Bipolar Disorder

Overview

Bipolar disorder involves periods of excitability (mania) alternating with periods of depression. The "mood swings" between mania and depression can be very abrupt.

Statistics

About 5.7 million Americans, or 2.6% of the American population over the age of 18, have bipolar disorder.

Symptoms

The manic phase may last from days to months and can include the following symptoms:

• Agitation or irritation


• Elevated mood



• Hyperactivity


• Increased energy


• Lack of self-control


• Racing thoughts




• Inflated self-esteem (delusions of grandeur, false beliefs in special abilities)


• Little need for sleep


• Over-involvement in activities


• Poor temper control


• Reckless behavior



• Binge eating, drinking, and/or drug use


• Impaired judgment


• Sexual promiscuity


• Spending sprees




• Tendency to be easily distracted

These symptoms of mania are seen with bipolar disorder I. In people with bipolar disorder II, hypomanic episodes involve similar symptoms that are less intense.

The depressed phase of both types of bipolar disorder involves very serious symptoms of major depression:

• Difficulty concentrating, remembering, or making decisions


• Eating disturbances



• Loss of appetite and weight loss


• Overeating and weight gain




• Fatigue or listlessness


• Feelings of worthlessness, hopelessness and/or guilt


• Loss of self-esteem


• Persistent sadness


• Persistent thoughts of death


• Sleep disturbances



• Excessive sleepiness


• Inability to sleep




• Suicidal thoughts


• Withdrawal from activities that were once enjoyed


• Withdrawal from friends

There is a high risk of suicide with bipolar disorder. While in either phase, patients may abuse alcohol or other substances, which can worsen the symptoms.

Sometimes there is an overlap between the two phases. Manic and depressive symptoms may occur simultaneously or in quick succession in what is called a mixed state.

How does bipolar disorder affect someone over time?

Bipolar disorder usually lasts a lifetime. Episodes of mania and depression typically come back over time. Between episodes, many people with bipolar disorder are free of symptoms, but some people may have lingering symptoms.

Doctors usually diagnose mental disorders using guidelines from the Diagnostic and Statistical Manual of Mental Disorders, or DSM. According to the DSM, there are four basic types of bipolar disorder:

1. Bipolar I Disorder is mainly defined by manic or mixed episodes that last at least seven days, or by manic symptoms that are so severe that the person needs immediate hospital care. Usually, the person also has depressive episodes, typically lasting at least two weeks. The symptoms of mania or depression must be a major change from the person's normal behavior.


2. Bipolar II Disorder is defined by a pattern of depressive episodes shifting back and forth with hypomanic episodes, but no full-blown manic or mixed episodes.


3. Bipolar Disorder Not Otherwise Specified (BP-NOS) is diagnosed when a person has symptoms of the illness that do not meet diagnostic criteria for either bipolar I or II. The symptoms may not last long enough, or the person may have too few symptoms, to be diagnosed with bipolar I or II. However, the symptoms are clearly out of the person's normal range of behavior.


4. Cyclothymic Disorder, or Cyclothymia, is a mild form of bipolar disorder. People who have cyclothymia have episodes of hypomania that shift back and forth with mild depression for at least two years. However, the symptoms do not meet the diagnostic requirements for any other type of bipolar disorder.

Some people may be diagnosed with rapid-cycling bipolar disorder. This is when a person has four or more episodes of major depression, mania, hypomania, or mixed symptoms within a year.  Some people experience more than one episode in a week, or even within one day. Rapid cycling seems to be more common in people who have severe bipolar disorder and may be more common in people who have their first episode at a younger age. One study found that people with rapid cycling had their first episode about four years earlier, during mid to late teen years, than people without rapid cycling bipolar disorder.  Rapid cycling affects more women than men.

Bipolar disorder tends to worsen if it is not treated. Over time, a person may suffer more frequent and more severe episodes than when the illness first appeared.  Also, delays in getting the correct diagnosis and treatment make a person more likely to experience personal, social, and work-related problems.

Proper diagnosis and treatment helps people with bipolar disorder lead healthy and productive lives. In most cases, treatment can help reduce the frequency and severity of episodes.

Treatment

For the manic phase of bipolar disorder, antipsychotic medications, lithium, and mood stabilizers are typically used. For the depressive phase, antidepressants are sometimes used, with or without the manic phase treatment.

There is very little long-term evidence suggesting that any medication has great success in the maintenance phase. However, in studies that followed patients for 2 years, lithium and some antipsychotics were found to be moderately successful.

Antipsychotic drugs can help a person who has lost touch with reality. Anti-anxiety drugs, such as benzodiazepines, may also help. The patient may need to stay in a hospital until his or her mood has stabilized and symptoms are under control.

Electroconvulsive therapy (ECT) may be used to treat bipolar disorder. ECT is a psychiatric treatment that uses an electrical current to cause a brief seizure of the central nervous system while the patient is under anesthesia. Studies have repeatedly found that ECT is the most effective treatment for depression that is not relieved with medications.

Getting enough sleep helps keep a stable mood in some patients. Psychotherapy may be a useful option during the depressive phase. Joining a support group may be particularly helpful for bipolar disorder patients and their loved ones.

Risk factors for bipolar disorder

Scientists are learning about the possible causes of bipolar disorder. Most scientists agree that there is no single cause. Rather, many factors likely act together to produce the illness or increase risk.

Genetics

Bipolar disorder tends to run in families, so researchers are looking for genes that may increase a person's chance of developing the illness. Genes are the "building blocks" of heredity. They help control how the body and brain work and grow. Genes are contained inside a person's cells that are passed down from parents to children.

Children with a parent or sibling who has bipolar disorder are four to six times more likely to develop the illness, compared with children who do not have a family history of bipolar disorder. However, most children with a family history of bipolar disorder will not develop the illness.

