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We must consider CAM for depression

Clinical Psychiatry News,  Nov, 2008  by James S. Gordon

It's time for psychiatrists to consider seriously an alternative approach to the treatment of depression. By alternative, I don't mean a fringe technique or a collection of them. I'm suggesting practicing in a way that is in harmony with the biopsychosocial model and backed by sound science as well as common sense.

Why now?

First, the limitations and hazards of antidepressants, including selective serotonin reuptake inhibitors (SSRIs), are increasingly apparent. The latest reviews of unpublished as well as published studies in The New England Journal of Medicine and in the online journal, PLoS Medicine, for example, show that SSRIs are far less effective at relieving symptoms of depression than the earlier studies and meta-analyses indicated.

Meanwhile, questions about efficacy continue to be compounded by the well-documented, short- and long-term side effects and withdrawal symptoms that the drugs produce as well as their potential for precipitating suicidal thoughts and feelings in younger people.

Second, more patients are looking to alternatives for answers. A recent national survey of depressed women by Columbia University researchers indicated that 54% were using complementary or alternative medicine (CAM), including self-care techniques, like dietary supplementation, prayer, meditation, and exercise.

Respondents most often used CAM because they were dissatisfied with the results of conventional approaches and their unpleasant side effects. They also found a greater harmony between CAM techniques and their own world-view - i.e., CAM helped fulfill their desire to participate in their own care.

Many of these people prefer to see depression signs and symptoms as a wake-up call rather than the end point of a disease process or as an indication of a biological and psychological imbalance that signals the need for deep change, growth, and healing.

These critical patient concerns lead me to the third reason we psychiatrists should look to alternatives: They are, or can be, as effective in relieving symptoms, reversing biochemical imbalances, and improving mood as they are appealing to patients.

This is not so surprising. Some of these alternative interventions directly address aspects of our biologic functioning that conventional approaches often ignore. For example, diets high in simple sugars and refined carbohydrates may contribute, perhaps through pathways of inflammation, oxidation, and increased insulin resistance, to depression. High consumption of saturated and trans fats may adversely affect brain functioning, possibly by making neuronal membranes rigid and inhibiting neurotransmitter efficacy.

Eliminating trans fats and cutting down on proinflammatory omega-6 fats (in red meat) and increasing intake of omega-3 fatty acids that are present in fish oil may make a difference; by itself, supplementation with omega-3s has been demonstrated to improve mood.

Deficiencies of micronutrients - including [B.sub.12] folic acid, selenium, and chromium - also might contribute to depressive symptoms that can be relieved by supplementation.

Many mind-body techniques such as meditation, guided imagery, journaling, aerobic exercise, and yoga also can easily be included in mainstream psychiatric treatment of depression. Each may have beneficial, direct effects on how we deal with stress and depression.

The scientific literature is replete with studies showing that these approaches can decrease Cortisol levels, raise endorphin and serotonin levels, make therapeutic changes in functional MRIs, promote neurogenesis in the hippocampus, and, in the case of regular meditation, even increase cortical thickness.

It's important, though, as we consider these techniques and approaches not to regard them as single, "stand-alone" alternatives. That's perpetuating a silver bullet model that, though sometimes useful, is limited (e.g., substituting the herb, St. John's wort for SSRIs). What's truly alternative, and will, I believe, prove far more effective, is a comprehensive "integrative" approach that may include synergistic combinations of a number of these other techniques and approaches, together with various forms of psychotherapy, individualized for each person and emphasizing that person's active participation in his or her care.

As we explore the possibilities of this approach, we may find that what we have thought of as alternative becomes the effective, scientifically validated, highly acceptable center of our therapeutic work.

Dr. Gordon is founder and director of The Center for Mind-Body Medicine, Washington, and clinical professor in the departments of psychiatry and family medicine at Georgetown Medical School. He describes this integrative approach to depression in Unstuck: Your Guide to the Seven-Stage Journey Out of Depression (New York: Penguin Press, 2008).


COPYRIGHT 2008 International Medical News Group
COPYRIGHT 2008 Gale, Cengage Learning

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Depression, cardiovascular disease 'intertwined'

Clinical Psychiatry News,  Nov, 2008  by Sharon Worcester

Patients with heart disease are at increased risk of depression and should be screened routinely, and referred and treated as necessary for the condition, a new science advisory from the American Heart Association states.

Depression has been shown in numerous studies to have profound adverse effects on prognosis and quality of life in heart disease patients. Findings from more than 60 prospective studies, several major review articles, and more than 100 additional narrative reviews of the literature have demonstrated links between depression and cardiovascular morbidity and mortality, according to the advisory, which was published online in September by the Prevention Committee of the American Heart Association Cardiovascular Nursing Council, Clinical Cardiology Council, Epidemiology and Prevention Council, and Interdisciplinary Council on Quality of Care and Outcome Research.

In particular, it has been shown that depression is about three times more common in acute myocardial infarction patients than it is in the general community, and in-hospital assessments indicate that up to 20% of patients with myocardial infarction meet the criteria for major depression. An even greater proportion exhibits depressive symptoms, Judith H.K. Lichtman, Ph.D., cochair of the committee, and her colleagues wrote (Circulation 2008 Sept. 29 [doi:10.1161/circulationaha.108.190769]).

