Your family can be your greatest source of support, comfort and love. But it can also be your greatest source of pain and grief. A health crisis, work problems or teenage rebellion may threaten to tear your family apart.
Family therapy may help your family weather the storm. Family therapy can help patch strained relationships among family members and improve how your family works together. Whether it's yourself, your partner, a child or even a sibling or parent, family therapy can help all of you relate more harmoniously.
What is family therapy?
Family therapy is a type of psychotherapy. It helps families or individuals within a family understand and improve the way family members interact with each other and resolve conflicts.
Family therapy is usually provided by therapists known as marriage and family therapists. These therapists provide the same mental health services as other therapists, simply with a different focus — family relationships.
Family therapy is often short term. You usually attend one session a week, typically for three to five months. In some cases, though, families may need more intensive treatment.
Who can benefit from family therapy?
In general, anyone who wants to improve troubled relationships can benefit from family therapy. Family therapy can help with such issues as:
Marital problems
Divorce
Eating disorders, such as anorexia or bulimia
Substance abuse
Depression or bipolar disorder
Chronic health problems, such as asthma or cancer
Grief, loss and trauma
Work stress
Parenting skills
Emotional abuse or violence
Financial problems
Family therapy may be an addition to other types of treatment, particularly for certain mental disorders that require more in-depth treatment. Family therapy shouldn't substitute for other necessary treatments. For instance, family therapy can help family members cope if a relative has schizophrenia. But the person with schizophrenia should continue with his or her individualized treatment plan, such as medication and possibly hospitalization.
In some cases, family therapy may be ordered by the legal system. Adolescents in trouble with the law may be ordered into family therapy rather than serving jail time, for instance. Violent or abusive parents are sometimes spared jail if they enter family therapy. Divorcing couples may also be required to attend family therapy.
How does family therapy work?
Family therapy often brings entire families together in therapy sessions. However, family members may also see a family therapist individually, and family therapy may include nonfamily members, such as schoolteachers, other health care providers or representatives of social services agencies.
Working with a family therapist, you and your family will examine your family's ability to solve problems and express thoughts and emotions. You may explore family roles, rules and behavior patterns in order to spot issues that contribute to conflict. Family therapy may help you identify your family's strengths, such as caring for one another, and weaknesses, such as an inability to confide in one other.
For example, say that your adult son has depression. Your family may not understand the roots of his depression or how best to offer help. Although you're worried about your son's health, you have such deep-rooted family conflicts that conversations ultimately erupt into arguments. You're left with hurt feelings, decisions go unmade, and the rift grows wider.
Family therapy can help you pinpoint your specific concerns and assess how your family is handling them. Guided by your therapist, you'll learn new ways to interact and overcome old problems. You'll set individual and family goals and work on ways to achieve them. In the end, your son may be better equipped to cope with his depression, you'll understand his needs better, and you, your spouse and your son may all get along better.
How do you choose a family therapist?
Like other psychotherapists, family therapists are licensed mental health professionals. Although different states have different licensing or credentialing requirements, most require advanced training, including a master's or doctoral degree, graduate training in marriage and family therapy, and training under the supervision of other experts. Many marriage and family therapists opt to become credentialed by the American Association for Marriage and Family Therapy (AAMFT), which sets specific eligibility criteria.
Most family therapists work in private practice. They may also work in clinics, mental health centers, hospitals and government agencies.
How do you find a family therapist who's right for you? The same way you'd find a psychiatrist, psychologist or other therapist: Ask lots of questions. Among them:
Are you a clinical member of the AAMFT or licensed by the state, or both?
What is your educational and training background?
What is your experience with my type of problem?
How much do you charge?
Are your services covered by my health insurance?
Where is your office, and what are your hours?
How long is each session?
How often are sessions scheduled?
How many sessions should I expect to have?
What is your policy on canceled sessions?
How can I contact you if I have an emergency?
Ask your primary care doctor for a referral to a marriage or family therapist. Family and friends also may give you recommendations based on their experiences. Your health insurer, employee assistance program, clergy or state or local agencies also may offer recommendations.
Monday, September 24, 2007
Defining mental illness: An interview with a Mayo Clinic specialist
Mental illnesses have been recognized for thousands of years. Today, advances in science are helping researchers better understand the origins of mental illness and find more effective treatments. But much remains to be learned. Here, Daniel Hall-Flavin, M.D., a psychiatrist at Mayo Clinic, Rochester, Minn., offers a modern interpretation of mental illness, including a look at how mental disorders are defined, the use of medications, the role of psychotherapy and how stress affects well-being.