Genetic research on bipolar disorder is being helped by advances in technology. This type of research is now much quicker and more far-reaching than in the past. One example is the launch of the Bipolar Disorder Phenome Database, funded in part by NIMH. Using the database, scientists will be able to link visible signs of the disorder with the genes that may influence them. So far, researchers using this database found that most people with bipolar disorder had:

• Missed work because of their illness


• Other illnesses at the same time, especially alcohol and/or substance abuse and panic disorders


• Been treated or hospitalized for bipolar disorder.

The researchers also identified certain traits that appeared to run in families, including:

• History of psychiatric hospitalization


• Co-occurring obsessive-compulsive disorder (OCD)


• Age at first manic episode


• Number and frequency of manic episodes.

Scientists continue to study these traits, which may help them find the genes that cause bipolar disorder some day.

But genes are not the only risk factor for bipolar disorder. Studies of identical twins have shown that the twin of a person with bipolar illness does not always develop the disorder. This is important because identical twins share all of the same genes. The study results suggest factors besides genes are also at work. Rather, it is likely that many different genes and a person's environment are involved. However, scientists do not yet fully understand how these factors interact to cause bipolar disorder.

Brain structure and functioning

Brain-imaging studies are helping scientists learn what happens in the brain of a person with bipolar disorder.  Newer brain-imaging tools, such as functional magnetic resonance imaging (fMRI) and positron emission tomography (PET), allow researchers to take pictures of the living brain at work. These tools help scientists study the brain's structure and activity.

Some imaging studies show how the brains of people with bipolar disorder may differ from the brains of healthy people or people with other mental disorders. For example, one study using MRI found that the pattern of brain development in children with bipolar disorder was similar to that in children with "multi-dimensional impairment," a disorder that causes symptoms that overlap somewhat with bipolar disorder and schizophrenia.  This suggests that the common pattern of brain development may be linked to general risk for unstable moods.

Learning more about these differences, along with information gained from genetic studies, helps scientists better understand bipolar disorder. Someday scientists may be able to predict which types of treatment will work most effectively. They may even find ways to prevent bipolar disorder.

Tests & diagnosis

A diagnosis of bipolar disorder involves consideration of many factors. The health care provider may do some or all of the following:

• Ask about your family medical history, particularly whether anyone has or had bipolar disorder


• Ask about your recent mood swings and for how long you've experienced them


• Observe your behavior and mood


• Perform a thorough examination to identify or rule out physical causes for the symptoms


• Request laboratory tests to check for thyroid problems or drug levels


• Speak with your family members to discuss their observations about your behavior


• Take a medical history, including any medical problems you have and any medications you take

Note: Use of recreational drugs may be responsible for some symptoms, though this does not rule out bipolar affective disorder. Drug abuse may itself be a symptom of bipolar disorder.

Prognosis

Mood-stabilizing medication can help control the symptoms of bipolar disorder. However, patients often need help and support to take medicine properly and to ensure that any episodes of mania and depression are treated as early as possible.

Some people stop taking the medication as soon as they feel better or because they want to experience the productivity and creativity associated with mania. Although these early manic states may feel good, discontinuing medication may have very negative consequences.

Suicide is a very real risk during both mania and depression. Suicidal thoughts, ideas, and gestures in people with bipolar affective disorder require immediate emergency attention.

Complications

Stopping or improperly taking medication can cause your symptoms to come back, and lead to the following complications:

• Alcohol and/or drug abuse as a strategy to "self-medicate"


• Personal relationships, work, and finances suffer


• Suicidal thoughts and behaviors

This illness is challenging to treat. Patients and their friends and family must be aware of the risks of neglecting to treat bipolar disorder.

When to contact a doctor

Call your health provider or an emergency number right way if:

• You are having thoughts of death or suicide


• You are experiencing severe symptoms of depression or mania


• You have been diagnosed with bipolar disorder and your symptoms have returned or you are having any new symptoms

If you have suicidal thoughts



Suicidal thoughts and behavior are common among people with bipolar disorder. If you or someone you know is having suicidal thoughts, get help right away. Here are some steps you can take:

• Contact a family member or friend.


• Seek help from your doctor, a mental health provider or other health care professional.


• Call a suicide hot line number — in the United States, you can reach the toll-free, 24-hour hot line of the National Suicide Prevention Lifeline at 800-273-8255 to talk to a trained counselor.


• Contact a minister, spiritual leader or someone in your faith community.

Sources and Additional Information:

https://health.google.com/health/ref/Bipolar+disorder

http://www.nimh.nih.gov/health/publications/bipolar-disorder/complete-index.shtml

http://en.wikipedia.org/wiki/Bipolar_disorder

http://www.mayoclinic.com/health/bipolar-disorder/DS00356/DSECTION=symptoms

http://health.nytimes.com/health/guides/disease/bipolar-disorder/background.html

Music Therapy is Effective for Depression Treatment

With origins believed to date back as early as Aristotle and Plato, music therapy has become an alternative to traditional cognitive and behavioral therapies.  Michigan State University developed the first college curriculum in 1944 in response to a positive impact music therapy had on veterans of WWI and WWII. Music therapy successes are based on the utilization of creative lyrics, in addition to harmony, to stimulate the senses of a patient. In doing so, music therapy provides an impact to the physical, cognitive, emotion and social well-being. More recently, music therapy has begun to incorporate into the treatment of eating disorders, ADHD and depression with a benefit exhibited to both genders and across various age groups.



In the treatment of depression, music therapy provides spoken words in addition to harmony in an effort to provide inspiration and promote wellness.  Music therapy alleviates pain and promotes calmness by slowing the heart rate and other bodily functions. It is through the therapy that a patient will feel more adept to expressing emotion and begin to feel a motivation to fight against the disease. 