Furthermore, the 12-month prevalence of major depression in patients with cardiac disease was 9.3%, compared with 4.8% in those with no comorbid medical illness, in nearly 40,000 participants in a recent National Health Interview Survey.

"There is general consensus that depression remains associated with at least a doubling in risk of cardiac events over the subsequent 1-2 years after an MI," the authors wrote. Biological factors and behavioral and/or social mechanisms - such as diet, exercise, medication adherence, tobacco use, social isolation, and chronic life stress - have been suggested as possible links between depression and heart disease.

'Although the specific behavioral and biological processes remain unclear, the alteration of these processes is associated with depressive symptoms, consistently in a direction that increases cardiovascular risk," wrote the committee, adding that depression is associated with decreased compliance with medications, reduced chances of successful modification of other cardiac risk factors and participation in cardiac rehabilitation, higher health care utilization and cost, and greatly reduced quality of life.

"Thus, whether depression impacts cardiac outcomes directly or indirectly, the need to screen and treat depression is imperative," they wrote.

The committee recommended the following:

* Routine screening for depression in heart disease patients in a variety of settings, including the doctor's office, hospital, clinic, and cardiac rehabilitation center. At a minimum, administration of the Patient Health Questionnaire (PHQ-2), a two-item assessment of depression that addresses loss of interest or pleasure in normal activities, and feelings of depression and hopelessness, is advised.

* Administration of PHQ-9, an expanded version of the PHQ-2, to those who answer "yes" to one or both of the PHQ-2 items.

* Follow-up assessment during a subsequent visit in patients with mild symptoms.

* Review the responses with those patients who had high depression scores.

* Referral for more comprehensive evaluation by a qualified professional in those with a PHQ-9 score of 10 or higher (out of a possible 27).

* Evaluation for other mental disorders, such as anxiety, in those who meet criteria for a more comprehensive clinical evaluation.

Data suggest that treatment with SSRIs soon after acute MI is safe and effective. Cognitive-behavioral therapy can also be of benefit.

In a written statement from the AHA, Dr. Lichtman stressed that depression and heart disease are "very much intertwined" adding that "you can't treat the heart in isolation from the patient's mental health," she noted.


Southeast Bureau

COPYRIGHT 2008 International Medical News Group
COPYRIGHT 2008 Gale, Cengage Learning

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Treating Parent Depression Helps Kids

When Parent's Depression Lifts, Children's Mental Health Improves
By Daniel J. DeNoon
WebMD Medical Nws
Reviewed by Louise Chang, MD

March 21, 2006 - When parents' depression gets better, their kids' mental health improves. But when parents' depression doesn't lift, the kids' mental health gets worse.

The finding is part of the large STAR-D trial funded by the National Institutes of Mental Health. The study is trying to find out what it takes to put serious clinical depression into remission - not just to improve symptoms, but also to get people over their illness.

Columbia University researcher Myrna M. Weissman, PhD, led a team that studied 151 depressed mothers enrolled in the STAR-D trial. The researchers also evaluated one of each woman's 7- to 17-year-old children. Their findings appear in the March 22/29 issue of The Journal of the American Medical Association.

"This offers dramatic evidence that children benefit from successful treatment of a parent's depression," Weissman tells WebMD.

Getting Help Is Essential

The study has a dark side. When depression treatment didn't work - or didn't reduce a mother's depressive symptoms by at least 1/2 - children suffered worsening mental health.

In the STAR-D study, only 1/3 of the mothers got fully better - what doctors call remission - within 3 months. Only 1/2 had a 50% reduction in symptoms, which is the minimal improvement found to help the depressed parent's children.

This means it's essential for a depressed parent to get immediate help & to stay with treatment until something works, says Eva Ritvo, MD. Ritvo is associate professor of psychiatry at the University of Miami's Miller School of Medicine & chief of psychiatry at Mount Sinai Medical Center in Miami Beach, Fla.

"Not only do children get well when the parent's depression gets better, but they get worse if the parent doesn't," Ritvo tells WebMD. "So a parent's depression should be treated early & aggressively & thoroughly. This tells us that depression is real, that treatment really helps & that other family members are impacted by this disease & by its treatment."

How Parents' Depression Affects Kids

Weissman's team found that at the beginning of the study, 1/2 the kids had a history of psychiatric disorders & 1/3 was currently suffering mental health problems.

The mothers all started treatment with Celexa, an SSRI antidepressant (as did all STAR-D participants).

If the mothers' depression fully lifted, the children's mental health problems decreased by 11%. If the mothers didn't fully respond to treatment, their child's psychiatric diagnoses increased by 8%.

For the children who already had a mental health problem, 33% fully recovered - that is, they lost their psychiatric diagnoses - if their mothers' depression fully lifted. If the mothers' symptoms didn't fully improve, only 12% of the kids fully recovered.

Even more impressive was what happened to children who hadn't yet suffered mental health problems. If the mothers' depression fully lifted, all the kids remained mentally healthy. But among mothers who didn't fully improve, 17% of their children were later diagnosed with a psychiatric disorder.

