treatment would be most helpful. If the doctor concludes that medication is not necessary, engaging in cognitive behavioral therapy to learn effective coping skills for anxiety would certainly be beneficial.

Research Update on Depression and Anxiety

Wed, 27 Aug 2008 06:00:00 CDT

Which comes first: depression or anxiety? This is the question researchers have begun to answer in a new study reported in the Archives of General Psychiatry.

It has been believed that generalized anxiety disorder (GAD) typically precedes the development of depression. However, researchers now assert that depression occurs before anxiety as frequently as anxiety manifests before depression, and that the two disorders often develop at the same time.

The observations are from a long-term New Zealand study that followed 1,037 people and examined them for anxiety and depression at seven intervals between ages 11–32. In 37% of those diagnosed with depression, anxiety surfaced before or at the same time as depression, while in those diagnosed with anxiety, depression began before or concurrently with anxiety in 32%. Seventy-two percent of lifetime anxiety cases had a history of depression, while 48% of lifetime depression cases had anxiety. As adults, 12% of the participants had been diagnosed with both GAD and major depressive disorder; of these people, 66% had recurrent depression, 47% had recurrent anxiety, 64% had used mental health services, 47% had taken psychiatric medication, 8% had been hospitalized, and 11% had attempted suicide.

The authors suggested that the lifetime prevalence of coexisting anxiety and depression is probably higher than typically estimated, and that the two conditions could be classified in one category of distress disorders. [This study was reported in the Archives of General Psychiatry, Volume 64, page 651.]

14 Signs of Bipolar Disorder

Wed, 04 Jun 2008 06:00:00 CDT

When properly diagnosed, bipolar disorder can be managed effectively with medications and therapy. In this excerpt from a recent Depression and Anxiety Bulletin, medical editor Karen L. Swartz, M.D. reviews 14 symptoms of bipolar disorder.

Formerly known as manic-depressive illness, bipolar disorder is a mental illness characterized by alternating periods of mania and major depression. Typically, the mood of a person with bipolar disorder will swing from overly "high" and irritable to sad and hopeless, and then back again, with periods of normal mood in between.

Manic episodes are characterized by a distinct period of abnormally and persistently elevated, expansive, or irritable mood. The episodes, with their restless energy and volatile mood swings, are severe enough to cause trouble at work and home. Episodes of milder manic symptoms are called hypomania.

Men with bipolar disorder tend to have more manic episodes; women are more likely to experience depressive episodes. The time between cycles can vary greatly. Bipolar disorder can begin with a bout of either depression or mania, but about two-thirds of bipolar disorder cases start with a manic episode, and mania tends to predominate. Signs and symptoms of mania include:

Excessively "high," overly good, euphoric mood

Extreme irritability

Increased energy, activity, and restlessness

Racing thoughts and talking very fast, jumping from one idea to another

Distractibility and inability to concentrate

Diminished need for sleep

Unrealistic, grandiose beliefs in one's abilities and powers

Poor judgment

Spending sprees

A lasting period of behavior that is distinctly different from usual behavior

Increased sexual drive

Abuse of drugs, particularly cocaine, alcohol, and sleeping medications

Provocative, intrusive, or aggressive behavior

Denial that anything is wrong

What To Do When Your Antidepressant Doesn't Work

Wed, 25 Jun 2008 06:00:00 CDT

If you’re on an antidepressant and it’s not working, don’t give up on it: You may need a higher dose, a longer duration of therapy, a different antidepressant altogether, or a combination of medications. That’s the important lesson to learn from a large, six-year, four-step government study called the Sequenced Treatment Alternatives to Relieve Depression trial, or STAR*D. In fact, the researchers found that systematically trying these treatment options can lead to a remission in symptoms in up to half of severely depressed, treatment-resistant patients.

The STAR*D study, which looked at the use of popular antidepressants in people with chronic depression (lasting, in some cases, 15–16 years), is the first to provide "real world" scientific data on what to do when someone doesn't respond to a particular antidepressant, has severe depression, or suffers from multiple mental and physical ailments. These types of treatment-resistant patients are not typically included in antidepressant drug trials sponsored by pharmaceutical companies.

Here are nine important take-home messages from the STAR*D study:

One antidepressant treatment does not fit all. You may need to try several medications to find a drug regimen that works for you. What fits one person may not fit your particular biology.
Persevering through several different treatment attempts, as arduous as that may be, can improve results for many people.
At standard doses of the most commonly used class of antidepressants -- selective serotonin reuptake inhibitors (SSRIs) -- 30% of patients with severe depression achieve remission with the first medication prescribed.
It often takes 12 weeks to achieve an adequate response to an antidepressant, not the standard four to eight weeks that most doctors and mental health specialists were previously using to guide decisions.
If the first choice of antidepressant does not provide adequate symptom relief, switching to a new drug is effective about 25% of the time.
Switching from one SSRI to another is almost as effective as switching to a drug from another class.
If the first choice of an antidepressant does not provide adequate symptom relief, adding a new drug while continuing to take the first medication is effective in about one-third of people.
For people who don’t respond to first-line therapy with an SSRI, adding a second drug to the SSRI drug regimen appears to be slightly better than completely switching medications.
For those who don’t respond to switching to a new antidepressant or adding a second drug, trying a third medication can still help about one in five people.

Linking Obesity and Depression

Wed, 14 May 2008 06:00:00 CDT

Does depression lead to poor health … or is it the other way around? Recent research explores the relationship between obesity and mood disorders, including depression, bipolar disorder, panic disorder, and agoraphobia.

Depression clearly has a harmful effect on physical health, although the biological reasons for the link between body and mind are unclear. It may be that depression affects health because people develop a fatalistic attitude and stop taking care of themselves.

Whatever the reasons, over the past 20 years, it has become clear that depression after a heart attack is much more than an “understandable emotional reaction” to a stressful, life-changing event -- it is profoundly dangerous, raising a person’s chances of having a second, fatal heart attack. Depression also makes chronic illnesses such as diabetes, arthritis, back problems, and asthma worse, leading to more work absences, disability, and doctor visits.

Recently an interesting study reported in the Archives of General Psychiatry (Volume 63, page 824) indicates that being obese is associated with about a 25% increased risk of major depression, bipolar disorder, panic disorder, and agoraphobia (a fear of being in public places).

In-person interviews were conducted with 9,152 people nationwide. The interviews included an assessment of a range of mental disorders and self-reports of height and weight. Obesity was defined as a body mass index (BMI) of 30 or greater. The lifetime risk of mood disorders was 18.3% among people with a BMI below 30 and 22% among people with a BMI of 30 or above. Men and women were equally affected, despite the fact that previous research suggested the link existed only in women. The risk was greatest for non-Hispanic white people and college graduates.

In contrast, substanceuse disorders were 25% less likely to affect obese people. The results of this study do not mean that obesity causes mood disorders, such as depression or that mood disorders cause obesity, but there is clearly an association between the two conditions. It’s possible that causality may be proven in the future. After all, increased appetite and weight gain are common symptoms of depression, and the stresses associated with obesity may lead to depression.

Finding the Courage To Seek Help for Depression or Anxiety

Wed, 02 Apr 2008 06:00:00 CST

Are you feeling down, sad, or anxious? For many people the biggest obstacle to recovery is the perceived stigma of appearing weak or vulnerable and needing professional help. Johns Hopkins discusses this common concern and offers advice.

Being clinically depressed or anxious is not a sign of mental weakness. Nor is it a normal part of aging or an inevitable consequence of having other health problems such as heart disease or diabetes. Rather, depression and anxiety are true medical illnesses, caused by biological changes in the brain. The good news is that both conditions can be treated effectively by a health professional, whether it be your family doctor, a therapist, or a psychiatrist. For many people, however, the biggest obstacle to recovery from depression or anxiety is convincing themselves to seek help in the first place.

Many people worry that they will be viewed as weak, vulnerable, abnormal, or troubled if they admit to depression or anxiety or to seeing a mental health professional. This is especially true for those of us who grew up in the era before people talked openly about mood disorders, when few medications were available to treat anxiety and depression, and when therapy was anything but commonplace.

A landmark survey of 9,282 people published in the Archives of General Psychiatry showed that one in four adults have symptoms of at least one mental disorder each year -- typically anxiety or depression -- and nearly half of all Americans suffer from a mental disorder at some point during their lifetime. Fortunately, this survey also highlighted how the stigma of anxiety and depression is beginning to fade: Today, 41% of people with anxiety or depression seek treatment, compared with only 15% in the mid-1990s and 19% in the mid-1980s. The fact is that Americans are more comfortable than ever before with acknowledging anxiety and depression as real medical problems that can and should be treated -- not only for mental health, but for overall health. Indeed, research strongly suggests that emotional and physical health are closely entwined.

Beyond improving mood, undergoing therapy can boost your immune system and help to relieve related symptoms such as pain, fatigue, and nausea. Still, if you’ve waited a long time to seek care, you’re not alone. In the survey, those with depression waited eight years on average, and those with generalized anxiety disorder, nine years. Older people and men tended to wait even longer to seek care, even after recognizing the symptoms.