Recent Studies

Music therapy might help ease the symptoms of depression, though its effectiveness as a stand-alone intervention is not certain, according to a recent review of five small studies.

Four of the studies found reduced depression symptoms in participants receiving music therapy compared to those who did not. The fifth study did not find any difference.

The benefits of music appeared greatest when providers used theory-based therapeutic techniques rather than “winging it.”

“In the four studies where there was an impact, there was a very coherent theoretical framework, a very coherent explanation of what went on in the session and obvious reasons why the therapists were there,” said lead author Anna Maratos. “In the study that showed no effect, there didn’t seem to be any theoretical underpinning to the intervention. We have no idea why the therapist was there, really.”

Therapeutic interventions included listening to music in groups, body movement and painting to music, and improvised singing.

The review appears in the most recent issue of The Cochrane Library, a publication of The Cochrane Collaboration, an international organization that evaluates medical research. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing medical trials on a topic.

Maratos, head of profession for Arts Therapies at the Central and Northwest London NHS Foundation Trust, and colleagues looked for randomized controlled trials that compared music therapy with other, more traditional interventions for depression. They found a dearth of rigorous research.

Because there was little or no uniformity in study approaches, study populations or therapeutic techniques, the researchers did not pool the results for meta-analysis.

Maratos said that although the fifth study did not meet reviewers’ eligibility criteria, it was included because it was the only study with a certified professional coordinating the sessions.

The reviewers defined music therapy as an intervention designed to improve health status that included musical interaction between therapist and patient within a structured theoretical framework and in which outcomes were born of music, talk inspired by music or therapeutic relationships.

Each study author determined his or her own definition of standard care, on the other hand, which included pharmacological, routine hospital and cognitive therapeutic treatment.

Three studies focused on adults aged 60 and older; one study looked at adults between ages 21 and 65; and one focused on 14- and 15-year-old adolescents.

Although the studies did not show a definitive cause-and-effect relationship between music therapy and clinical improvement in depression, the authors found a positive correlation. They attributed the unevenness of the studies’ results to the varied uses of music by therapists in the studies and the relative weakness of some researchers’ methods.

The researchers found unusually high levels of participation and compliance among patients receiving the interventions.

Shara Sand, Psy.D., clinical assistant professor of psychology at Yeshiva University in New York City, agreed with researchers’ conclusion that meta-analysis was not possible in the review, but said that the evidence of music’s influence on mood makes the research question interesting.

“It does make me wonder: What is standardized treatment [in music therapy]? There’s really a whole avenue of research that should be done,” Sand said.

She adding that music therapy broadens the range of interventions available to people who might shy away from traditional approaches: “There’s often an isolation and alienation; a difficulty connecting and with relatedness” for people with depression, and the music therapy might offer a less threatening option.

Maratos said that her own status as a licensed music therapist spurred her interest in doing the review and added that music therapy is a state-sanctioned mental health treatment in the United Kingdom.

The Graduate School of Art Therapy Study

Researchers from the Graduate School of Art Therapy, Daejeon University, Daejeon, South Korea, tested whether group music therapy is effective for improving depression, anxiety and relationships in 26 patients allocated to either a music intervention group or a routine care group.

The music intervention group received 60 minutes of music intervention for 15 sessions (one or two times weekly).

The study found that after 15 sessions, the music intervention group showed significant improvements in depression, anxiety and relationships compared with the control group.

The authors concluded that despite the positive results, objective and replicable measures are required from a randomized controlled trial with a larger sample size and an active comparable control.

There is evidence that music that reflects the listener's personal preference is more likely to have desired effects. It is possible that music through headphones during medical procedures could interfere with the patient's cooperation with the procedures. Further research is needed in this area.

Entrainment List for Depression

For successful music therapy, the entrainment list for depression should be made based on an individual's musical tastes. Classical and pop music tend to be the easiest styles to use when producing a progression from depression to neutral/happy. Sometimes country or rock will work as well, but heavy metal music is not usually a good choice.

The following factors are important to consider when trying music as an anti-depressant:

• The most important factor is the meaning of each song to the person listening.


• Ten to 14 songs make up the ideal list.


• The first three songs are increasingly depressing and the fourth is the most depressing.


• The fifth song is slightly brighter – hope has been introduced.


• Subsequent songs become happier until a neutral or slightly happy mood is reached by the tenth song.


• If desired, a few more songs may be added to reinforce the desired mood (relaxed, happy, carefree, inspired, etc.).

The person experiencing the depressed mood should find a comfortable position either sitting or lying down. Then he or she should listen to the playlist from start to finish.

During the depressing songs, it is important to thoroughly feel and experience the sadness or hopelessness, rather than attempting to fight it off. Continuing with the rest of the list should naturally improve the mood; it is unlikely that the person will get "stuck" in a very depressed state (unless the entrainment list is not completed). The natural anti-depressant effect of the music will bring the person out of the undesired mood and into a neutral or happy state.

Sources and Additional Information:

http://www.associatedcontent.com/article/26744/music_therapy_as_treatment_for_depression.html

http://www.sciencedaily.com/releases/2008/01/080122203158.htm

http://depressiongrief.suite101.com/article.cfm/music_therapy_for_depression

http://www.alternateheals.com/music-therapy/depression-music-therapy.htm

http://blog.naturalstandard.com/natural_standard_blog/2008/07/music-therapy-f.html

http://alzheimers-review.blogspot.com/2010/02/music-therapy-for-alzheimers-patients.html

Can St. John's Wort replace Prozac for Depression Treatment?

The extract from St. John's wort (Hypericum perforatum), a bushy, wild-growing plant with yellow flowers, has been used for centuries in many folk and herbal remedies. Today in Europe, it is used extensively to treat mild to moderate depression. In the United States, it is one of the top–selling botanical products.