What is mental illness?
Mental illness is a term that refers to all the different types of mental disorders, including disorders of thought, mood or behavior. To be classified as a mental illness, the condition must cause distress and result in a reduced ability to function psychologically, socially, occupationally or interpersonally.
This means that someone who has a mental illness may have trouble coping with emotions, stress and anger, for instance, and trouble handling such things as daily activities, family responsibilities, relationships, or work and school responsibilities. You can have trouble, to a greater or lesser degree, with one area or all of them. And you can have more than one type of mental illness at the same time.
How is the classification of mental illness evolving?
Today, we classify mental illness based on the symptoms a person experiences and the clinical features of the illness, such as feeling hopeless or having delusions. But as we continue to gain a clearer understanding of how specific genes interact with illnesses or behaviors, we may be able to develop a much more sophisticated classification system that is directly linked to a biological cause of mental illness, rather than just symptoms. This can help us better tailor treatment to individuals. For instance, some disorders have similar symptoms and clinical features but are actually very different in terms of their underlying biology. To treat them similarly simply because they share the same symptoms may not be appropriate. We suspect, for example, that there are different types of schizophrenia, with different causes, and that they possibly respond differently to different treatments.
What are the classes of mental illness?
Our evolving understanding of genetics and how the brain works may eventually change how we classify mental illnesses. For now, we think of several main classes of mental illness:
Mood disorders. These include disorders that affect how you feel, such as persistent sadness or feelings of euphoria. They include major depression and bipolar disorder.
Anxiety disorders. Anxiety is an emotion characterized by the anticipation of future danger or misfortune accompanied by a feeling of being ill at ease. Examples include panic disorder, obsessive-compulsive disorder, specific phobias and generalized anxiety disorder.
Substance-related disorders. These include problems associated with the misuse of alcohol, nicotine, caffeine and illicit drugs.
Psychotic disorders. These disorders impair your sense of reality. The most notable example of this is schizophrenia, although other classes of disorders can be associated with psychosis at times.
Cognitive disorders. These disorders affect your ability to think and reason. They include delirium, dementia and memory problems. Perhaps the most well-known of these disorders is Alzheimer's disease.
Developmental disorders. This category covers a wide range of problems that usually first begin to make themselves known in infancy, childhood or adolescence. They include autism, attention-deficit/hyperactivity disorder and learning disabilities. But just because they're all grouped in this category doesn't necessarily mean they share a common cause or that there's a relationship among the disorders.
Personality disorders. A personality disorder is an enduring pattern of inner experience and behavior that is dysfunctional and leads to distress or impairment. Examples include borderline personality disorder and antisocial personality disorder.
Other disorders. These include disorders of impulse control, sleep, sexual functioning and eating. Also included are dissociative disorders, in which a person's sense of self is disrupted, and somatoform disorders, in which there are physical symptoms in the absence of a clear physical cause, such as hypochondriasis.
Does all mental illness have a biological basis — a problem with the brain's chemistry?
No, not all of them. We know that many serious mental illnesses do have a strong biological basis. But that's not the entire story.
Some people, for example, might have an inherited, biological tendency to develop depression. They can experience serious depression even though no specific event triggers it. Others, however, have no known inherited tendency for depression. But if something happens, such as the death of a loved one, it can trigger major depression.
We don't yet know if the underlying neurochemical aspects of these two depressive reactions are the same. In other words, one person may have a mental illness because of their nature — their genetic vulnerabilities and, their neurochemical functioning. And another person may have a mental illness because of nurture — an environmental cause that perhaps changes their neurochemistry. Most of the time, however, it's probably a complex interaction of both nature and nurture.
With so many medications available to treat depression and other mental illness, is psychotherapy still a good option?
Yes, there is still a major role for psychotherapy in treating mental illness. Among the many forms of psychotherapy are brief therapy, cognitive-behavioral therapy, psychodynamic therapy, and family or couples therapy. Psychotherapy remains a very important part of treatment for many individuals, couples and families and often is the treatment of choice.
Medication might be all that some people need to restore their brain chemistry to a more normal state. But it's psychotherapy and education that can help change coping behaviors and offer strategies to help understand and modify risk factors for illness. In some cases, medication is entirely ineffective and psychotherapy alone is helpful. In other cases, someone may not be able to take psychiatric medications, for health or other reasons. But very often, a combination of medication and psychotherapy is most effective in treating mental illness.