Why the delay? It isn’t only the fear of being stigmatized. Many people may think – incorrectly -- that there is no real help for their problem. Others may be concerned about the cost of mental health care. Studies about anxiety and depression show that these reasons are not valid, so don’t let them deter you from seeking help.

The bottom line is that you don’t have to live with depression or anxiety. There is no shame in seeking help -- and no one needs to know but you and your doctor if discretion is important to you. The only shame is in letting outdated notions about depression and anxiety stop you from taking advantage of the help that is available.

Mixing Wine With Antidepressants

Wed, 12 Mar 2008 06:00:00 CST

Is it safe to drink wine or another alcoholic beverage if you take antidepressant medication? In this Q and A from a recent issue of the Depression and Anxiety Bulletin, Dr. Karen L. Swartz responds to a reader’s question.

Q. I have been drinking wine with my dinner for more than 30 years. Now that I am taking an antidepressant for the first time, my wife has told me that I should not drink any more wine. Although my doctor never mentioned this, my wife’s brother (who takes antidepressants) told her that alcohol of any sort could interfere with the antidepressant. Is there an interaction between antidepressants and two glasses of wine a night? Frederick, MD

A. Alcohol does not mix well with mood disorders for a variety of reasons. Although there is not a hard and fast rule about how much alcohol is safe to drink while taking antidepressants, generally it is recommended that alcohol consumption be kept to a minimum.

Alcohol is a chemical depressant that can worsen or destabilize one’s mood. Some patients report that alcohol seems to alleviate anxiety or even helps their depressive symptoms. While alcohol may provide “an escape” from feeling bad temporarily, evidence shows that it significantly worsens the course of all mood disorders in the long run. Alcohol can essentially negate the effect of antidepressants and mood stabilizers. When a person is diagnosed with major depression, it is always a good idea to stop drinking alcohol entirely for several months to see how this affects mood. Many individuals who stop drinking alcohol completely find that this alone improves their mood dramatically.

In addition to affecting one’s mood, alcohol significantly disrupts sleep. Individuals who drink alcohol regularly have abnormal sleep studies with more periods of wakefulness and less restorative, slow-wave sleep. Disrupted, restless sleep is not only a symptom of depression, but it also makes anyone feel weary and worn out. Thus, because consistent, good sleep is imperative to the treatment of mood disorders and to vitality in general, it is important to limit alcohol consumption to prevent sleep problems.

Light Therapy and Wellbutrin XL for SAD

Wed, 30 Jan 2008 06:00:00 CST

Now patients with seasonal affective disorder have two effective therapies to relieve depression in the winter months – light therapy and the antidepressant, Wellbutrin XL.

At this time of year, changes in the amount of daily sunlight cause changes in the body’s internal biological clock, known as circadian rhythm. This rhythm is a 24-hour cycle that affects our eating and sleeping patterns, brain wave activity, hormone production, and other biological activities. In some people, less daily sunlight and changes in circadian rhythm can bring about depression. One theory is that the relative lack of sunlight during these times may alter brain levels of certain mood-related chemicals.

If you have SAD, what can you do?

Light Therapy

Some people with seasonal affective disorder can be successfully treated with exposure to bright light. In one study, 57% of 191 people with SAD responded to light therapy. In another study, light therapy was comparable in effectiveness to antidepressant therapy but worked faster and caused fewer side effects.

Light therapy involves sitting in front of a bank of full-spectrum fluorescent lights for 30–60 minutes each day. Improvement can often be seen within a few days, with symptoms disappearing after two to three weeks. Continued light therapy is needed to prevent a relapse.

Wellbutrin XL

The FDA has approved bupropion HCL extended-release tablets (Wellbutrin XL) for the prevention of major depressive episodes in people with a history of SAD. Wellbutrin XL is the first drug officially approved for SAD.

The efficacy of Wellbutrin XL for the prevention of SAD episodes was demonstrated in three double-blind, placebo-controlled trials -- the gold standard of medical research -- in adults with a history of recurrent major depressive disorder in autumn and winter. Treatment was started before the onset of symptoms in the autumn (September to November) and was discontinued following a two-week taper starting the first week of spring (fourth week of March).

In these trials, the percentage of patients who were depression free at the end of treatment was significantly higher for those on Wellbutrin XL than for those on placebo. Combining data from all three studies, the overall rate of people depression free at the end of treatment was 84% for those on Wellbutrin XL, compared with 72% for those on placebo.

These findings have not surprised psychiatrists and primary care physicians, who have long been using antidepressant drugs off label for treating SAD. But the approval of Wellbutrin XL by the FDA adds credibility to the treatment approach.

Religion and Panic Disorder

Wed, 19 Dec 2007 06:00:00 CST

For patients with phobias or panic disorder, strong religious belief may help to quell symptoms.

The treatment of panic disorder often involves both psychotherapy and medication. Now a study reported in the journal Depression and Anxiety (Volume 23, page 266) shows that people with panic disorder who perceive themselves as being religious are more likely to experience improvements in their panic symptoms than people who rank religion or spirituality as unimportant to them.

The study enrolled 56 people with panic disorder and had them participate in group cognitive-behavioral therapy sessions for a year, during which they reviewed their panic symptoms, learned relaxation techniques, and discussed dysfunctional thinking patterns that contributed to their panic attacks. Some of the patients were also taking antianxiety medications.

The investigators assessed the participants’ ratings of the importance of religion, perceived stress, self-esteem, sense of control over one’s life (mastery), and social isolation at the start of the study, at six months, and at 12 months.

Placing a high value on religion was more important in predicting improvements in panic symptoms than age, gender, lifetime presence of moderate mania symptoms, self-esteem, mastery, and feeling socially isolated. Those who rated religion as very important had fewer anxiety, panic, and phobia symptoms and less perceived stress than other participants.

Previous research suggests that engaging in organized religious activities leads to many health benefits, such as reduced reliance on alcohol. The social aspect of attending religious functions now also appears to help quell panic and anxiety.

Trends in Psychotherapy

Wed, 20 Feb 2008 06:00:00 CST

In the place of Freudian psychoanalysis is a trend toward short-term cognitive-behavioral therapy and a new kind of therapy, called acceptance and commitment therapy.

One of the newest therapies to emerge -- acceptance and commitment therapy (ACT) -- is considered a third-generation behavioral therapy (traditional behavioral therapy being the first generation and cognitive-behavior therapy the second).

Championed by psychologist Sean Hayes, Ph.D., of the University of Nevada in Reno, ACT therapy hinges on the idea that our normal thinking patterns both distort and enlarge our perceptions of unpleasant emotions and lead us to engage in behaviors that are designed to avoid or lessen those unpleasant feelings. For instance, we may avoid elevators for fear of having a panic attack or avoid trying a new activity because of a belief that we will be bad at it.

ACT therapy suggests that, rather than attempting to challenge and change negative thoughts and beliefs (as cognitive therapy advocates), we should accept and feel our negative thoughts and feelings (in effect, embrace our pain) in an attempt to defuse them -- the acceptance part of the ACT therapy equation. The defusing process develops from allowing the negative thoughts and beliefs to wash over us until they become meaningless, stripped of emotion, and we can distance ourselves from them.

ACT therapy also stresses the importance of dedicating ourselves to living a more personally meaningful life according to our core values -- the commitment part of the equation. According to Hayes, what we truly desire from life, based on our values, often takes "a backseat to more immediate goals of being right, looking good, feeling good, defending a conceptualized self, and so on. People lose contact with what they want in life, beyond relief from psychological pain."

Although ACT therapy is controversial, preliminary research supports its efficacy: In a review of 13 small trials, ACT therapy was found to be better at relieving depression than other treatment approaches, up to a year after therapy ended. The therapy also appears to be effective for anxiety and addiction disorders. Of course further research and experience with ACT is needed before this type of therapy earns validity.

Is Electroconvulsive Therapy The Right Choice?

Wed, 28 Nov 2007 06:00:00 CST

When is electroconvulsive therapy an appropriate treatment for depression? Irving M. Reti, M.B.B.S., director of the Electroconvulsive Therapy Service at The Johns Hopkins Hospital, offers advice.

Electroconvulsive therapy (ECT) is hands-down the most controversial treatment in modern psychiatry. No other treatment has generated such a fierce and polarized public debate. Critics of ECT say it’s a crude tool of psychiatric coercion; advocates say it is the most effective, lifesaving psychiatric treatment that exists today.

The truth is that modern-day ECT is a far cry from the old methods that earned ECT its sinister reputation. For many of you reading this, the thought of ECT conjures up images of the 1975 movie "One Flew Over the Cuckoo’s Nest," with Jack Nicholson thrashing about, forced against his will to endure painful, violent seizures. This is not an accurate portrayal of how ECT is used today. The treatment has evolved into a relatively painless procedure with proven effectiveness in the fight against depression. It has survived its critics because it is safe and because it works.