Historical St. John's Wort Applications

The historical use of medical St. John's wort is well documented. Commencing 2400 years ago St. John's wort was used as a nerve tonic, a painkiller for arthritis, menstrual cramping, gastrointestinal problems (such as diarrhea and nausea) as well as ulcers.



The ancient Greeks and Romans used to treat many ailments, including sciatica and poisonous reptile bites as well as to ward against evil spirits, placing sprigs of the plant on statues of their Gods. In fact, the genus name Hypericum is from Greek and means "over an apparition" as the herb was once considered odiferous enough to cause evil spirits to depart.



In the first century St. John’s wort was referred to in Pliny the Elders famous book on natural history for its bracing quality in treating diarrhea and promoting urine flow and bladder troubles.



Dioscorides, a Roman army surgeon, recommended drinking St Johns wort in his medical text, “For it expels choleric excrements…” He also recommended rubbing it on burns. Paracelsus, a medical authority of the Renaissance also wrote of using St. John’s wort to treat wounds. He was also the first to mention using it for psychotic symptoms which he called “phatasmata”.



During medieval times, the Europeans used the plant to treat all forms of madness (They thought St. Johns wort had magical properties) as it blooms near the Summer Solstice. The Saltenitan drug list of the thirteenth century also referred to St. John’s wort as herba demonis fuga--an herb to chase away the devil.



Sixteenth century medical books refer to the plant as Fuga demonum, or devil’s scourge, a term that was repeated frequently in the literature of the next several hundred years.



The oil made from the flowers was listed in the first Pharmacopoeia Londinensis (1618). 1630 Angelo Sala stated that St. John’s wort treated illnesses of the imagination, melancholia, anxiety and disturbances of understanding. He wrote, “St. John’s wort cures these disorders as quick as lightening.” Gerard wrote that its use as a balm for wounds, burns, ulcers and bites was without equal (Gerard 1633).



There is even evidence that the American Indians used St. John's wort used it in the treatment of Tuberculosis and other breathing ailments.



Civil War soldiers collected St. John's wort to use on battle wounds. A prolific and hardy plant that threatened grazing land, a beetle was introduced into the Pacific Northwest in the early 1900's to keep St. John's wort under control.



19th century literature incorporated the use of hypericum to treat melancholia. 19th century British and American literature stressed the superficial use of the herb for the treatment of burns and wounds. A powerful antibacterial, St. John’s wort has been used through the centuries as an analgesic (pain reliever) to treat saddle sores and in poultices for certain lameness's in horses.



More contemporary St. Johns Wort applications

• Over time, and the advent of modern pharmaceutical science, St. John's Wort was nearly forgotten as a medicinal herb. Only recently has St. John's Wort gained a renewed reputation as an effective treatment for all manner of infirmities most notably depression. Its complex and diverse chemical makeup has also shown to support depression related infirmities such as chronic fatigue syndrome, and pms.


• St. John's Wort's antibacterial / antiviral properties render it very useful adjunctive treatment for bacterial and viral infections.


• St. Johns Wort has also been shown to be useful in treating pulmonary complaints, bladder trouble, suppression of urine, dysentery, worms and nervous depression.


• St. Johns Wort can act to dissolve and remove bacterially based tumors and boils. It calms the nerves and increase the flow of urine.


• St. John's Wort is an excellent blood cleanser and blood purifier.


• For Tourette's syndrome - used with Wormseed


• Bells' Palsy (apply directly on face)


• St. Johns Wort antibacterial/viral properties have been shown useful in relieve phlegm obstructions in the chest and lungs. It can be beneficial in addressing bronchitis as well.


• Like Horsechestnut, St. Johns Wort may be valuable for treating internal bleeding.


• St. Johns Wort is used to treat chronic uterine problems and will correct irregular and painful menstruation.


• St. Johns Wort contains an alkaloid that is a heart and artery stimulant


• Is useful for low back pain


• Mattioli wrote of its use as an emmenagogue and antimalarial (Bombardelli and Morazzoni 1995).


• Most recent research at two of the world's leading medical institutions, New York University and the Weizman Institute of Science in Israel ,found that 2 of the main constituents of St. John's Wort namely hypercin and pseudohypericin were found to inhibit the growth of retroviruses( including HIV, the AIDS virus) in animals. Although the results of these studies are promising, more work needs to be done. The mechanism is thought to involve the production of oxygen free radicals which can damage the viral envelope. 

Why people use St. John's Wort as an alternative therapy for depression

Some patients who take antidepressant drugs do not experience relief from their depression. Other patients have reported unpleasant side effects from their prescription medication, such as a dry mouth, nausea, headache, or effects on sexual function or sleep.



Sometimes people turn to herbal preparations like St. John's wort because they believe "natural" products are better for them than prescription medications, or that natural products are always safe. Neither of these statements is true (this is discussed further below).



Finally, cost can be a reason. St. John's wort costs less than many antidepressant medications, and it is sold without a prescription (over the counter).

How is St. John's wort sold?

St. John's wort products are sold in the following forms:

• Capsules


• Teas--the dried herb is added to boiling water and steeped for a period of time.


• Extracts--specific types of chemicals are removed from the herb, leaving the desired chemicals in a concentrated form.

Does St. John's wort work as a treatment for depression?

There has been scientific research to try to answer this question.



In Europe, results from a number of scientific studies have supported the effectiveness of certain St. John's wort extracts for depression. An overview of 23 clinical studies, published in the British Medical Journal in 1996, found that the herb might be useful in cases of mild to moderate depression. The studies, which included 1,757 outpatients, reported that St. John's wort was more effective than a placebo (a "dummy" pill designed to have no effect) and appeared to produce fewer side effects than some standard antidepressants.



Other studies conducted recently have found no benefit from the use of St. John's wort for certain types of depression. For example, the results of a study funded by Pfizer Inc., a pharmaceutical company, found that St. John's wort, when compared with placebo, was not effective for treating major depression.