This shows the powerful effect of a parent's depression on a child, says child & family psychiatrist Marilyn B. Benoit, MD, past president of the American Academy of Child & Adolescent Psychiatry & clinical associate professor at Georgetown University in Washington, D.C.

"What you have to consider is, this is affecting the children on a day-to-day basis," Benoit says. "How the parent greets them in the morning sets the tone for their day. And if you have an ill-tempered, angry, or isolated parent, that changes the dynamics of the interaction immediately."

Generations of Depression

These effects are passed from generation to generation.

"In a previous study, we showed that depression was transmitted across generations," Weissman says. "And if a parent and grandparent are depressed, rates of anxiety and depression in the grandchild are very high."

The good news is that successful depression treatment counteracts this effect.

"This is big. Think of a funnel and how the impact of treating parents broadens as you look at their children and grandchildren," Benoit says. "By changing the parents' symptoms and changing the parent-child dynamics from negative to positive, you've affected the trajectory for a whole generation. And over 30 years, I've seen the 3rd generation come along. I've seen how changing the grandparents has made life better for their grandchildren."

Sticking With Treatment

Only 1/3 of the mothers enrolled in the STAR-D trial fully responded to treatment in the first phase of the study. But the whole point of the study is to keep treating patients until something works.

"If you start with antidepressant treatment and don't get full recovery, the story is not over," STAR-D study co-leader Madhukar H. Trivedi, MD, tells WebMD. Trivedi is professor of psychiatry and director of the mood disorders research program at the University of Texas Southwestern Medical Center.

Weissman, Ritvo and Benoit stress that it's important not to give up on depression treatment - especially for a parent.

"Mothering is a heavy task and you have to be well to do it," Ritvo says. "If mothers with depression don't get well, we physicians have to be more aggressive in finding a treatment that works because more than one person is suffering."

"This is the message: Depression is a treatable disorder," Weissman says. "There are many treatments. In this case, it was medication. Sometimes it's psychotherapy. As a parent, you must know that depression isn't your fault. It's a medical illness - and you have to get help. So get treated and get better because it'll help you and help the family."

Fathers and Depression

Weissman says that while her study focused on mothers, she is sure that a father's depression also affects his children.

"Fathers get depressed. And they deserve the same kind of aggressive treatment," she says. "Fathers' rates of depression aren't as high as in mothers, but their treatment is important."

Benoit says in most families, mothers still have more interaction with children than fathers. This means that a mother's depression often will have a stronger effect than a father's depression.

"If the father is depressed, the mothers tend to serve as a buffer from the father's pathology," Benoit says. "So that's why I think the mothers have a more critical role to play."

Treating the child of a depressed parent can help the child. But it's not as effective as getting to the root of the problem.

"It's possible to help the child cope with the parent's depression. By working with the children, you help them to get the protective buffer they need," Benoit says. "But there's nothing quite as good as getting that depressed parent treated."

source: WebMd   Sources



You and the blues: your job sucks. your relationship is worse. You hate the way you look and feel. You don't want to wake up in the morning and can't wait to go to bed at night. You are not alone. Millions of men today suffer from depression, but they do it in silence

Men's Fitness,  Sept, 2008  by Linda Villarosa

Terahshea J. McCray will often power through 100 pullups and 700 pushups during a typical workout. He may also bench 420 pounds. Beyond being in tip-top shape, this lifestyle coach and personal trainer in New York City is the kind of guy you want to grab a beer with.

He's funny, and his energy, is infectious. During his tough, one-on-one training sessions, he's always quick to remind his clients, "I believe in you." [paragraph] And yet McCray, this buff 33-year-old guy's guy - considered a paragon of positivity by his clients - often struggles to believe in himself.

He has grappled with bouts of spirit-crushing depression steadily since his early teen years. Not until he was 16, with his hormones surging and his parents' divorced, did McCray began to realize he was prone to anger and sadness.

Even today, he describes his parents' breakup as "the loss of my father," an event that made the already volatile teen even more prone to mood swings. Fast-forward to about 10 years ago, when McCray reached his bluest point yet. Crushed by the breakup of a long-term relationship and embroiled in a custody battle for his son, Nadir, McCray found himself suffering what he now describes as a meltdown.

"I can remember vividly being at work and feeling so overwhelmed I started to cry uncontrollably in front of everyone," he recalls. "I was, I ran, a physically strong man. But I couldn't control my emotions. I had no idea that I was depressed. I had no idea what was wrong with me." McCray was depressed. With love and support from his mother, and the help of a therapist who confirmed his diagnosis, he eventually began to accept his condition.

McCray wasn't alone, of course. The National Institute of Mental Health estimates that at least six million men will be diagnosed with depression this year and millions more will suffer in confused, lonely silence. Experts who study depression stress that the emotional pain men suffer is often either ignored or wildly misunderstood. "Men start out with the assumption that they don't get depressed because depression is a women's disease," says Martin Kantor, Ph.D., a psychiatrist and author of the book Lifting the Weight: Understanding Depression in Men, Its Causes and Solutions.