ECT involves passing a carefully controlled electrical current through a person’s brain to trigger a seizure -- a rapid discharge of nerve impulses throughout the brain. The electricity is passed between two electrodes that are placed on the patient’s scalp.

Is ECT right for you or your loved one with depression? Here are five questions to ask yourself:

Is fast symptom relief crucial? If a person is acutely suicidal, is so depressed that he/she refuses to eat or drink, or experiences delusions or hallucinations that put him at risk for hurting himself or others, there is not time to wait for antidepressants to take effect. In these emergency situations, ECT can offer faster benefits than antidepressant medications.

Have several antidepressants been ineffective? When a person has failed two or three adequate trials of antidepressant medications (and possibly psychotherapy as well), ECT is a feasible option. “Adequate” means an antidepressant medication is taken at high enough doses for a long enough period of time to give it a real chance to be effective.

Is taking antidepressants out of the question? Some people experience intolerable side effects from antidepressants, even at the lowest possible therapeutic doses. For these people, antidepressant medications are not an option. Antidepressants may potentially be dangerous to women who are pregnant and want to avoid exposing their unborn child to psychiatric medications. ECT is a viable option for pregnant women.

Have you had ECT in the past and responded well to it? If ECT successfully treated your depression in the past, it makes sense to stick with a treatment that you know has worked for you previously.

Have you failed to respond to other treatments in the past? If you’ve suffered from depression in the past and could not find an effective treatment, it may be time to consider ECT for your current depression.

Anxiety and Older Adults

Wed, 07 Nov 2007 06:00:00 CST

Johns Hopkins Health Alerts | Depression and Anxiety |

Anxiety and Older Adults

"Over the last four weeks, have you felt nervous, anxious, or on edge?" A group of 279 patients – aged 19-87 -- were asked this question, and their answers may surprise you.

Anxiety is a common, normal, and often useful response to life's challenges and dangers. But in people who suffer from an anxiety disorder, anxiety levels spin out of control, causing psychological and physical symptoms that interfere with normal functioning, appear even in the absence of obvious external stressors, or are clearly excessive in the face of the stressors.

Anxiety is a common problem for older people -- far more prevalent than depressive disorders -- affecting 10 -24% of the elderly. But do younger and older people experience anxiety in the same way? Not always, according to a study of 279 patients, age 19–87, recruited from an outpatient primary care clinic.

Participants were asked to rate their health on a scale from 0 (poor) to 10 (excellent) and to complete three anxiety questionnaires as well as answer the question, “Over the last four weeks, have you felt nervous, anxious, or on edge?” The majority of participants were white, well educated, and married. Women comprised two-thirds of the group. Most rated their health as relatively good.

Of the 279, 145 reported symptoms of anxiety. When the results were sorted by age, older people with anxiety had the same somatic symptoms (bodily symptoms such as numbness, tingling, or feeling hot) and affective symptoms (psychological responses such as feeling nervous or irritable) but reported fewer cognitive symptoms (less worry) than younger adults with anxiety, regardless of race, gender, education, and health status.

When screening for anxiety disorders in older adults, doctors and patients should pay more attention to somatic and affective symptoms rather than cognitive symptoms such as worrying, given that worry plays a less prominent role in anxiety disorders in older adults. This data was reported in the journal Aging and Mental Health (Volume 10, page 298).

Johns Hopkins Health Alerts | Depression and Anxiety |

Anxiety and Older Adults

Research on Depression

Wed, 05 Sep 2007 06:00:00 CDT

Johns Hopkins Health Alerts | Depression and Anxiety |

Research on Depression

Depression Study 1: Mild Sadness Can Trigger Depression Relapse

People who recover from major depression may experience marked sensitivity to emotional stress, raising the risk of falling back into dysfunctional and depressive thought patterns, according to a Canadian study. Even mild negative moods can reactivate the thinking styles associated with depression and may predict the recurrence of major depression.

The study, which was reported in the Archives of General Psychiatry (Volume 63, page 749), had two phases:

Phase 1 -- Investigators enrolled 301 patients, age 18–65, with a diagnosis of major depression. Participants were randomly assigned to receive treatment for six months with an antidepressant drug or weekly cognitive-behavioral therapy (CBT) sessions.

Phase 2 -- 99 patients who had recovered from their depression were exposed to melancholy music and asked to recall a time in their lives when they felt sad, as a means of provoking a sad mood. Patients who received drug therapy were more likely to fall into negative thinking patterns as a result of their sad mood, compared with those who had undergone CBT. The greater the reactivation of dysfunctional thinking, the more likely the patient was to relapse into major depression over the next 18 months.

To prevent depression relapses, it is vital to teach people skills to monitor and recognize dysfunctional thinking when they’re feeling down and then inhibit or disengage from such thoughts.

Depression Study 2: Five Years of Depression Research

A review of developments in depression research over the past five years suggests that, despite the availability of effective treatments, depression among adults remains a common and often untreated condition.

Medications remain the mainstay of depression treatment and the most likely choice for most depressed patients, because they are effective and readily available, with benefits that outweigh the potential for an increase in suicidal thoughts or withdrawal problems.

Electroconvulsive therapy has proven the most effective treatment for depression but, because it involves general anesthesia and may cause memory loss, it is typically only used when depression is treatment resistant, psychotic symptoms such as delusions are present, medication has failed, or a patient is acutely suicidal.

Depression has been linked to cognitive impairment -- compromised ability to process information, remember things, and maintain mental flexibility. Magnetic resonance imaging (MRI) scans show that the size of a part of the brain known as the hippocampus is reduced in people with major depression and that antidepressant medications may reverse these changes. MRI studies further show that people with depression have abnormally high activity levels in emotion-related areas of the brain and decreased activity in cognition-related regions. This data was reported in The Lancet (Volume 367, page 153).

Johns Hopkins Health Alerts | Depression and Anxiety |

Research on Depression

The Exercise Prescription

Wed, 15 Aug 2007 06:00:00 CDT

Johns Hopkins Health Alerts | Depression and Anxiety |

The Exercise Prescription

Karen L. Swartz, M.D., Director of the Johns Hopkins Mood Disorders Center, provides six practical exercise tips to help your ease depression or anxiety with exercise.

After decades of investigation, there is now indisputable evidence that regular physical exercise can relieve and perhaps even prevent stress, anxiety, and depression -- especially for women, who tend to suffer from these problems more often than men. Research also shows that exercise can treat depression and prevent relapses in some older individuals as effectively as antidepressant drugs. Exercise may even reverse some of the mental decline that can occur with aging, probably because it improves blood flow to the brain.

A study conducted at the University of Texas at Austin found that, for people with major depressive disorder, a half hour of brisk walking on a treadmill is more effective in producing feelings of well-being and boosting energy than resting. Study participants also reported less tension, depression, anger, and fatigue after walking. What’s more, the effects of exercise were immediate: As soon as the subjects stepped off the treadmill, they were in a better mood, and they felt good for up to one hour later.

Here is our best prescription for boosting your mood with exercise:

Exercise tip 1: Exercise now…and again. Research shows that a 10- minute walk can improve your mood for two hours. Another study demonstrates that 10 minutes of pedaling on a stationery bike is enough to make you feel better, at least temporarily. The key to sustaining mood benefits is to exercise regularly -- stop exercising, and the psychological lift will disappear. The converse is also true: If you’re used to regular physical activity, your mood will suffer if you take an exercise vacation.

Exercise tip 2: Choose activities that are moderately intense. Aerobic exercise, such as walking and swimming, undoubtedly has mental health benefits, but you don’t need to sweat strenuously to see results.

Exercise tip 3: Find exercises that are continuous and rhythmic (rather than intermittent). Walking, swimming, dancing, stationery biking, and yoga are good choices.

Exercise tip 4: Be wary of competitive sports. Exercise that pits people head-to-head with opponents may be too stressful, leading to a bad mood in the face of defeat. If you’re the type whose competitive spirit may get the better of you, choose a physical activity that you enjoy and that allows you to de-stress.

Exercise tip 5: Add a mind-body element. Activities such as yoga and tai chi rest your mind and pump up your energy. But if you don’t want to do yoga or the like, you can add a meditative element to walking or swimming by repeating a mantra (a word or phrase) as you move.

Exercise tip 6: Start slowly, and don’t overdo it. More isn’t better. Athletes who overtrain find their moods drop rather than lift. You also risk injury and boredom if you push too hard, too fast, or too far.

Johns Hopkins Health Alerts | Depression and Anxiety |

The Exercise Prescription

Depression and Older Adults

Wed, 17 Oct 2007 06:00:00 CDT

Johns Hopkins Health Alerts | Depression and Anxiety | Depression and Older Adults

Researchers explore the link between depression and nursing home admissions among adults aged 65 and older.