In addition, several components of the National Institutes of Health--NCCAM, the Office of Dietary Supplements, and the National Institute of Mental Health--funded a large, carefully designed research study to find out whether St. John's wort extract benefits people with major depression of moderate severity. This trial found that St. John's wort was no more effective for treating major depression of moderate severity than placebo.

Are there any risks to taking St. John's wort for depression?

Yes, there are risks in taking St. John's wort for depression.



Many so-called "natural" substances can have harmful effects--especially if they are taken in too large a quantity or if they interact with something else the person is taking.



Research from the NIH has shown that St. John’s wort interacts with some drugs--including certain drugs used to control HIV infection (such as indinavir). Other research shows that St. John’s wort can interact with anticancer, or chemotherapeutic, drugs (such as irinotecan). The herb may also interact with drugs that help prevent the body from rejecting transplanted organs (such as cyclosporine). Using St. John’s wort limits these drugs’ effectiveness.



Also, St. John's wort is not a proven therapy for depression. If depression is not adequately treated, it can become severe and, in some cases, may be associated with suicide. Consult a health care practitioner if you or someone you care about may be experiencing depression.



People can experience side effects from taking St. John's wort. The most common side effects include dry mouth, dizziness, gastrointestinal symptoms, increased sensitivity to sunlight, and fatigue.

To address increasing American interests in St. John's wort, the National Institutes of Health conducted a clinical trial to determine the effectiveness of the herb in treating adults who have major depression. Involving 340 patients diagnosed with major depression, the eight–week trial randomly assigned one-third of them to a uniform dose of St. John's wort, one–third to a commonly prescribed SSRI, and one–third to a placebo. The trial found that St. John's wort was no more effective than the placebo in treating major depression. Another study is looking at the effectiveness of St. John's wort for treating mild or minor depression.



Other research has shown that St. John's wort can interact unfavorably with other medications, including those used to control HIV infection. On February 10, 2000, the FDA issued a Public Health Advisory letter stating that the herb appears to interfere with certain medications used to treat heart disease, depression, seizures, certain cancers, and organ transplant rejection. The herb also may interfere with the effectiveness of oral contraceptives. Because of these potential interactions, patients should always consult with their doctors before taking any herbal supplement.

In general, you should be alert for any of the following effects if you are taking St. John's Wort:

• allergic reactions


• fatigue and restlessness with long-term use


• increased blood pressure


• increased sensitivity to the sun -- especially if you are fair-skinned and taking large doses


• stomach upsets

Sources and Additional Information:

http://www.depressiontreatment.com/articles/146/Depression-Treatment

http://www.hypericum.com/

http://www.mamashealth.com/mental/johndep.asp

http://altmedicine.about.com/cs/anxietydepression/a/SJW.htm

http://www.webmd.com/depression/guide/st-johns-wort?page=2

http://nccam.nih.gov/health/stjohnswort/sjw-and-depression.htm

The Center for Epidemiologic Studies Depression Scale (CES-D)

The CES-D scale is a short self-report scale designed to measure depressive symptomatology in the general population. The items of the scale are symptoms associated with depression which have been used in previously validated longer scales. The scale was tested in household interview surveys and in psychiatric settings. It was found to have very high internal consistency and adequate test- retest repeatability. Validity was established by pat terns of correlations with other self-report measures, by correlations with clinical ratings of depression, and by relationships with other variables which support its construct validity. Reliability, validity, and factor structure were similar across a wide variety of demographic characteristics in the general population samples tested. The scale should be a useful tool for epidemiologic studies of depression.

The CES-D was developed in the 1970s by Lenore Radloff while she was a researcher at the National Institute of Mental Health. Almost 85% of those found to have depression after an in-depth structured interview with a psychiatrist will have a high score on the CESD. However, about 20% of those who score high on the CESD will have rapid resolution of their symptoms and not meet full criteria for major or clinical depression.

For the 20 items below, circle the number next to each item that best reflects how frequently the indicated event was experienced in the past 7 days.

Rarely or none of the time (less than 1 day)	Some or a little of the time (1-2 days)	Occasionally or a moderate amount of time (3-4 days)	Most or all of the time (5-7 days)
DURING THE PAST WEEK:
1. I was bothered by things that usually don’t bother me.	0	1	2	3
2. I did not feel like eating; my appetite was poor.	0	1	2	3
3. I felt that I could not shake off the blues even with help from my family or friends.	0	1	2	3
4. I felt that I was just as good as other people.	3	2	1	0
5. I had trouble keeping my mind on what I was doing.	0	1	2	3
6. I felt depressed.	0	1	2	3
7. I felt that everything I did was an effort.	0	1	2	3
8. I felt hopeful about the future.	3	2	1	0
9. I thought my life had been a failure.	0	1	2	3
10. I felt fearful.	0	1	2	3
11. My sleep was restless.	0	1	2	3
12. I was happy.	3	2	1	0
13. I talked less than usual.	0	1	2	3
14. I felt lonely.	0	1	2	3
15. People were unfriendly.	0	1	2	3
16. I enjoyed life.	3	2	1	0
17. I had crying spells.	0	1	2	3
18. I felt sad.	0	1	2	3
19. I felt that people disliked me.	0	1	2	3
20. I could not get "going."	0	1	2	3

Scoring: Since items 4, 8, 12, and 16 reflect positive experiences rather than negative ones, the scale should be reversed on these items so that 0 = 3, 1 = 2, 2 = 1, and 3 = 0. To determine the "depression score," add together the numbers for each answer. The score will be somewhere in the range of 0 to 60. A score of 16 or greater indicates that some depression may have been experienced in the past week.