It's not surprising that men are much less likely than women to know when they're depressed. Even if they do realize something is indeed wrong with them or receive an actual diagnosis of clinical depression, men often avoid treatment due to embarrassment or fear of being belittled. Many physicians and mental health professionals also miss signs, since the condition manifests itself differently in men than women. "Depression is a concept we've created based on symptoms seen in women," says Kantor. "When the symptoms don't match, even doctors assume that men aren't depressed. But that doesn't make any sense."


Depression is more than just sadness or a case of the "blues." It's not a sign of weakness, and you can't make it go away by bucking up and pulling yourself together - by "being a man." It's a serious medical condition, caused by a combination of genetic, chemical, and psychological factors.

Depression tends to run in families and is more common in people who have undergone a serious trauma - such as abuse or violence. It can have devastating effects, of course: interfering with your ability to work, sleep, study, eat, and enjoy activities that used to be fun, like sex. Unrecognized depression can transform nice guys into jerks, ruin otherwise-solid relationships and even kill.

Studies show that men, overall, are four times more likely to kill themselves than women. Depression is one of the leading reasons why. "Women generally internalize their feelings by becoming sad, while men lash out instead, hurting themselves and others; says Sam V. Cochran, Ph.D., director of the University Counseling Service at the University of Iowa.

He cites the Feb. 14 shooting at Northern Illinois University: A male student who had stopped taking antidepressant medication shot and killed five classmates before turning the gun on himself. "Ninety-nine percent of shootings like these are men or boys," cites Cochran. "They have succumbed to our culture of violence as a twisted way to cope with their feelings."

For some guys, like McCray, depression comes and goes. Unpredictable episodes are often triggered by an onrushing, overwhelming sense of failure. The pressures created by the current down economy, including the plethora of layoffs nationwide, make men today particularly susceptible.

"Men are action-oriented and focus on performance more than women;' says Cochran, who is also the co-author of the book Men and Depression: Clinical and Empirical Perspectives. "Men see themselves as winners or losers. So if a relationship breaks up, a man may feel that he's failed, he's not good enough. The same overwhelming feelings of failure come up for a man who loses his job."


Nate Reynolds, a 35-year-old manager of a Riverside, Calif., cement company, has suffered from depression his whole life. He hit rock bottom several years ago after his wife discovered he was having an affair. He felt as if he'd failed as a husband, father, and, ultimately, as a man, which only exacerbated his condition.

"Our marriage hadn't been going well, but I hadn't been able to talk about it and instead got involved with another woman;' admits Reynolds, a former Air Force man. "After [our marriage] unraveled, I saw the disappointment in my son's eyes and had this profound feeling of shame. I thought I had lost everything - my wife, my son, and my self-respect."

Separated and feeling totally alone, Reynolds moved into an empty house in Palm Springs, Calif. "I couldn't eat, I couldn't sleep; I lay on the floor crying" he confesses. "I would've hung myself, but I couldn't find anything that would hold me."

Neither Reynolds' actions nor emotions are unique. "I'm seeing more and more men in my practice who are depressed because they feel as if they are utter failures at being husbands and fathers" says David B. Wexler, Ph.D., author of the book "He Depressed or What?

"There's always been a lot of pressure on men to perform and achieve. But now men are also expected to be in touch with their feelings, balance work and home life, and be good parents - skills that have traditionally been women's domain."


Though some men cope in ways that fit the standard pattern of depression - withdrawing, crying, talking negatively about themselves, and crawling into bed - many others don't. And that's what can make a diagnosis so challenging. In fact, a man suffering from depression might actually look to be the total opposite - maybe even an overachieving, fife-of-the-party guy.

"In classic depression, you usually see a reduction of behavior, but in male-type depression, there's often a desperate attempt to do more" says Wexler. "To jump-start his system and feel alive again, a man might actually seem more productive. He might become a workaholic, engage in high-risk behavior like drinking or using drugs, or demand more sex from his partner or someone else. It might work temporarily, but it doesn't solve the problem."

Back when he was experiencing trouble in his marriage, McCray tried to avoid reigniting his depression by being almost maniacally productive. "I was working two jobs, going to school, and training really hard" he says. "I would begin a run at 1 a.m. It didn't seem unreasonable at the time. I was being so productive that I had no idea I was depressed. But now I know that I was using my work, my workouts, my education as a crutch. I was literally and physically running away from my problems."

Other men simply fall back on the emotion they're most comfortable with: anger. "For men, depression can look like heightened antagonism, irritability, and blame of others," says Wexler. "But if you peel back that layer of being pissed, what you see is an unhappy soul."


For still others, depression feels like a performance problem: I can't concentrate; I can't get it up in bed; I'm not getting enough done; my grades are down. Or depression might manifest itself as a physical illness. "A man might go to his doctor complaining of back pain, chest pain, or feeling tired and fatigued" says Kantor. "He has no idea that his depression is showing up as bodily symptoms. It feels more confusing if his doctor says, 'I can't find anything wrong with you.'"


Unfortunately, most men generally don't seek help unless they're prodded or forced by friends or family. "Some [men] are forced to seek treatment because of anger-management problems or domestic violence" says Drexler. "Others because someone in their lives, most often a female partner, insists that they get help."