Depression and aging do not necessarily go hand in hand. A survey of Californians age 50-95 found that factors such as chronic illness, physical disabilities, and social isolation -- which often coincide with increasing age -- were stronger predictors of depression than age itself. That said, the incidence of depression is clearly higher in older adults. The National Institute of Mental Health’s Epidemiologic Catchment Area Study, which focuses on several major geographical areas, estimated that at least one million of the nation’s 31 million people age 65 and older suffer from major depression, and an additional five million have symptoms of depression that are severe enough to require treatment. Unfortunately, the depression is often undiagnosed, misdiagnosed, or left untreated in the elderly. There is also reason to believe that late-life depression can be more serious than depression in younger people.

Now a study in the Journal of the American Geriatrics Society (Volume 54, page 593) reports that older people who frequently feel sad or depressed are at greater risk for needing to be admitted to a nursing home than older people who feel well – this according to a review of data from Medicare beneficiaries age 65 and older. They are also at increased risk for subsequent death.

Of the 137,632 people for whom data were available, 11,220 were admitted to a nursing home within 2.5 years. Of the total group, 13,621 subjects said they had experienced symptoms of depression much of the time over the past year; of these, 2,005 (13.1%) entered a nursing home within the 3.5-year study period.

Other factors associated with nursing home admission were poor health (such as heart failure, diabetes, cancer, history of stroke, heart attack, and arthritis), limited physical functioning, increasing age, and low income. Men and women were equally likely to need nursing home care, although after adjustment for health and other factors, men had a higher risk than women. The researchers suggested that symptoms of depression may exacerbate existing medical illnesses or be caused by medical illnesses, both of which can increase the risk of frailty and the need for institutionalized care. Depression may also lead to poor health habits, such as inadequate nutrition and increased alcohol use.

Johns Hopkins Health Alerts | Depression and Anxiety | Depression and Older Adults

Compulsive Hoarding -- Clutter Out of Control

Fri, 21 Sep 2007 11:09:34 CDT

Johns Hopkins Health Alerts | Depression and Anxiety | Compulsive Hoarding

When saving and collecting take over your life, it may signal compulsive hoarding.

Many people are closet clutterers. But what if you've taken saving and collecting to such an extreme that it’s difficult to move around your home or you’re embarrassed to invite people in because of all the clutter? In that case, you may have crossed the line from a bad habit into a mental disorder known as compulsive hoarding.

Compulsive hoarding affects an estimated one million Americans. Compulsive hoarding is typically considered a form of obsessive-compulsive disorder (OCD), because between 18% and 42% of OCD patients have a compulsion to hoard and save things. But compulsive hoarding can also affect people who do not have OCD.

Compulsive hoarding often starts during childhood or the teen years, but doesn't usually become severe until adulthood. Compulsive hoarding may be driven by an irrational fear of losing items that you believe you'll need later or eventually find a use for (a magazine article, a garment that may someday fit again, a broken lamp that you’re meaning to get fixed). Or compulsive hoarding may be linked to a strong emotional attachment to an inordinately large number of your possessions -- a feeling that they are special, have sentimental value, or are even a part of your identity or family.

Sometimes hoarding is more about fear of discarding than about collecting and saving. The thought of having to throw something out may make you anxious or upset, so you keep it instead. Many hoarders are perfectionists who fear making the wrong decision about what to keep and what to toss, so they just keep everything.

Hoarding is considered to be a compulsive problem when it meets three criteria:

1. You keep a large number of possessions that others view as junk.
2. Rooms in your home are so laden with possessions that you can no longer use them for their intended purpose. 3. You feel significant distress over the clutter, and it is impairing your ability to behave normally. You won’t allow friends, family, or repairmen to enter your home because you’re embarrassed by the clutter. You may even feel depressed, anxious, and hemmed in by all those possessions you've accumulated.
Compulsive hoarding can be a difficult behavior to stop. Unfortunately, the problem doesn't always respond to the same treatments as OCD, which is why many researchers now believe that compulsive hoarding may be a separate disorder.

A brain-imaging study conducted at the University of California–Los Angeles with OCD patients bears this out: Researchers found different patterns of brain activity among hoarders compared with non-hoarders with OCD and study participants without OCD. Hoarders had less activity in the part of the brain that is linked to motivation, self-control, and the ability to choose between conflicting options. The study also found less brain activity among hoarders in areas of the brain that typically register a response to antidepressant treatments. This may explain why hoarders do not always respond to selective serotonin reuptake inhibitors (SSRIs), such as citalopram (Celexa), sertraline (Zoloft), and fluoxetine (Prozac), the standard medications prescribed for OCD.

For more Alerts and Special Reports, please visit the Depression and Anxiety Topic page.

Johns Hopkins Health Alerts | Depression and Anxiety | Compulsive Hoarding

The Many Benefits of Pets

Wed, 25 Jul 2007 06:00:00 CDT

Johns Hopkins Health Alerts | Depression and Anxiety |

The Many Benefits of Pets

Pets really do improve our mental (and physical) health. Here’s why.

Pets are more than just furry friends and loyal companions. Yes, pets tug at our heartstrings, but they also improve our health, both mental and physical, helping us to live longer and happier lives. Studies over the past 25 years have shown that stroking a dog or cat can lower blood pressure and heart rate and boost levels of the mood-related brain chemicals serotonin and dopamine. Heart attack sufferers recover more quickly and survive longer when they have a pet at home, and children who are exposed to pets early in life may have a reduced risk of allergies and asthma.

For people with disabilities, pets can offer a lifeline to a more normal existence: guiding the blind, hearing for the deaf, and performing tasks for those who can’t do for themselves. Dogs and cats, even a tankful of fish, calm frazzled nerves and ease anxiety and depression, according to research. In one study, pets seemed to temper some of the psychological stress of being a caregiver to someone who is ill or suffering from dementia.

Dogs also act as conversation starters among strangers, a common interest, and a shared purpose. By getting their owners out of the house, dogs can also be a great stimulus for exercise and a tool for weight loss. In a recent study, researchers at the University of Missouri-Columbia found that people who walked a dog for 10 minutes three times a week, eventually working up to 20 minutes five times a week over the course of a year, lost an average of 14 lbs, without changing their diets.

Why do pets make us feel better? One reason is that pets alter our behavior. When they are near, we tend to calm down and speak more slowly and softly. All types of pets offer distractions from the worries of the day, because we naturally shift our attention to them when they are around. Pets also provide an opportunity to touch and stroke another living thing, which has been shown to be of value to our mental and physical health.

For more Alerts and Special Reports, please visit the Depression and Anxiety Topic page.

Johns Hopkins Health Alerts | Depression and Anxiety |

The Many Benefits of Pets

The Depression Patch

Wed, 23 May 2007 06:00:00 CDT

Johns Hopkins Health Alerts | Depression and Anxiety |

The Depression Patch

Karen L. Swartz, M.D., Assistant Professor of Psychiatry at Johns Hopkins, explains why the transdermal Emsam patch offers new hope for patients with depression.

Emsam (selegiline) is the first FDA-approved skin (transdermal) patch for treating major depression. The once-a-day depression patch works by delivering selegiline, a monoamine oxidase (MAO) inhibitor, through the skin and directly into the bloodstream, without having to pass through the digestive tract first.

At its lowest strength, Emsam can be used without the dietary restrictions required for all oral MAO inhibitors, making it a far more attractive drug option for people whose depression responds best to MAO inhibitors.

MAO inhibitors, such as Nardil (phenelzine) and Parnate (tranylcypromine), increase brain levels of norepinephrine, serotonin, and dopamine by blocking the action of the enzyme MAO, which normally inactivates these three neurotransmitters. They are effective in many people with depression , especially those whose depression is accompanied by marked anxiety, panic attacks, heightened appetite, or excessive sleeping.

But, as a drug class, MAO inhibitors are typically a last choice for people with depression because of their safety risks. In the intestines, the enzyme MAO breaks down tyramine, a substance found in certain foods and beverages. Oral MAO inhibitors block the breakdown of tyramine in the intestine. This is dangerous because, if a large amount of tyramine is absorbed from the intestine, it can lead to a sudden and extreme elevation in blood pressure called “hypertensive crisis,” which is potentially life threatening and requires immediate medical treatment. Foods high in tyramine include aged cheese, aged or smoked meats, tap beer, and very ripe bananas. Nasal decongestants and cold and allergy medicines also contain tyramine.

Emsam represents a significant advance because the innovative transdermal delivery system allows the MAO inhibitor to bypass the digestive tract. At the lowest dose of the patch, which delivers 6 mg of selegiline over a 24-hour period, no dietary restrictions are necessary.

For more Alerts and Special Reports, please visit the Depression and Anxiety Topic page.