Scoring and Assessment

Less than 16 Depression is not indicated

Consult a social worker to address any concerns you may have. People with scores in this range usually do not have clinical depression. However, emotional distress can be common in people with cancer. You are encouraged to get assistance from friends, family, clergy, social worker or your primary health care team.

16 - 20 Mild depression indicated

Seek assistance from mental health professional and/or a physician. People with scores in this range usually have a mild clinical depression that should be addressed. Getting help is not a sign of weakness; depression is a medical illness that can commonly affect people with cancer.

21-25 Moderate depression indicated

Seek assistance from mental health professional and/or a physician. People with scores in this range usually have a moderate clinical depression that should be addressed. Getting help is not a sign of weakness; depression is a medical illness that can commonly affect people with cancer.

26 or higher Severe depression indicated

It is important that you get assistance as soon as possible from your physician or mental health professional. People with scores in this range usually have a severe clinical depression. Getting help is not a sign of weakness; depression is a medical illness that can commonly affect people with cancer.

Sources and Additional Information:

http://pathwayscourses.samhsa.gov/aaap/aaap_4_supps_pg8.htm

http://www.cancerquest.org/index.cfm?page=4003

http://www.friendsnrc.org/download/outcomeresources/toolkit/annot/cesd.pdf

http://www.bmedreport.com/archives/7139

Monoamine Oxidase Inhibitors (MAOIs) - Antidepressants for Major Depression

Monoamine oxidase inhibitors (MAOIs) are one of the oldest classes of antidepressants and are typically used when other antidepressants have not been effective. They are used less frequently because they often interact with certain foods and require strict dietary restrictions. MAOIs can also result in severe adverse reactions if taken with many other medicines, including some over-the-counter cough and cold remedies. MAOIs are mostly used for atypical depression.

A newer type of MAOI called moclobemide is slightly different to the older MAOIs. It is considered to be a safer choice than the older MAOIs, as it requires fewer dietary restrictions and has fewer significant interactions with other medicines. Moclobemide is considered a second-line treatment for major depression.

How do MAOIs work?

It is thought that depression may be linked to an imbalance of chemicals within the brain.

Within the brain there are chemical messengers or neurotransmitters, called monoamines. Examples of these are noradrenaline and serotonin.

Neurotransmitters are involved in controlling or regulating bodily functions, and noradrenaline and serotonin are involved in the control and regulation of mood.

When depression occurs, there may be a decrease in the amount of these monoamines released from nerve cells in the brain. Monoamines are broken down by a chemical (enzyme), called monoamine oxidase.

MAOIs prevent monoamine oxidase from breaking down the monoamines. This results in an increased amount of active monoamines in the brain.

By increasing the amount of monoamines in the brain, the imbalance of chemicals, thought to be important in causing depression, is altered. This helps relieve the symptoms of depression.

Moclobemide is a more selective type of MAOI, called a reversible inhibitor of monoamine oxidase type A (RIMA). It works specifically on monoamine oxidase type A, which gives it its slightly different profile.

How long do MAOIs take to work?

MAOIs can take a while to have an effect so you may not feel better immediately when you start treatment with one.

You may experience an effect on your mood within two weeks, however, the full benefits of treatment with MAOIs may not occur for a further two to four weeks. It is important to keep taking the medicine even if you think it is not working at first.

If you feel your depression has got worse, or if you have any distressing thoughts or feelings in these first few weeks, then you should talk to your doctor.

How long will I have to take them for?

MAOIs usually help mood improve over a number of weeks or months. Even when things seem back to normal, you should keep taking them for a further six months to minimise the chances of the depression coming back.

Are they addictive?

No. It is possible for MAOIs to produce unpleasant withdrawal symptoms (sometimes called a discontinuation syndrome) when they are stopped. But this is temporary, does not involve a craving for the medication, and can usually be avoided if the drug is tapered off rather than stopped suddenly. This is not addiction.

Withdrawal symptoms may include nausea, headache, insomnia, giddiness, vivid dreams, agitation and irritability. These can sometimes occur if you miss a dose of the antidepressant, which is why it is important to take them as directed by your doctor.

When stopping treatment withdrawal symptoms can be minimized or avoided if the dose of the MAOI is gradually decreased over a period of a few weeks. Your doctor will help you do this.

Tolerance

Some people develop a tolerance to MAO inhibitors. This could mean that the drug will work for you at first, but you could suddenly become depressed again in the middle of treatment. This sort of reaction is particularly disturbing because it sets off a plummeting depression that may not respond to any other antidepressant. Oddly, if you develop tolerance to an MAOI, the best solution may be to switch to another antidepressant for a few weeks, and then start taking the same MAOI again. This way, the drug may regain its effectiveness.

Overdose

The MAO inhibitors are somewhat more dangerous drugs than other antidepressants when taken in excessive amounts -- far more so than newer drugs such as Prozac, Zoloft or Desyrel. Symptoms of overdose include severe anxiety, confusion, convulsions or seizures, cool clammy skin, severe dizziness, severe drowsiness, fast and irregular pulse, fever, hallucinations, severe headache, high or low blood pressure, muscle stiffness, breathing problems, severe sleeping problems, or unusual irritability.

Side Effects

Unfortunately, monoamine oxidase doesn't just destroy neurotransmitters to increase level of monoamines in the brain; it's also responsible for mopping up another amine called tyramine, a molecule that affects blood pressure. So when monoamine oxidase gets blocked, levels of tyramine begin to rise, too. And that's when the trouble starts.

While a hike in neurotransmitters is beneficial, an increase in tyramine is disastrous. Excess tyramine can cause a sudden, sometimes fatal increase in blood pressure so severe that it can burst blood vessels in the brain.