Reynolds had considered therapy at different times in his life but was too embarrassed to follow through. "At one point in the late '90s, I was really miserable and knew something was wrong, but I convinced myself that I could just suck it up and get over it," Reynolds says. "I didn't know anybody who was going to therapy, and I couldn't go to my family doctor. So in the end, though I was closed off and sleeping all the time, I decided 'I'm a man, I don't need help.'"

Splitting with his wife was what finally drove Reynolds into treatment. "My wife was willing to work on things, if I agreed to get help" he says. "I joined a men's group that talks about relationships, family, and career issues. It was profound to see that I didn't need to be ashamed of what I was feeling and what I was going through. I learned that I wasn't alone and that it was OK to admit that I needed help."

Fredric E. Rabinowitz, Ph.D., a clinical psychologist and professor at the University of Redlands, runs that group, which first began 20 years ago. He says talking and support has had a huge impact on the men he works with. In fact, his first group became so popular, that he started a second to accommodate the demand.

"Men are hungry to talk about things that are bothering them" he says. "A lot of guys feel that if they talk about their problems, they'll fall into the loser category. So many of them end up pouring out everything only when they're drunk. They have a good drunk cry with a friend and get it out. The more healthy response is to have that same talk when sober."

So after demonstrating the guts to seek a diagnosis and, if needed, treatment, what does life hold for a man suffering from depression? Though some require medication to help ease the symptoms, others get better through therapy (in a group or individual setting).

Reynolds takes antidepressant medication but says the group has been most helpful. "I still have days when I'm down" he says. "But talking with the other men in the group has made me much more self-aware and better able to deal with things."


McCray also credits therapy with helping him cope with his dark days. Now he relies on regular, but not obsessive, exercise, along with spending time with his sons, to stabilize his moods. "I realize that I'm the kind of person who suffers from intermittent depression," he says. "Understanding what I'm feeling and accepting that depression is more than just having a bad day has been extremely important in keeping me healthy."

Reynolds also rims several times a week now, and spends the majority of his free time with his wife and son. And he's going back to school - to be a therapist. "Recognizing my problems and getting help," he says, "has been the best thing I've ever done."



While some men experience classic symptoms of depression - hopelessness, fatigue, and loss of appetite - many others feel and behave differently. According to psychotherapist Jed Diamond, author of The Irritable Male Syndrome: Managing the 4 Key Causes of Depression and Aggression, chronic forms of these behaviors may also be a warning sign of possible depression:





Feelings of under-appreciation


Feeling unloved






For more info, visit Diamond's Web site, www.menalive.com


Depression should not be taken lightly. Once you are ready to look for help, there are many easily accessible options.

Go to http://mentalhealth.samhsa.gov/databases/ to find mental health services in your city.

If you start having thoughts of suicide, the National Suicide Prevention Lifeline is available 24 hours a day: 1-800-273-TALK.

COPYRIGHT 2008 Weider Publications
COPYRIGHT 2008 Gale, Cengage Learning

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U.S. PSYCH: Depression Remission Rates Remain Low, But There's Hope
By Crystal Phend, Staff Writer, MedPage Today
April 26, 2007
SAN FRANCISCO, April 25 - Remission rates remain low for major depression even with multiple antidepressant drug classes available, but the recently approved selegiline patch (Emsam) aims to bring the rates up.

"The mission for the condition is remission," said James W. Jefferson, M.D., of the University of Wisconsin in Madison, but "we're still stuck with this low remission rate."

Just getting a response with treatment, defined as reducing depression scores by at least 1/2 isn't enough, he said in a presentation here at the U.S. Psychiatric and Mental Health Congress regional extension.

The consequences of failing to achieve remission include greater relapse risk, increased risk of resistance to treatment & worse prognosis for Axis III disorders.

Remission should encompass complete resolution of symptoms & full restoration of psychosocial & work-related functioning, Dr. Jefferson said. But the cutoffs that somewhat arbitrarily define remission on rating scales - such as a score of 7 or more on the Hamilton Rating Scale for Depression - allow for residual symptoms.

Several studies, including the National Institutes of Health-funded STAR*D trial (Sequenced Treatment Alternatives to Relieve Depression), have shown complete remission rates as low as 7%, he noted.

While there are few neuropeptide-based agents on the horizon for depression, a new administration route of an old agent may be a new tool in improving remission rates, Dr. Jefferson suggests.

The monoamine oxidase inhibitors were "decent drugs but a little hard to use," he acknowledged. Adverse events, particularly the risk of acute hypertensive effects with tyramine intake from cheese & other foods & with concomitant use of over-the-counter decongestants, were a major problem.

But the selegiline transdermal patch, FDA approved in February 2006 for treating depression, bypasses the gut to eliminate those problems, Dr. Jefferson said.

One study showed a "large margin of safety" for tyrosine intake & others showed it was well-tolerated compared with placebo, which led the FDA to allow the lowest dose of the drug (6 mg/day) to be used without dietary restriction.

Five placebo-controlled clinical trials have now been done, of which two were positive for efficacy, two showed a trend toward efficacy & one failed. The one placebo-controlled study of the selegiline patch showed it was effective in preventing relapse.

"Monoamine reuptake is helpful for half of depressed patients, but only 1/3 or fewer reach remission," Dr. Jefferson concluded. "Other mechanisms of action are needed & are becoming available."