Is mental illness more common these days?
More people seek help today than in the past. But is that because more people have a mental illness? Or is it because now it's more acceptable to seek help, and help is more readily available? Also, the world is more complicated and fast paced than it once was. Does this change in environment contribute to increased mental illness? We don't know the answers to those questions.
Is mental illness simply whatever a culture or society defines it as?
Behaviors that are approved of or frowned upon can vary greatly from culture to culture. But research shows a surprising consistency in the prevalence of serious mental illness across all cultures. Schizophrenia, for instance, occurs in about 1 percent of all populations worldwide. Major depression also has a consistent prevalence in countries around the world. This information supports the idea that serious mental illnesses have a biological basis common to all humans.
How does stress affect mental illness?
Going through a stressful event doesn't necessarily mean that you'll develop a mental illness, such as depression or an anxiety disorder. But it can increase your risk of developing a mental illness. Stress runs the gamut, from daily hassles, such as traffic jams and financial worries, to major life events, such as the breakup of a relationship or the death of a loved one. People who have experienced depression in the past are more vulnerable to depression after a major loss. People with an active, problem-solving style are less likely to experience mental illness such as depression than are those with a passive, emotion-focused style.
Many people are hesitant to get treatment for mental illness. How can they take that first step?
People may be hesitant to seek treatment for a number of reasons. They may think that their depression, for instance, will go away on its own. Or they may consider it a sign of weakness. In addition, some people fear the stigma that's sometimes attached to mental illness. But it's important to understand that biological factors play a major role in the development of mental illness, just as they do with other medical disorders. Effective treatment is available that can eliminate or minimize symptoms, improve a person's ability to function and ultimately improve the quality of their life.
What is mental illness?
Mental illness is a term that refers to all the different types of mental disorders, including disorders of thought, mood or behavior. To be classified as a mental illness, the condition must cause distress and result in a reduced ability to function psychologically, socially, occupationally or interpersonally.
This means that someone who has a mental illness may have trouble coping with emotions, stress and anger, for instance, and trouble handling such things as daily activities, family responsibilities, relationships, or work and school responsibilities. You can have trouble, to a greater or lesser degree, with one area or all of them. And you can have more than one type of mental illness at the same time.
How is the classification of mental illness evolving?
Today, we classify mental illness based on the symptoms a person experiences and the clinical features of the illness, such as feeling hopeless or having delusions. But as we continue to gain a clearer understanding of how specific genes interact with illnesses or behaviors, we may be able to develop a much more sophisticated classification system that is directly linked to a biological cause of mental illness, rather than just symptoms. This can help us better tailor treatment to individuals. For instance, some disorders have similar symptoms and clinical features but are actually very different in terms of their underlying biology. To treat them similarly simply because they share the same symptoms may not be appropriate. We suspect, for example, that there are different types of schizophrenia, with different causes, and that they possibly respond differently to different treatments.
What are the classes of mental illness?
Our evolving understanding of genetics and how the brain works may eventually change how we classify mental illnesses. For now, we think of several main classes of mental illness:
Mood disorders. These include disorders that affect how you feel, such as persistent sadness or feelings of euphoria. They include major depression and bipolar disorder.
Anxiety disorders. Anxiety is an emotion characterized by the anticipation of future danger or misfortune accompanied by a feeling of being ill at ease. Examples include panic disorder, obsessive-compulsive disorder, specific phobias and generalized anxiety disorder.
Substance-related disorders. These include problems associated with the misuse of alcohol, nicotine, caffeine and illicit drugs.
Psychotic disorders. These disorders impair your sense of reality. The most notable example of this is schizophrenia, although other classes of disorders can be associated with psychosis at times.
Cognitive disorders. These disorders affect your ability to think and reason. They include delirium, dementia and memory problems. Perhaps the most well-known of these disorders is Alzheimer's disease.
Developmental disorders. This category covers a wide range of problems that usually first begin to make themselves known in infancy, childhood or adolescence. They include autism, attention-deficit/hyperactivity disorder and learning disabilities. But just because they're all grouped in this category doesn't necessarily mean they share a common cause or that there's a relationship among the disorders.
Personality disorders. A personality disorder is an enduring pattern of inner experience and behavior that is dysfunctional and leads to distress or impairment. Examples include borderline personality disorder and antisocial personality disorder.
Other disorders. These include disorders of impulse control, sleep, sexual functioning and eating. Also included are dissociative disorders, in which a person's sense of self is disrupted, and somatoform disorders, in which there are physical symptoms in the absence of a clear physical cause, such as hypochondriasis.