Johns Hopkins Health Alerts | Depression and Anxiety |

The Depression Patch

Qs & As on Insomnia

Wed, 02 May 2007 06:00:00 CDT

Johns Hopkins Health Alerts | Depression and Anxiety | Qs & As on Insomnia

Melatonin, antihistamines, and bright light therapy for insomnia

Q. What do you think about melatonin and valerian as treatments for insomnia?

A. Melatonin is a hormone produced in the body by the pineal gland in response to darkness and as a cue for sleep. Valerian is an herb promoted as a mild sedative. Both melatonin and valerian are sold as dietary supplements in the United States and are marketed as sleep aids. The National Institutes of Health’s June 2005 chronic insomnia state-of-the science conference statement did not recommend the use of melatonin or valerian for insomnia, based upon lack of evidence for either efficacy or safety.

Melatonin may have a role for other sleep disturbances, particularly circadian rhythm disorders and perhaps jet lag, but there is no good evidence that it is beneficial as a sleep-promoting medication for the treatment of insomnia. This is true for valerian as well. It may just be that the proper research has not been done yet; studies published to date have not been convincing. The bottom line is that I don’t recommend trying either of these supplements as a treatment for chronic insomnia.

Q. Are over-the-counter antihistamines effective sleep aids for insomnia?

A. Antihistamines, such as diphenhydramine (the active ingredient in products like Tylenol PM), are the most commonly used nonprescription treatments for chronic insomnia. However, there is no convincing evidence that these drugs are effective over time for chronic insomnia, and major concerns about their risks have emerged. Residual daytime sedation, compromised cognitive function (a particular concern in the elderly), constipation, and dry mouth are some of the adverse effects of antihistamines. For transient insomnia (just for a night or two) antihistamines may help, but they are not a solution for more persistent insomnia, and patients should not use them as such.

Q. Is bright-light therapy an effective treatment for insomnia?

A. Bright-light therapy has proven efficacy for people with circadian rhythm disorders. It involves sitting in front of a therapeutic bright-light box for about 20–60 minutes each day. To be maximally effective, the light should come from a fluorescent light box that delivers an intensity of 10,000 lux. It is important to position the light box according to your doctor’s instructions and to use it at the same time each day as consistently as possible. For so-called night owls, we aim to maximize their bright-light exposure early in the day, as soon as they wake up and get out of bed. We do the opposite for early birds with advanced sleep phase pattern. We use bright light in the evening to shift their circadian rhythm later.

For more Alerts and Special Reports, please visit the Depression and Anxiety Topic page.

Johns Hopkins Health Alerts | Depression and Anxiety | Qs & As on Insomnia

Alleviating Dry Mouth

Wed, 04 Jul 2007 06:00:00 CDT

Johns Hopkins Health Alerts | Depression and Anxiety | Alleviating Dry Mouth

Johns Hopkins experts provide eight practical tips to help you reduce medication-related dry mouth.

Dry mouth is a common side effect of many psychiatric medications. Dry mouth occurs when a drug blocks the receptor sites of the neurotransmitter acetylcholine, which controls saliva production. There are several simple, helpful remedies to help you relieve dry mouth:

Take frequent sips of water or sugar-free drinks throughout the day.

Avoid coffee, tea, soft drinks, and alcohol, as they are diuretics leading to dehydration.

Have water available at your bedside to avoid dry mouth during the night.

Drink frequently during all meals.

Carry sugar-free hard candies, mints, or chewing gum (sugar-containing remedies increase the risk for dental cavities).

Try to avoid spicy, salty, and acidic foods, as well as tobacco.

Some patients find it soothing to use a humidifier, particularly through the night.

Under your physician’s guidance, a minimal decrease in medication dosage, or dividing the dose into a twice-daily regimen, may help diminish many side effects, including dry mouth.

If these remedies do not help relieve dry mouth, your doctor may prescribe the medication Salagen (pilocarpine in 1% solution) as a mouthwash to use three times daily. Salagen is a cholinergic agonist, which means it has a strong affinity for the acetylcholine receptor sites that many psychiatric medications block. Cholinergic agonists increase the flow of saliva, thereby helping to counteract dry mouth.

Another medication often prescribed for dry mouth is bethanechol tablets, 10–30 mg once or twice daily. Bethanechol is sold under the brand names Duvoid, Urabeth, and Urecholine. Like Salagen, it is a cholinergic agonist, so it stimulates saliva production.

Because dry mouth increases the risk for dental cavities, it is important to be particularly vigilant about dental hygiene if you are troubled by this medication side effect. Dentists recommend brushing your teeth at least twice a day (and immediately after eating sticky, sugary foods), using dental floss after every meal, and using toothpaste that contains fluoride.

For more Alerts and Special Reports, please visit the Depression and Anxiety Topic page.

Johns Hopkins Health Alerts | Depression and Anxiety | Alleviating Dry Mouth

Antidepressant-Induced Sexual Dysfunction

Wed, 21 Mar 2007 06:00:00 CST

Johns Hopkins Health Alerts | Depression and Anxiety | Antidepressant-Induced Sexual Dysfunction

What should you do if your antidepressant medication causes decreased libido? Karen L. Swartz, M.D., Director of Clinical Programs at the Johns Hopkins Mood Disorders Center, weighs in on this common problem.

Unfortunately, sexual dysfunction is a common side effect of all classes of antidepressant medications. Sexual dysfunction includes diminished libido, inability to orgasm, decreased sensation in the genitals, vaginal dryness (in women), and erectile dysfunction (in men).

The first thing your doctor will do if you report sexual dysfunction is a thorough medical workup to rule out any possible physical problems. Hypertension, diabetes, urological problems, and neurological problems can all cause sexual dysfunction.

If antidepressants are the likely cause, there are several possible remedies. First, you and your doctor may consider switching to an antidepressant with a low rate of sexual side effects, such as Wellbutrin (bupropion). This must be done carefully to minimize the risk of a relapse of depression. As an alternative, your doctor may suggest adding Wellbutrin to your current antidepressant regimen. Research indicates that small doses of Wellbutrin (75–150 mg daily) in combination with other antidepressants can be helpful in alleviating the sexual side effects of those antidepressants. Here are some other remedies you might try:

Add Viagra (sildenafil), which is potentially effective for combating antidepressant-induced sexual dysfunction in both men and women.

Decrease your antidepressant dose slightly. If you want to try this approach, however, it’s important to develop a plan with your doctor to decrease the antidepressant dose slowly and in small increments to avoid a recurrence of depressive symptoms.

Change the time you take your antidepressant medication. If your symptoms involve difficulty achieving orgasm, taking the antidepressant after sexual activity often proves helpful. For example, if you are most likely to engage in sexual activity in the evening, take the antidepressant medication just before falling asleep. Blood levels of the drug will be lowest the following night, so the extent of side effects will also be lowest at that time.

Divide medication doses. Rather than taking the full dose once a day, some people find that taking half the dose twice a day helps diminish side effects.

Try a “drug holiday.” This involves taking a short respite from your medication. Evidence shows that periodic two-day breaks from antidepressant therapy can lower the rate of sexual side effects during the “drug holiday,” without increasing the risk of a recurrence of depressive symptoms. For example, in one study, taking medication Sunday through Thursday and skipping it Friday and Saturday allowed participants to enjoy improved sexual functioning 50% of the time on weekends, with no overall worsening of mood. This approach works with quick-clearing drugs, such as Zoloft (sertraline) and Paxil (paroxetine), but not with Prozac (fluoxetine), which has a longer half-life and therefore clears more slowly from the body. One potential risk with taking a “drug holiday” from antidepressants that have very short half-lives, such as Zoloft and Paxil, is the onset of withdrawal symptoms.

All the remedies discussed above should be implemented only with physician support and supervision to prevent relapse of depressive symptoms and drug withdrawal reactions.

For more Alerts and Special Reports, please visit the Depression and Anxiety Topic page.

Johns Hopkins Health Alerts | Depression and Anxiety | Antidepressant-Induced Sexual Dysfunction

Insomnia and Mood Disorders

Wed, 11 Apr 2007 06:00:00 CDT

Johns Hopkins Health Alerts | Depression and Anxiety | Insomnia and Mood Disorders

David N. Neubauer, M.D, associate director of the Johns Hopkins Sleep Disorders Center, answers patients’ questions about the interrelationship between insomnia and mood disorders. He begins with the chicken-and-egg question…

Q. Do sleep disorders cause mood disorders or vice versa?

A. That’s not an easy question to answer. It is a relationship that goes both ways. There is very clear evidence that when a person is experiencing a mood disorder, particularly a major depressive episode, he or she is highly likely to suffer from sleep disturbance -- most often, insomnia. In fact, insomnia is so expected that it’s part of the diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV).

When surveying people who are depressed, we find that 80% experience sleeplessness, and it’s not only the classic early-morning awakening associated with depression, but rather all the possibilities, including difficulty falling asleep and middle-of-the-night awakenings. There is also the issue of severity: The more depressed someone is, the more likely it is that he or she will have insomnia. The converse is true, too. If a person suffers from insomnia, over time it creates a risk for developing a mood disorder such as major depression. There are several excellent observational studies that demonstrate the link between insomnia and the future risk of developing a mood disorder. The link is evident as quickly as one year after an episode of insomnia, and can last as long as decades.