In a study of fluoxetine (Prozac) published in the Journal of Clinical Psychiatry in 1999, only 20% of patients who achieved a remission score were fully in remission.

Of the rest, 44% had sleep disturbance, 38% had fatigue & 27% had low interest or pleasure scores.

For a more clinically relevant look at remission rates, the NIH-funded STAR*D trial (Sequenced Treatment Alternatives to Relieve Depression) was undertaken. The results were published in 2006 in the American Journal of Psychiatry and the New England Journal of Medicine.

In the trial, patients progressed from initial treatment with citalopram (Celexa) to bupropion (Wellbutrin), sertraline (Zoloft), venlafaxine (Effexor), or augmented citalopram, then to mirtazapine (Remeron) or nortriptyline (Aventyl, Pamelor) or their previous therapy augmented with lithium or another antidepressant & finally to tranylcypromine (Parnate) or mirtazapine plus venlafaxine.

Only about 30% of patients achieved remission in the first treatment level. In the second level, remission was about 20% when medication was switched or about 30% when it was augmented, with no significant difference between medications.

In the 3d level, remission was 12% to 19% when medication was switched & 16% to 25% when it was augmented, with no difference between the medications in remission rates.

By the 4th level, remission rates were "terribly low" at 7% & 14% with no significant difference between treatments.

STAR*D showed how hard it is to achieve remission, Dr. Jefferson said.

Nonetheless, "don't settle for less than remission," he admonished psychiatrists. "Don't give up!"

source: Medpage Today

"I feel like myself again": after a bout with depression, this reader took control of her life through diet and exercise - and is happier and fitter than ever

Shape,  Oct, 2008  by Kelly Marages

Brook Barth


Age 28

Height 5'4"

Pounds lost 65

At this weight 1 year

Brook's challenge

Through her early 20s, Brook was slim thanks to cheerleading and regular workouts. But after the birth of her daughter, she suffered from postpartum depression, which triggered poor eating and exercise habits. in three years, she packed on 65 pounds.

Weighing the facts

Brook recognized that her erratic lifestyle - eating either too much or not enough, staying out late with friends, or not leaving the house for days - was a problem and consulted a psychiatrist. But she didn't realize how heavy she'd become until her husband voiced his concern for her physical health.

That's when Brook stepped on the scale and saw the number that changed everything: 180. "I was shocked. I weighed exactly what I did the day I gave birth, but this time I wasn't pregnant," she says. "Since it was January, I made a resolution: Lose 40 pounds and get back to my old self for my sake and my family's."

Pursuit of happiness

To start, Brook began walking in her neighborhood every day, pushing her daughter in her stroller. At night she scanned nutrition Web sites. "When I saw that my big portions of starches, sweets, and chicken nuggets easily added up to 3,000 calories a day, I knew my diet needed an overhaul," she says.

She began eating 5 times a day: three meals including whole grains, vegetables, and lean proteins, and two snacks, like yogurt or almonds. "For motivation, I kept picturing what I would look like if I kept it up," she says. In three months, she was down 20 pounds.

Brook felt confident enough then to join a gym - and was surprised by how easy it was to get into an exercise routine. "My stamina - and drive - had improved more than I'd expected," she says. By summer she'd lost the 40 pounds, and her mood soared.

Pushing the limits

Brook was so proud of her transformation that even after she reached her original goal, she continued to challenge herself at the gym. "I wanted to be in peak shape, so I tried yoga, kick boxing, and strength-training classes," she says.

By fall, she'd settled in at 115 pounds. "After spending a long time being depressed, I was my bubbly self again. I couldn't even recognize the person I'd been for several years," she says. "It's amazing how much exercising and eating right can do for your body and your mind."

RELATED ARTICLE: 3 stick-with-it secrets

* Consider exercise a prescription "My workouts make me feel more balanced, so I think of them like medicine. I wouldn't skip medication, so why would I skip the gym?"

* Supercharge your journal "Rather than record just the food I eat, I also write down the calories I burn at the gym. That way, I can make sure the energy I take in and the energy I put out stays equal."

* Have a substitute "When I want something that's not good for me, like fried chicken, I don't ignore the craving. I just make a healthier version, like baked chicken."

Weekly workout schedule

Cardio 30 to 45 minutes/5 days a week Strength training or yoga 30 minutes/4 days a week

COPYRIGHT 2008 Weider Publications
COPYRIGHT 2008 Gale, Cengage Learning

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Physician suicide rates suggest lack of treatment: greater awareness of depression needed

Clinical Psychiatry News,  July, 2008  by Jane Anderson

Each day in the United States, roughly one doctor dies by suicide. Studies over the past 4 decades have confirmed that physicians--especialy women physicians--die. by suicide more frequently than people in other professions or those in the general population.

"Physicians have the means and the knowledge and access to ways to kill themselves," Dr. Paula Clayton, a psychiatrist and medical director for the American Foundation for Suicide Prevention, said in an interview.

But the data on physician suicide are difficult to come by, and "We certainly don't have any data that [say] any particular specialty has any higher rates of suicide," Dr. Clayton said.