Every time you eat chicken liver, aged cheese, broad-bean pods, or pickled herring, tyramine floods into your brain. Normally, MAO enzymes take care of this potentially harmful tyramine excess. But if you're taking an MAO inhibitor, the MAO enzyme can't stop tyramine from building up. This is exactly what happened when the drugs were introduced in the 1960s. Because no one knew about the tyramine connection, a wave of deaths from brain hemorrhages swept the country. Other patients taking MAO inhibitors experienced severe headaches caused by the rise in blood pressure. These early side effects were particularly disturbing because nobody knew why they were happening.

The mystery was solved when a British pharmacist noticed that his wife, who was taking MAO inhibitors, got headaches when she ate cheese. But the early MAOIs were considered so dangerous (they also can damage the liver, brain, and cardiovascular systems) that even after the MAO-tyramine connection was finally understood, these drugs were taken off the American market for a time. (A related European antidepressant drug, Deprenyl, is marketed in this country as an anti-Parkinson's medication; it requires less stringent dietary cautions.)

Eventually the MAOIs were reintroduced in this country despite the tyramine risk because some depressed people don't respond to any other medication. Nevertheless, MAO inhibitors are usually the antidepressant of last resort.

"I call it the 'St. Jude' drug," says psychiatrist Andy Myerson. "It's the drug I use when nothing else works and someone is willing to give up anything in the hope that something will help their depression."

Side effects of MAOIs include:

• Drowsiness


• Constipation


• Nausea


• Diarrhea


• Stomach upset


• Fatigue


• Dry mouth


• Dizziness


• Low blood pressure


• Lightheadedness, especially when getting up from a lying or sitting position


• Decreased urine output


• Decreased sexual function


• Sleep disturbances


• Muscle twitching


• Weight gain


• Blurred vision


• Headache


• Increased appetite


• Restlessness


• Shakiness


• Trembling


• Weakness


• Increased sweating

3

Safety concerns with MAOIs

MAOIs can cause dangerous interactions with certain foods and beverages. And you can understand why. If you take MAOIs, you'll face dietary restrictions that require you to limit consumption of foods that contain a high level of tyramine, such as many cheeses, pickled foods, chocolates, certain meats, beer, wine, and alcohol-free or reduced-alcohol beer and wine. The interaction of tyramine with MAOIs can cause a dangerously high increase in blood pressure, which can lead to a stroke. Your doctor can give you a complete list of dietary restrictions.

Emsam may offer a way to avoid these dietary restrictions. At its lowest dose of 6 milligrams a day, you don't need to follow those dietary restrictions. At higher doses of Emsam, you do, though. Talk to your doctor or mental health provider to see if this may be an option for you.

MAOIs can also cause serious reactions when you take them while you're also taking certain other medications. Examples of medications to avoid include other antidepressants, certain pain medications such as tramadol (Ultram) and meperidine (Demerol) over-the-counter decongestants and herbal weight-loss products, and St. John's wort. Always check with your doctor or pharmacist before taking any new prescription medication, over-the-counter medication or supplement while taking MAOIs.

Dietary Restrictions

Don't eat or drink any of the following when taking MAOIs unless your doctor advises otherwise:

• aged foods


• alcoholic beverages (especially chianti, sherry, liqueurs, and beer)


• alcohol-free or reduced-alcohol beer or wine


• anchovies


• bologna, pepperoni, salami, summer sausage, or any fermented sausage


• caviar


• cheeses (especially strong or aged varieties), except for cottage and cream cheese


• chicken livers


• fermented foods


• figs (canned)


• fruit: raisins, bananas (or any overripe fruit)


• meat prepared with tenderizers; unfresh meat; meat extracts


• smoked or pickled meat, poultry, or fish


• soy sauce

Foods you can eat in moderation:

• avocados


• beer


• caffeine (including chocolate, coffee, tea, cola)


• chocolate


• raspberries


• sauerkraut


• soup (canned or powdered)


• sour cream


• yogurt

Serotonin syndrome and MAOIs

A rare but potentially life-threatening side effect of MAOIs is serotonin syndrome. This condition, characterized by dangerously high levels of serotonin in the brain, can occur when an MAOI interacts with another type of antidepressant called selective serotonin reuptake inhibitors (SSRIs). Because of this, don't take any MAOIs while you're taking any SSRIs or within two weeks of each other. Serotonin syndrome requires immediate medical treatment.

Signs and symptoms of serotonin syndrome include:

• Confusion


• Restlessness


• Hallucinations


• Extreme agitation


• Fluctuations in blood pressure


• Increased heart rate


• Nausea and vomiting


• Fever


• Seizures


• Coma

Stopping treatment with MAOIs

Discontinuation of MAOIs has been associated with nausea, vomiting and malaise. Rarely, discontinuation has caused an uncommon withdrawal syndrome involving vivid nightmares with agitation, psychosis and convulsions. The syndrome is treated with a low-dose MAOI and more gradual tapering off. Talk to your doctor before stopping treatment with MAOIs.

Suicidal feelings and MAOIs

In some cases, antidepressants may be associated with worsening symptoms of depression or suicidal thoughts or behavior in those ages 18 to 24. It's likely to occur in the first one to two months of treatment or when you change your dosage. Be sure to talk to your doctor about any changes in your symptoms. You may need more careful monitoring when beginning or changing treatment, or you may need to stop the medication if your symptoms worsen. Adults age 65 and older taking antidepressants have a decreased risk of suicidal thoughts.