Regardless of which comes first, there is a lot of comorbidity (coexistence) between insomnia and depression, and it’s important to address both conditions. One of the greatest challenges in depression is to find the medication (or combination of medications) that will alleviate the depression as well as the insomnia.

Q. What is the connection between insomnia and anxiety disorders?

A. Researchers have documented the frequency of insomnia among specific subcategories of anxiety disorders, such as panic disorder, generalized anxiety disorder, post-traumatic stress disorder, and even social anxiety disorder. Data indicate that insomnia is just as common among people with anxiety disorders as people with depressive disorders. It is an equally strong link.

For more Alerts and Special Reports, please visit the Depression and Anxiety Topic page.

Johns Hopkins Health Alerts | Depression and Anxiety | Insomnia and Mood Disorders

Results from the STAR*D Study

Wed, 07 Feb 2007 06:00:00 CST

Johns Hopkins Health Alerts | Depression and Anxiety |

Results from the STAR*D Study

What do you do if you’re suffering from depression and are not responding to antidepressant treatment? Now the government-sponsored STAR*D study provides evidence-based guidelines to help you and your doctor find the right answer.

After failure on an antidepressant, the next step you and your doctor decide to take is largely a matter of trial and error based on your doctor’s experience with other patients, your medical history, and your doctor’s consultation with other mental health professionals. This trial-and-error approach may soon be a thing of the past, however.

Results from the largest and longest study ever done to evaluate depression treatment -- the Sequenced Treatment Alternatives to Relieve Depression trial, or STAR*D -- are starting to give doctors some evidence-based guidance toward optimal next-step strategies. The study, which looked at the use of popular antidepressants in people with chronic depression -- lasting, in some cases, 15 -16 years -- is the first to provide “real-world” scientific data on what to do when someone doesn’t respond to a particular antidepressant, has severe depression, or suffers from multiple mental and physical ailments. These types of treatment-resistant patients are not typically included in antidepressant drug trials sponsored by pharmaceutical companies.

By contrast, STAR*D is a government-sponsored study, funded by the National Institute of Mental Health. It didn’t shy away from including these difficult-to-treat patients, and it was designed to mimic real-word treatment settings. Moreover, STAR*D is an effectiveness trial, which typically asks tougher questions than traditional efficacy trials. Effectiveness trials measure symptom reduction and patient function, and also take into account the complex and sometimes messy realities that clinicians face in everyday practice. The goal of STAR*D was remission, because people who become symptom-free generally function better and are less prone to relapse. Efficacy trials normally seek only a reduction in symptoms. What all this means is that the results of STAR*D are immediately relevant to you and your doctor, especially if you’re still searching for a drug regimen that will effectively treat your depression.

Take-home messages from the STAR*D study on antidepressants:

One antidepressant treatment does not fit all. You may need to try several antidepressants to find a drug regimen that works for you.

Persevering through several different treatment attempts, as arduous as that may be, can improve results for many people.

At standard doses of the most commonly used class of antidepressants -- selective serotonin reuptake inhibitors (SSRIs) -- 30% of patients with severe depression achieve remission with the first antidepressant prescribed.

It often takes 12 weeks to achieve an adequate response to an antidepressant, not the standard four to eight weeks that most doctors and mental health specialists were previously using to guide decisions.

If the first choice of an antidepressant does not provide adequate symptom relief, switching to a new antidepressant is effective about 25% of the time.

Switching from one SSRI to another is almost as effective as switching to a drug from another class.

If the first choice of antidepressant does not provide adequate symptom relief, adding a new antidepressant while continuing to take the first medication is effective in about one-third of people.

For people who don’t respond to first-line therapy with an SSRI, adding a second drug to the SSRI drug regimen appears to be slightly better than completely switching medications.

For those who don’t respond to switching to a new antidepressant or adding a second drug, trying a third medication can still help about one in five people.

From The Johns Hopkins Depression and Anxiety Bulletin

For more Alerts and Special Reports, please visit the Depression and Anxiety Topic page.

Johns Hopkins Health Alerts | Depression and Anxiety |

Results from the STAR*D Study

First Drug Approved for Seasonal Depression

Wed, 17 Jan 2007 06:00:00 CST

Johns Hopkins Health Alerts | Depression and Anxiety | First Drug Approved for Seasonal Depression

Feeling SAD? Wellbutrin XL may help.

The Food and Drug Administration (FDA) recently approved Wellbutrin XL (bupropion HCL extended-release tablets) for the prevention of major depressive episodes in people with a history of seasonal affective disorder (SAD). Wellbutrin XL is the first drug officially approved for seasonal affective disorder, which is characterized by recurrent bouts of major depression that coincide with the shorter daylight hours of autumn and winter (thus the nickname "winter depression”).

At this time of year, changes in the amount of daily sunlight cause changes in the body’s internal biological clock, known as circadian rhythm. This rhythm is a 24-hour cycle that affects our eating and sleeping patterns, brain wave activity, hormone production, and other biological activities. In some people, less daily sunlight and changes in circadian rhythm can bring about depression. One theory is that the relative lack of sunlight during these times may alter brain levels of certain mood-related chemicals. People with seasonal affective disorder often eat and sleep excessively, crave sugary or starchy foods, and have a full remission of seasonal affective disorder in the spring and summer when more daily sunlight is available.

The efficacy of Wellbutrin XL for the prevention of seasonal affective disorder episodes was demonstrated in three double-blind, placebo-controlled trials -- the gold standard of medical research -- in adults with a history of recurrent major depressive disorder in autumn and winter. Treatment for seasonal affective disorder was started before the onset of symptoms in the autumn (September to November) and was discontinued following a two-week taper starting the first week of spring (fourth week of March). In these trials, the percentage of patients who were depression-free at the end of treatment was significantly higher for those on Wellbutrin XL than for those on placebo. Combining data from all three studies, the overall rate of patients depression-free at the end of treatment was 84% for those on Wellbutrin XL, compared to 72% for those on placebo.

These findings have not surprised psychiatrists and primary care physicians, who have long been using antidepressant drugs off label for treating seasonal affective disorder. But the stamp of approval by the FDA adds credibility to this treatment approach.

For more Alerts and Special Reports, please visit the Depression and Anxiety Topic page.

Johns Hopkins Health Alerts | Depression and Anxiety | First Drug Approved for Seasonal Depression

Bipolar Disorder and Older Adults -- When Symptoms Strike for the First Time in Late Life

Tue, 21 Nov 2006 06:00:00 CST

Johns Hopkins Health Alerts | Depression and Anxiety | Bipolar Disorder and Older Adults

Just as depression is not a normal and natural side of aging, neither are extreme irritability, angry outbursts, paranoia, or irrationally hyper behavior.

One of the myths associated with bipolar disorder is that it follows a predictable pattern, with cycles of mania and depression following one another as neatly and symmetrically as day follows night. Not true. Bipolar disorder is an unpredictable disease. And while bipolar disorder usually makes its first appearance during adolescence or young adulthood, another, often unexpected, feature is that bipolar disorder can show up for the first time in late adulthood.

While the scientific literature on bipolar disorder in older adults is fairly limited, recent studies have begun to take a closer look at the condition. Some points to consider:

Bipolar disorder: Percent affected. In a large study of people treated at Veterans Administration hospitals, 25% of the more than 65,000 people with bipolar disorder treated during one year were age 60 years or older. And in this over-60 age group, approximately 6% had new-onset bipolar disorder. And in a second study, 9.8% of 1,157 people between the ages of 18 and 70 years treated in an urban primary care clinic screened positive for bipolar disorder. Of those, 41% reported first being affected at age 40 years or older. The most commonly reported manic symptoms were being very irritable or “hyper.” Other frequently reported symptoms of bipolar disorder included being easily distractible, having racing thoughts, and being more talkative.

Bipolar disorder: Men vs. women. Overall, men are more likely than women to have bipolar disorder, but women may be more likely to experience the late-onset form of bipolar disorder. In a study of 48 older adults with bipolar disorder, women were 2.8 times more likely to be in the late onset group.

Bipolar disorder: Symptoms. Some research suggests that late-onset bipolar disorder may have a less-severe course of symptoms than early onset disease. As a result, many people may be under- or misdiagnosed. One review of mood disorders in late adulthood suggests that agitated depression in older people may be a form of bipolar disorder, but notes that this should be studied further.

Other conditions that mimic bipolar disorder. It is important to note that late-life mania, like late-life depression, can be a symptom of another illness, such as dementia or another neurological condition, or a side effect of a medication taken for another illness, such as corticosteroids.

Johns Hopkins Health Alerts | Depression and Anxiety | Bipolar Disorder and Older Adults

Don't Overlook Dysthymia

Fri, 20 Oct 2006 14:56:51 CDT

Johns Hopkins Health Alerts | Depression and Anxiety | Don't Overlook Dysthymia

Left untreated, dysthymia can lead to major depression, or worse.