No information is available on the risk of suicide by specialty, but researchers do know that physician suicides are equally divided between men and women, whereas in the general population, four times as many men kill themselves as do women, according to Dr. Clayton.

Awareness of the problem remains low, and professional and cultural barriers deter or prevent physicians who are depressed from seeking treatment for their illness, Dr. Clayton said. For example, most physicians do not have a regular source of health care; only 35% of doctors have a personal physician, and even fewer interns and residents have a doctor themselves.

Dr. W. Gerald Austen, surgeon-in-chief emeritus at Massachusetts General Hospital, has first-hand experience with physician suicide. Twenty-eight years ago, when he was surgeon-in- chief, one of his younger staff committed suicide. And about 11 years ago, a surgical resident committed suicide.

Those two deaths were the two saddest moments of his career, yet Dr. Austen said he doesn't know what the department and the hospital could have done to prevent these young physicians from taking their own lives.

"It wasn't as if the institution and the department weren't aware that they had some problems." he said in an interview. "Both of these individuals were under psychiatric care. They were believed by both their doctors and their contemporaries and colleagues to be doing rather well."

In each case, the surgery department reviewed the situation with the psychiatry department, Dr. Austen said, and "we certainly did everything we could in terms of their family in both cases." But he said the department did not find any procedures to change internally as a result of the deaths.

It's possible that increasing awareness of physician depression could help get physicians the help they need before it's too late, Dr. Austen said. "Friends who work with people in medicine need to be aware that, if they see something that concerns them, they need to transmit the message to the powers that be."

But it's difficult to know the difference between someone who is simply unhappy, and someone who is clinically depressed and potentially at risk for suicide, he added. "[Physicians believe] their job is to help other people with problems. If they have a problem themselves, they would prefer to not have people know about it," Dr. Austen said.

"There's this proudness about their ability to cope," Dr. Clayton said. "They are reluctant to seek help because they fear the stigma will harm them--people won't refer them patients, the hospital might revoke their privileges, and licensing could become a problem."

State medical licensing boards ask for information on whether the person applying for licensure has been treated for a mental illness, and that information can affect licensing, she said. "I worked with a physician who took lithium," she said. "The state board made him get blood drawn periodically to prove he continued to take it. That's punitive--they don't do that for other illnesses." However, some progress has been made in reducing the stigma: A total of 19 states now focus specifically on whether an applicant is impaired because of psychiatric illness, she said.

Dr. Clayton's group recently funded the production of three films on physician suicide as part of an ongoing outreach campaign that seeks to educate physicians about depression. The goal is to help them better recognize the symptoms in themselves and their patients while also cultivating a more thorough understanding of mood disorders in the community at large.

One of the films was designed specifically as an educational video for use at medical schools. Because many of the mood disorders that can lead to suicide might become evident first during medical school, where professional and institutional barriers already exist, the goal of that program is to encourage medical students to seek help for depression.

Good treatments exist. Dr. Clayton said. "The treatment clearly is antidepressants and psychotherapy that focuses on your problems. There's very good short-term psychotherapy for depression--even for bipolar disorder."

The medical licensing boards of 19 states now focus on whether an applicant is impaired because of psychiatric illness.

BY JANE ANDERSON Contributing Writer

COPYRIGHT 2008 International Medical News Group
COPYRIGHT 2008 Gale, Cengage Learning

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medpage today!

MSNBC / MSN Health

Postpartum Depression: A Risk for New Dads, Too: In one large study, 10% of fathers reported symptoms

Depression and Divorce

How does depression affect marriage and relationships?
By Kathleen Doheny

The 20-something couple, married just a few years, was eagerly looking forward to the birth of their first baby.

Labor and delivery went fine, and the baby was born healthy. But problems began when the new mom, overwhelmed by motherhood, suffered depression.

"The husband had to take care of everything," recalls Joan R. Sherman, MFT, a licensed marriage and family therapist in Lancaster, Pa., who saw the couple in counseling.  When he was at work, he worried that his wife was so depressed she wasn't paying needed attention to the baby. He became so worried he secretly set up a "nanny cam."

She got more and more depressed; he got more anxious, angry, and resentful.

As this case history suggests, depression that affects one partner has an effect on the other partner, the relationship and ultimately the entire family. Nearly 15 million American adults, or about 6.7% of the U.S. population age 18 and older, is affected with a major depression in a given year, according to the National Institute of Mental Health.

Statistics about how frequently depression affects one partner in a relationship are elusive, say Sherman and other experts. But mental health counselors like Sherman say depression often leads couples to seek counseling, fearful the depression will lead to divorce.

Depression and Divorce: Inevitable?

The depression itself doesn't lead directly to divorce, experts say. Rather, it is the consequences of not addressing the depression.

"I don't usually hear, 'I got a divorce because my wife was depressed,'" Sherman tells WebMD. Much more typical: "My spouse became distant and had an affair."

"Depression can lead to other problems," agrees Constance Ahrons, PhD, professor emeritus of sociology at the University of Southern California, Los Angeles, and an author and speaker based in San Diego who has researched and written about divorce. Affairs aren't the only problems, she says. Often, one partner may get so depressed he stops working, and that can lead to a cascade of other problems.

