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 The latest reviews of unpublished as well as published studies in The New England Journal of Medicine and in the online journal, PLoS Medicine, for example, show that SSRIs are far less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).

BY JAMES S. GORDON, M.D.

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.

BY SHARON WORCESTER

Southeast Bureau

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

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Treating Parent Depression Helps Kids

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."

WHY DEPRESSION STRIKES

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."

WHAT IT LOOKS LIKE

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.'"

TREATMENT

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."

PHOTOGRAPHY BY AJ MAST

IRRITABLE MALE SYNDROME?

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:

• Anger
• Impatience
• Blaming

Dissatisfaction

Sarcasm

Anxiety

Hypersensitivity

Feelings of under-appreciation

Tension

Feeling unloved

Hostility

Argumentativeness

Frustration

Defiance

Defensiveness

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

GET HELP

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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