Does all mental illness have a biological basis — a problem with the brain's chemistry?
No, not all of them. We know that many serious mental illnesses do have a strong biological basis. But that's not the entire story.
Some people, for example, might have an inherited, biological tendency to develop depression. They can experience serious depression even though no specific event triggers it. Others, however, have no known inherited tendency for depression. But if something happens, such as the death of a loved one, it can trigger major depression.
We don't yet know if the underlying neurochemical aspects of these two depressive reactions are the same. In other words, one person may have a mental illness because of their nature — their genetic vulnerabilities and, their neurochemical functioning. And another person may have a mental illness because of nurture — an environmental cause that perhaps changes their neurochemistry. Most of the time, however, it's probably a complex interaction of both nature and nurture.
With so many medications available to treat depression and other mental illness, is psychotherapy still a good option?
Yes, there is still a major role for psychotherapy in treating mental illness. Among the many forms of psychotherapy are brief therapy, cognitive-behavioral therapy, psychodynamic therapy, and family or couples therapy. Psychotherapy remains a very important part of treatment for many individuals, couples and families and often is the treatment of choice.
Medication might be all that some people need to restore their brain chemistry to a more normal state. But it's psychotherapy and education that can help change coping behaviors and offer strategies to help understand and modify risk factors for illness. In some cases, medication is entirely ineffective and psychotherapy alone is helpful. In other cases, someone may not be able to take psychiatric medications, for health or other reasons. But very often, a combination of medication and psychotherapy is most effective in treating mental illness.
Is mental illness more common these days?
More people seek help today than in the past. But is that because more people have a mental illness? Or is it because now it's more acceptable to seek help, and help is more readily available? Also, the world is more complicated and fast paced than it once was. Does this change in environment contribute to increased mental illness? We don't know the answers to those questions.
Is mental illness simply whatever a culture or society defines it as?
Behaviors that are approved of or frowned upon can vary greatly from culture to culture. But research shows a surprising consistency in the prevalence of serious mental illness across all cultures. Schizophrenia, for instance, occurs in about 1 percent of all populations worldwide. Major depression also has a consistent prevalence in countries around the world. This information supports the idea that serious mental illnesses have a biological basis common to all humans.
How does stress affect mental illness?
Going through a stressful event doesn't necessarily mean that you'll develop a mental illness, such as depression or an anxiety disorder. But it can increase your risk of developing a mental illness. Stress runs the gamut, from daily hassles, such as traffic jams and financial worries, to major life events, such as the breakup of a relationship or the death of a loved one. People who have experienced depression in the past are more vulnerable to depression after a major loss. People with an active, problem-solving style are less likely to experience mental illness such as depression than are those with a passive, emotion-focused style.
Many people are hesitant to get treatment for mental illness. How can they take that first step?
People may be hesitant to seek treatment for a number of reasons. They may think that their depression, for instance, will go away on its own. Or they may consider it a sign of weakness. In addition, some people fear the stigma that's sometimes attached to mental illness. But it's important to understand that biological factors play a major role in the development of mental illness, just as they do with other medical disorders. Effective treatment is available that can eliminate or minimize symptoms, improve a person's ability to function and ultimately improve the quality of their life.
Wednesday, September 19, 2007
Antidepressants: Selecting one that's right for you
Medication is often the first treatment choice for adults with moderate or severe depression. Although antidepressant medications don't cure depression, they can help you achieve remission — the disappearance or nearly complete reduction of symptoms. Sadness, anxiety, depression-related sleep and appetite problems, concentration, and energy levels all can improve with antidepressant medications.
For many people, combining medication use with psychotherapy, such as cognitive-behavioral therapy, proves most effective. With scores of antidepressants available, though, finding the right one for your situation can be challenging. Understanding what a treatment plan entails and what goes into determining the right medication for you will help you sort through your options.
How antidepressants work
Precisely how antidepressants work to treat depression remains speculative. Scientists do know that antidepressants can influence brain activity through the effects they have on mood-related brain chemicals called neurotransmitters and certain nerve cell receptors. Nerve cells release neurotransmitters to communicate with other nerve cells in the brain. Neurotransmitters transmit signals across a gap (synapse) between the nerve cells.
Neurotransmitters associated with depression are serotonin (ser-oh-TOE-nin), norepinephrine (nor-ep-ih-NEF-rin) and possibly dopamine (DOE-puh-mene). Research suggests that people with depression have lower levels of one or more of these neurotransmitters.