It is far better to treat dysthymia (recurrent, mild depression; also called subclinical depression) than to think of it as a minor condition. That reminder comes from a seven-year prospective study of more than 1,000 young people in New Zealand, reported in the Archives of General Psychiatry.

People with dysthymia have some, but not all, of the symptoms of major depression. But as this study indicates, bypassing treatment places them at increased risk of subsequently developing major depression. The study followed 17- and 18 year-olds, 18.4% of whom had a diagnosis of major depression and 7.3% who had a diagnosis of subclinical depression. Seven years later, the rate of depression and suicidal behavior was similar between the two groups.

These findings make a strong case that people with dysthymia should not be treated as though their projected outcome is similar to that of people with no symptoms of depression, the researchers say. They caution that the effects of subclinical depression are not transitory— people with the disorder face future health risks similar to those experienced by people with major depression.

So how do you know if you or a loved one suffers from dysthymia? Dysthymia is characterized by the presence of depressed mood for most of the day for more days than not, over a period of at least two years. It may be intermittent and interspersed with periods of feeling normal, but these periods of improvement last for no more than two months.

Like major depression, dysthymia is twice as common in women as in men. People who have dysthymia before age 21 tend to have a higher incidence of personality disorders. Because the onset of symptoms is insidious, dysthymia often goes unnoticed—and because of its chronic nature, the person may come to believe, “I’ve always been this way.”

In addition to depressed mood, dysthymia symptoms include two or more of the following:

Poor appetite or overeating

Insomnia or hypersomnia (excessive sleeping)

Low energy or fatigue

Low self-esteem

Poor concentration or difficulty making decisions

Feelings of hopelessness

Johns Hopkins Health Alerts | Depression and Anxiety | Don't Overlook Dysthymia

The Genetics of Depression

Mon, 28 Aug 2006 13:52:17 CDT

Johns Hopkins Health Alerts | Depression and Anxiety | The Genetics of Depression

Why do some people bounce back from stressful events while other fall into depression?

Genetic factors play a role in the development of depression and other mood disorders. For example, a gene that may be linked to bipolar disorder has been identified and one study showed that a common family gene mutation could predict whether a person will experience clinical depression when faced with traumatic events in his or her life.

Identical twins, for instance, share the same genes. Research shows that when one identical twin has a mood disorder, there is about a 50% chance that the other will develop the same illness at some point in life. One study showed that if one twin developed depression, the other twin also suffered from depression in 46% of identical twins, compared with 20% of fraternal twins (who share half of their genes, like any full siblings).

When Depression Is All in the Family

A recent study reported in the Archives of General Psychiatry showed that children whose parents and grandparents experienced moderate to severe depression are at much greater risk of developing psychiatric problems, such as depression, than those whose parents or grandparents were not affected. In this three-generation study of 161 children, their parents, and their grandparents, nearly 60% of the children whose parents and grandparents both had a history of depression had at least one psychiatric disorder themselves. In particular, anxiety disorders were an early sign of other, more serious psychiatric problems in children from depressed families; the same was true of their parents.

The researchers stressed that family history of depression and its severity and impairment in previous generations should be taken seriously, as it may help identify young people who are at risk of developing depression later in life. In particular, they note that children with two generations of major depression should be identified and considered for treatment if they develop anxiety disorders.

Johns Hopkins Health Alerts | Depression and Anxiety | The Genetics of Depression

Taking Care of the Caregiver

Tue, 22 Aug 2006 11:32:42 CDT

Johns Hopkins Health Alerts | Depression and Anxiety | Taking Care of the Caregiver

If you’re a caregiver for a chronically ill relative or friend and are feeling overwhelmed, even depressed, this advice can help.

Being a caregiver for a chronically ill family member is a 24-hour job. With all the attention you give to others, it’s understandable that you may feel tired, unhappy, or irritable. But you may be beyond feeling just “worn down.” The strain of being a caregiver can eventually lead to diagnosable mental distress. A recent study of 200 caregivers found that 13% of the caregivers met the diagnostic criteria for one or more of these disorders: major depressive disorder, post-traumatic stress disorder, generalized anxiety disorder, and panic disorder.

If you suspect that you may be suffering from depression or another illness (see bulleted list below), it may not be easy to get the help you need. You may feel guilty about asking for help for yourself. On a practical level, it can be difficult to find a substitute caregiver, even for short periods of time. If it is at all possible, you owe it to yourself to get treatment. You will feel better, and the quality of care you can provide will improve.

Where a Caregiver Can Find Help

If you are a caregiver for someone who is chronically or terminally ill, you probably work closely with a doctor or team of doctors. What you may not know is that your loved one’s doctor may be able to help you as well. Speak to your doctor about your concerns about your mental health. He or she may be able to give you a referral to a mental health practitioner.

You may want to find a therapist on your own. If you have insurance through an HMO, the best place to start your search is through your health plan, which will have a list of approved mental health practitioners. You can also contact your state psychological association through the American Psychological Association (locator.apahelpcenter.org or 1-800-964-2000) to find the names and locations of psychologists in your area. Remember, however, that psychologists are not able to prescribe medication.

Support groups are also wonderful ways to improve your life as a caregiver. Many of your fellow caregivers will be dealing with the same issues and will be able to share coping strategies and tips. To find a support group, try the Yellow Pages or ask your doctor. Online support groups are also helpful, especially for people who have trouble scheduling time away from their loved one.

Symptoms of Common Psychiatric Disorders

Symptoms of depression:

changed eating/sleeping habits

exhaustion

feelings of hopelessness and anger

loss of interest in activities

unexplained physical symptoms like headache/stomachache thoughts of death/suicide

Symptoms of generalized anxiety disorder:

excessive worry and irritability

inability to relax

insomnia

unexplained physical symptoms like headache/stomachache

Symptoms of panic disorder:

episodes of intense fear

sweating and shaking, pounding heart, faintness, nausea, numbness, hot flashes

feelings of detachment from reality

fear of dying or losing control

intense anxiety between episodes

Symptoms of post-traumatic stress disorder:

memories and flashbacks of traumatic event

emotional numbness

difficulty concentrating

For More Information:

The National Family Caregivers Association -- www.thefamilycaregiver.org

The Family Caregiver Alliance -- www.caregiver.org

The Alzheimer’s Association -- www.alz.org

Johns Hopkins Health Alerts | Depression and Anxiety | Taking Care of the Caregiver

Is it a Panic (Anxiety) Attack or a Heart Attack?

Thu, 21 Dec 2006 06:00:00 CST

Johns Hopkins Health Alerts | Depression and Anxiety | Is it a Panic (Anxiety) Attack or a Heart Attack

Roger S. Blumenthal, M.D., medical editor of The Johns Hopkins Heart Bulletin, explains the importance difference between a panic attack and a heart attack.

Q. I had the shock of my life last week when I found my 58-year-old husband slumped over in his chair shortly after dinner. He had chest pain, a rapid heartbeat, shortness of breath, and he was sweating through his shirt. I called 911 and went with him to the hospital. The good news is that everything checked out OK. The strange news is that the doctor said he had suffered a panic attack, not a heart attack. What could be the problem? Our children are doing well in college, my husband owns his own business, and our lives are better than ever before. What kind of medical workup should he get so he can take steps to prevent another panic attack?

A. An acute anxiety attack, or panic attack, is a terrifying ordeal to experience. During a panic attack, a surge of fear overcomes the individual, often without any clear provocation. Many patients truly believe they are going to die, and some experience syncope, or fainting, as a reaction to this stressor.

The signs and symptoms of a panic attack are quite similar to those of a heart attack: palpitations, difficulty breathing, a sense of doom, lightheadedness, nausea, chest pain, and sudden chills. Unlike a heart attack, however, a panic attack is not medically dangerous.

Anyone diagnosed with panic attacks should be seen and evaluated by a psychiatrist who treats panic attack patients. Fortunately, panic or anxiety disorder is highly treatable. A type of therapy called "cognitive restructuring" helps people understand the nature of their symptoms, and many are greatly helped by understanding the diagnosis and learning to replace their maladaptive response with a clear recognition of what is happening to them. Cognitive therapy can help identify triggers, and can potentially lead to reduction in the frequency of panic attacks. Behavioral modification therapy and relaxation techniques are also used. In addition, anti-anxiety medications have been used with success.

Johns Hopkins Health Alerts | Depression and Anxiety | Is it a Panic (Anxiety) Attack or a Heart Attack

Men and Depression

Fri, 21 Jul 2006 09:23:01 CDT

Johns Hopkins Health Alerts | Depression and Anxiety | Men and Depression

Men often experience nontraditional symptoms of depression, which can keep them from recognizing the problem and seeking help.

If you’re a man and suffer from depression, you’re not alone! Nearly six million men in the United States are diagnosed with depression each year. But because men are less likely than women to recognize their symptoms and seek treatment, many more men probably suffer from this condition.