But there's hope, mental health experts say, if couples address the depression. Try to understand how it affects each partner, determine its roots, keep communication open, and get professional help if needed.

Depression: Partners in Agony

Depending on the extent of the depression, the depressed spouse often tunes out and gives up on life. A depressed person may sleep too much, or too little. Depressed people often stop eating much, or overeat, and may have difficulty concentrating and conversing.

"The depressed person often feels responsible, but they feel like they can't do anything about [their inertia]," says Ahrons. "Many of them don't even know why they are depressed."

Meanwhile, the other partner feels compelled to pick up the slack, especially if there are children. They may be very understanding and sympathetic at first, say Ahrons and Sherman.

How Depression Can Lead to an angry Marriage

But as exhaustion and frustration increase, the feelings of the unaffected partner may turn to anger or resentment. If the depressed partner doesn't enjoy engaging in activities the couple used to do together, that's another source of irritation, Ahrons says. "The other partner either has to do things on their own or stay home, too," she says.

If a partner has never been depressed, he or she may have a hard time understanding the mood disorder. That can be difficult if you're a very upbeat type, Ahrons says. She says she often hears an upbeat partner say of a depressed spouse: "Why can't he just pull himself up?"

The partner who isn't depressed may also feel cheated, says Dan Jones, PhD, director of the Counseling and Psychological Services Center at Appalachian State University in Boone, N.C. That's understandable, he says, because the depressed partner is typically not much fun.

"Most people fall in love because they are enjoying each other's company and having fun together," he says.

"The depressed person will [often] give the impression he doesn't care," he says. "It's hard to feel intimate with someone [who looks like he does not care]," he says.  There is often a loss of interest in sex by the depressed person, which further strains the relationship.  

If the depression persists for months, or years, both partners can feel the distance between them widening. The non-depressed spouse will often think: "How can he be depressed?  "We have a happy marriage," says Anita H. Clayton, MD, professor of psychiatry and neuro-behavioral sciences at the University of Virginia, Charlottesville. But sometimes, one has nothing to do with the other. Other times, the depression is due to marital dissatisfaction.

Unraveling the Roots of Depression

Some depression is transient, such as when a partner loses a parent or other family member. Within a few weeks, typically, the person feels a bit better.

Other times, the depression might continue or reoccur several times. Having a history of depression makes it more likely to have another episode, says Clayton. "With the first depression, we can usually link it to some event," she says, such as job loss, or a serious medical problem. "We can identify a trigger."

"The more episodes you have, the less likely it is linked to an event," she says, perhaps because of underlying brain changes.

Getting Help for Depression in Marriage: What Works?

If a couple decides that professional counseling is needed, the depressed partner may want to go alone first, Jones says. Or, he has found that some non-depressed partners try to persuade the depressed person to get help and the partner won't go.

Seeing a therapist together can give a couple valuable perspective, he says. "The therapist mediates," he says. "It's not a blaming session, but rather the therapist helps the depressed person recognize they are contributing to [the problem]. If they improve the depression, they could improve the marriage."

In a study, Italian researchers reviewed the data on whether couple therapy was a better way to treat depression in one partner and found no difference between couple therapy and individual therapy on the symptoms of depression. But couple therapy better reduced "relationship distress," they report in the journal Psychiatric Quarterly.

Often, talking about the depression -- whether alone or with a partner in therapy -- brings up other issues in a marriage that, when addressed, help ease the depression, Sherman says.

Combining Talk Therapy With Antidepressants for Depression

If depression doesn't improve with behavior or talk therapy, a physician may decide to prescribe an antidepressant, or may prescribe it along with the therapy.

Antidepressant medications can help, Clayton says. "Medications and therapy are often very useful." If the depression is milder, one or the other may be enough, she says; if it is more severe a combination treatment may be better.

In a study published in the Journal of Consulting and Clinical Psychology, Stanford University researchers compared medication alone, talk therapy alone, or a combination in 656 patients with chronic depression. They concluded that the combination produces a faster, fuller remission of chronic depression.

Like many medications, antidepressants can interact with other medicine, and cause side effects.  Patients should always tell their doctors about the medicines they take, and call the doctor if they notice side effects. Another class of antidepressant may be prescribed.

Depression and Relationships: Prognosis?

Sometimes, the partner of a person with depression will feel responsible, and stick with the marriage even if they’ve become more of a caretaker than a spouse.

But more often, if the depression continues for years, the partner does get tired of it and seeks divorce, Ahrons says.

Which couples are most likely to stay together? Those who acknowledge depression as a problem, try to relieve it, and keep talking with each other.

Remember the young couple at the beginning of this story? The new mother and her husband actually strengthened their marriage once they acknowledged the depression and sought treatment, Sherman says.

When she counseled the couple, the wife acknowledged she had ambivalence about becoming a mother. Her husband took issue with her housekeeping and his displeasure only grew worse when motherhood reduced available time to clean. The marital dissatisfaction may have contributed to her depression.

So they worked on those issues. He eased up on housekeeping standards. She talked through her ambivalence about motherhood. It was mainly rooted, Sherman found, in her lack of confidence.

"Her depression lifted once they started talking," Sherman says. Their relationship improved.

"The last time I talked to them," she reports, "they were doing well."

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