Several Types of MAO Inhibitors and Their Dosages

-        Isocarboxazid (Marplan)

Usual Starting Dose: 30 mg/day

Maximum Dose: 30 mg/day

-        Phenelzine (Nardil)

Usual Starting Dose: 15 mg/day

Maximum Dose: 60 mg/day

-        Tranylcypromine (Parnate)

Usual Starting Dose: 30 mg/day

Maximum Dose: 60 mg/day

Sources and Additional Information:

http://www.netdoctor.co.uk/diseases/depression/monoamineoxidaseinhibitors_000101.htm

http://www.healthyplace.com/depression/antidepressants/monoamine-oxidase-inhibitors/menu-id-68/

http://www.mayoclinic.com/health/maois/MH00072

http://en.wikipedia.org/wiki/Monoamine_oxidase_inhibitor

Neuroreasons for Clinical Depression by Charles Nemeroff

Charles Nemeroff, a writer for Scientific America, states both decreased activity of a neurotransmitter, as well as overactivity of a hormonal system, can lead to severe depression and, concurrently, suicide. Neurotransmitters travel between neurons, or nerve cells, in order to perform functions vital to life. Nemeroff states norepinephrine and serotonin, both monoamine type neurotransmitters, are natural anti-depressants. In order to understand the way these monoamines affect human biological make-up, it is necessary to have a brief understanding of the way neurotransmitters work.

Between two neurons lies a small gap called the synapse. Neurotransmitters cross the synapse, being “fired” from one neuron and attaching to the next. Sometimes the receiving neuron will send out a message instructing the sending neuron to slow its rate of firing neurotransmitters. The sending neuron then has to pull the neurotransmitters back into itself, a process known as “reuptake”. Nemeroff points out that, due to overactive reuptake, reduced levels of norepinephrine have been noted in the brain of many depressed patients. Similarly, the study points out that in many patients who have committed suicide increased norepinephrine receptors were located in the brain’s cortex. Often receptors in the brain expand in number in order to compensate for low levels of transmitter molecules.

Due to these findings, reports Nemeroff, some drugs are now available that block norepinephrine reuptake and increase norepinephrine in the synapse, allowing it to act as an antidepressant. Serotonin is also a natural antidepressant and relates to drugs such as Prozac, which blocks serotonin reuptake. Nemeroff details how cells which produce serotonin often extend into many areas of the brain thought to contribute to depression, such as the hypothalamus. The drugs which prohibit serotonin reuptake are some of the most effective antidepressants ever made. Effexor is an especially effective drug because it blocks reuptake of serotonin and norepinephrine. Neurotransmitters are not the only biological elements which contribute to depression. Much research has been done that seems to show correlation between hormones and depression.

The hypothalamus regulates the hormonal system in the human body. As Nemeroff observed, the system that manages the body’s stress response is often singled out for causing severe depression. When there exists a physical or psychological threat to the body, the HPA-axis (hypothalamus-pituitary-adrenal) increases production of cortisol and, in effect, initiates the “fight or flight” function of the body. Nemeroff reports numerous studies show over-activation of the HPA-system may lead to depression. Because this system reacts to stress, however, it is unlikely that it will initiate itself without some type of anxiety-causing event. External sociological forces, coupled with increasingly negative psychological conflict, can cause the stress necessary to activate the HPA-system.

Biochemical functions, though extremely powerful and relevant to human behavior, rarely act alone. Simply because one may have a hyperactive HPA-axis or low levels of serotonin or norepinephrine monoamines, it is not definite a person will suffer from extreme depression or attempt suicide. Obviously emotions, though they may exist in chemical form, result from the ways people internalize and perceive external events as well as the ways in which people view themselves. The fact of the matter is people are strongly influenced by society, on conscious and subconscious levels. Society exists inside and outside of people, intermixing with the mind and with the psyche. The entire idea of consciousness is so complex and enigmatic, it is severely limiting to relate any aspect of it to only one particular school of science.

Nemeroff, 59, a psychiatrist at Emory University, is an internationally recognized expert on depression whose résumé spans 215 pages.

He has treated some of Atlanta’s top business leaders, including Ted Turner, retired CNN head Tom Johnson and the late J.B. Fuqua, whose family has given $10 million to Emory to study and treat depression. Under Nemeroff’s leadership, Emory’s psychiatry department pulled in more than $22 million in National Institutes of Health grants just

last year.



From 2000 through 2006, Nemeroff received just over $960,000 from GlaxoSmithKline (GSK), but only disclosed no more than $35,000 to Emory. Between 2000 and 2007, he earned more than $2.8 million from various drug makers but failed to report at least $1.2 million. He signed a letter in 2004 promising Emory administrators that he would earn less than $10,000 a year from GSK but on the same day he was at a hotel earning $3,000 of what would become $170,000 in income from the company—17 times greater than the figure he agreed upon. He was the principal investigator for a five-year $3.9 billion grant financed by the NIMH for which GSK provided the drugs, during which he received more than the annual $10,000 threshold allowed from the company. In 2006, he stepped down as editor of Neuropsychopharmacology after publishing a favorable review of the vagus nerve stimulation (VNS) device, manufactured by Cyberonics, for which he was a paid consultant.  In 2003, he coauthored a favorable review of three therapies in Nature Neuroscience failing to mention his significant financial interests in these, including owning the patent for one of the treatments—a lithium patch.  Nemeroff has consulted for 21 drug and device companies simultaneously.  In 1991 Nemeroff testified before the FDA on behalf of Eli Lilly in hearings into Prozac, saying that the drug did not cause suicidal acts of ideation—yet 13 years later, the FDA concluded the opposite and issued a black box warning about suicide risks. Nemeroff resigned his position at Emory in 2008.



Now he’s a primary target of a U.S. Senate Finance Committee investigation into whether pharmaceutical money compromises the integrity of medical research and scholarship, an ethics controversy that has set the international world of academic medicine abuzz. Studies, speeches and articles can influence which drugs are prescribed for patients (2008).

Sources and Additional Information:

http://newsgroups.derkeiler.com/Archive/Sci/sci.med.psychobiology/2008-10/msg00131.html

http://thebrain.mcgill.ca/flash/capsules/pdf_articles/neurobiology_depression02.pdf

http://www.cchrint.org/cchr-issues/the-corrupt-alliance-of-the-psychiatric-pharmaceutical-industry/