Depression in men is under diagnosed for at least two reasons:

Men tend not to experience some of the typical symptoms of depression, for example, crying episodes and feelings of sadness, worthlessness, and guilt, which are common in women. Instead, men with depression may experience anger, irritability, frustration, and physical problems, such as headaches, gastrointestinal symptoms, and sexual dysfunction. They may also experience sleeping problems, withdrawal, and loss of interest in activities once enjoyed, just like women. In addition, they may become self-critical and doubt their abilities. Men often mask their depression by turning to drugs or alcohol, or by working excessively long hours.

Men may be less likely than women to talk about their symptoms or report them to their doctor. Moreover, they may feel that they can handle their depression or that it will go away on its own. However, men’s reluctance to seek treatment may explain why more than four times as many men than women die by suicide, although more women attempt suicide. In fact, the highest suicide rate is for white men over 85 years of age. Even men who do not attempt suicide may engage in reckless behavior that is life threatening.

The good news

The good news is that men who do receive treatment for depression respond as well to medication and psychotherapy as women. If you think you might be experiencing some of the symptoms of depression, see your primary care physician. He or she may start treatment or refer you to a mental health professional. Some men are reluctant to consider therapy, but most research suggests that a combination of antidepressant medication and psychotherapy is the most effective treatment approach.

Johns Hopkins Health Alerts | Depression and Anxiety | Men and Depression

Is it Normal Grief or Depression?

Wed, 21 Jun 2006 16:08:14 CDT

Johns Hopkins Health Alerts | Depression and Anxiety | Is it Normal Grief or Depression

A good sign that grieving is successful is a shift to positive and realistic plans for the future.

The loss of a loved one can cause intense mental anguish. Occasionally, this anguish triggers a major depressive episode, but few people in mourning experience true clinical depression.

Grieving may produce a wide range of feelings. The grieving process is considered successful when it permits the mind to adjust to the acute sorrow of a loss. The end of the grieving process is not marked by an end of sadness—deep sadness over a death may last a lifetime. Instead, it is indicated by the griever’s acceptance of the loss.

A good sign that grieving is successful is a shift to positive and realistic plans for the future. As this shift occurs, and the mourner enjoys life more than feeling weighed down by it, the work of grieving proceeds.

The sadness of grief usually comes in “waves,” with varying degrees of intensity. In contrast, the sadness of major depression is persistent or varies by time of day. Grieving may have been unsuccessful and require the help of a physician or other health professional if the following symptoms are present for a prolonged period or if they arise months or even years after the loss:

physical symptoms that mimic the illness or injury of the person who died

overuse of alcohol, illicit drugs, or prescription medications

persistent signs of major depression, which include loss of interest in everyday activities formerly enjoyed, noticeable changes in appetite and weight, decreased energy and/or sexual drive, inability to concentrate, feelings of worthlessness, and helplessness

chronic sleep difficulties

thoughts of or attempts at suicide (a health professional should be seen immediately if this occurs)

an inability to carry out normal daily routines

It is important to seek medical help for physical symptoms that arise during grieving and to attend to conditions that existed prior to the loss. Some evidence suggests that acute grieving may suppress the immune system and make people more susceptible to illness.

Johns Hopkins Health Alerts | Depression and Anxiety | Is it Normal Grief or Depression

Natural--but not Always Harmless--Remedies for Depression and Anxiety

Tue, 23 May 2006 15:57:04 CDT

Johns Hopkins Health Alerts | Depression and Anxiety | St. John's Wort for Depression

Recent reports have illustrated that St. John's wort, used by many people to relieve depression, may not be as benign as it appears.

Despite the availability of a full arsenal of medications proven to be effective for treating depression and anxiety, many people have turned to herbal remedies—which are classified as dietary supplements in the United States and so have not been tested or approved by the U.S. Food and Drug Administration (FDA). No one is sure how well they work as a treatment for depression and anxiety or how they may interact with prescription medications, nor is there any guarantee of the purity of any herbal product you buy.

In addition, one concern with any alternative treatment is that people tend to medicate themselves instead of being evaluated and monitored by a health professional. As a result, they may not recognize worsening symptoms.

St. John's wort, which is extracted from a yellow flowered plant called Hypericum perforatum, is the best known of the supplements purported to be natural antidepressants. The American College of Physicians and the American Society of Internal Medicine recently included St. John’s wort in their guidelines as a treatment option for mild depression, but two large studies published in the Journal of the American Medical Association in 2000 and 2001 found that St. John's wort was no more effective than a placebo for treating major depression.

Thus, the authors recommend that people with major depression not take St. John's wort until well-designed studies support its use. People with mild to moderate depression would be wise to follow the same advice and not take St. John's wort.

Recent reports have illustrated that St. John's wort may not be as benign as it appears. Researchers have shown that St. John's wort lowers blood levels of Crixivan (indinavir), a drug prescribed for HIV (human immunodeficiency virus) infection as well as Sandimmune (cyclosporine), a drug given to prevent organ rejection in transplant patients. Physicians suspect that St. John's wort might interfere with a range of medications, including those prescribed to treat depression, heart disease, seizures, and some cancers. St. John's wort may also cause increased sensitivity to the sun.

Kava, which is prepared from the crushed root of Piper methysticum (a shrub-like pepper plant), is marketed as a natural remedy for anxiety and stress. However, the FDA has issued a warning that the supplement can damage the liver. In addition, long-term use of kava may result in allergic reactions, visual disturbances, or difficulties maintaining. Kava should not be used if you are pregnant, breast feeding, or taking antidepressants.

Johns Hopkins Health Alerts | Depression and Anxiety | St. John's Wort for Depression

When To Consider A New Antidepressant?

Mon, 17 Apr 2006 12:05:13 CDT

Johns Hopkins Health Alerts | Depression and Anxiety | When To Consider A New Antidepressant

Antidepressant medication may require up to eight weeks at a therapeutic dose to produce the full benefit

When an antidepressant proves ineffective, a new antidepressant is often selected from a different class of medications

By themselves, antidepressant drugs usually produce a significant improvement by four to six weeks, although it may take up to eight weeks at a therapeutic dose to see the full benefit. According to one study, when an antidepressant that is given at an adequate dosage fails to produce any significant results after the first four weeks, it is unlikely that the drug will work at all. In such cases, the researchers recommend that a new antidepressant be considered.

If the antidepressant produces only partial results after five weeks, they suggest that the antidepressant be continued into the sixth week. If there is no further improvement by then, a new antidepressant can be tried. These trial periods may be somewhat longer for the drugs known as selective serotonin reuptake inhibitors (SSRIs), since this class of drugs was not included in the study.

When an antidepressant proves ineffective, a new antidepressant is often selected from a different class of medications, because drugs in the same class tend to work similarly. In 20% to 50% of patients, adding the drug lithium can help augment the action of an antidepressant. However, this combination increases the risk of side effects and adverse drug interactions. (For this reason, lithium should be prescribed only by a physician knowledgeable in its use.)

If a drug from one class is producing good results but unacceptable side effects, changing to a different drug from the same class may help. If maintenance treatment is no longer required, drugs are discontinued slowly over a period of one to three weeks to avoid withdrawal symptoms. Relapses are most common during the first two months after stopping an antidepressant. Therefore, individuals should remain in contact with their physician during this period. (Should a relapse occur, the same antidepressant that was used successfully the first time often proves effective again.)

Johns Hopkins Health Alerts | Depression and Anxiety | When To Consider A New Antidepressant

Using Relaxation Techniques To Help Conquer Anxiety

Mon, 17 Apr 2006 12:00:30 CDT

Johns Hopkins Health Alerts | Depression and Anxiety | Relaxation Techniques To Help Anxiety

Relaxation techniques show promise for the treatment of anxiety

Common relaxation techniques for anxiety include meditation and guided imagery

Relaxation techniques may help people cope with the stresses that contribute to anxiety and help relieve some of the mental and physical symptoms of anxiety. The most commonly used relaxation techniques for anxiety are meditation, guided imagery, progressive muscle relaxation, and autogenic training (which involves imagining that certain body parts are becoming warm and heavy one at a time). These techniques may promote relaxation by reducing the activity of the sympathetic nervous system, which in turn can lead to decreases in blood pressure, heart rate, respiratory rate, and muscle tension.

Although relaxation techniques show promise for the treatment of anxiety, large, randomized, controlled trials are still needed to confirm their effectiveness. Consequently, relaxation techniques to treat anxiety should be used only in combination with proven treatments and not as a substitute for medication or psychotherapy. In addition, these techniques may worsen anxiety or other medical conditions in a small number of individuals, so it’s best to consult your doctor before trying any of them.

Mastering relaxation techniques to treat anxiety requires practice and some training from a professional. If your primary care physician, psychiatrist, or psychologist does not teach these techniques, he or she can refer you to a practitioner who does.

Johns Hopkins Health Alerts | Depression and Anxiety | Relaxation Techniques To Help Anxiety