Nerve cells send a signal and then reabsorb (reuptake) the neurotransmitters after they've communicated with other nerve cells. Antidepressants interfere with this reuptake. This results in a greater quantity of a particular neurotransmitter remaining in the synapse. This can change the activity of certain nerve cells and influence brain activity. Maintaining a higher level of neurotransmitters improves neurotransmission — the sending of those nerve impulses — which, in turn, improves your mood.
In addition, a type of antidepressant called alpha-2 receptor blockers is thought to work by preventing neurotransmitters from binding with the nerve cell receptors called alpha-2 receptors. This indirectly increases the levels of norepinephrine and serotonin in your brain.
Numerous types of antidepressants available
Dozens of antidepressants are available, each affecting neurotransmitters in a different way. Antidepressants are typically grouped into categories, either based on when the medications came into use, their chemical structure or how they affect brain chemistry.
Here are the antidepressants that have been approved by the Food and Drug Administration (FDA) specifically to treat depression, with their generic names followed by available brand names in parentheses, and grouped by how they affect brain chemistry.
Selective serotonin reuptake inhibitors (SSRIs)
Citalopram (Celexa)
Escitalopram (Lexapro)
Fluoxetine (Prozac, Prozac Weekly)
Paroxetine (Paxil, Paxil CR)
Sertraline (Zoloft)
Serotonin and norepinephrine reuptake inhibitors (SNRIs)
Duloxetine (Cymbalta)
Venlafaxine (Effexor, Effexor XR)
Norepinephrine and dopamine reuptake inhibitors (NDRIs)
Bupropion (Wellbutrin, Wellbutrin SR, Wellbutrin XL)
Alpha-2 receptor blockers
Mirtazapine (Remeron, Remeron Soltab)
Combined reuptake inhibitors and receptor blockers
Trazodone (Desyrel)
Nefazodone (Serzone)
Maprotiline
Tricyclic antidepressants (TCAs)
Amitriptyline
Desipramine (Norpramin)
Doxepin (Sinequan)
Imipramine (Tofranil)
Nortriptyline (Aventyl, Pamelor)
Protriptyline (Vivactil)
Trimipramine (Surmontil)
Monoamine oxidase inhibitors (MAOIs)
Phenelzine (Nardil)
Tranylcypromine (Parnate)
Isocarboxazid (Marplan)
Off-label use of drugs
The FDA normally approves a drug to treat a specific condition in a particular population. Many drugs used to treat depression in adults have been FDA approved specifically for that use.
But doctors may also prescribe drugs to treat depression that haven't actually been approved to treat depression — a practice known as off-label use. For instance, doctors often prescribe clomipramine (Anafranil) because it may improve depression even though it's FDA approved for obsessive-compulsive disorder. The same may be true of other psychiatric drugs, as well.
Finding the right medication for you
So among the dozens available, which antidepressant should you take?
Finding the right one might take time. Each medication has its own pros and cons, and until you try one, you won't know how it'll affect you or how well it'll work. You may need to try several antidepressants before finding the one, or the combination, that's most effective for you with the fewest side effects.
Consider your health profile
Your family doctor or psychiatrist will take into account your symptoms and their severity, your health history, other illnesses you have and lifestyle factors when determining which antidepressant to prescribe.
Your doctor will also consider your age, sex, weight and diet, mostly because of concerns about side effects. Older adults, for instance, generally tolerate the side effects of the newer antidepressants better than the side effects of the older tricyclic antidepressants. However, for some people, the older medications are more effective in treating depression.
Pregnancy is also an issue. Some psychiatric medications may pose a risk to the developing baby. Other medications may be excreted in breast milk to infants.
If any close relatives, such as a brother or sister, have taken antidepressants, their experiences could predict how well a medication will work for you or what side effects you may experience. Tell your doctor if any of your close relatives have taken antidepressants.
Make your personal preferences known
How you take an antidepressant may also influence your medication choice. Some medications come in pill form, while others come as solutions or injections. You may not be comfortable taking an antidepressant that must be injected, for instance. Or you may prefer a once-a-week medication, while someone else doesn't mind taking several doses a day.
Cost is also a consideration. Some antidepressants are available in a generic form, which is generally cheaper than a brand-name version. Newer versions of a drug are sometimes more expensive than the original. But watch out — those newer versions aren't necessarily more effective.
Trying the medications
Once you and your doctor have selected an antidepressant for you to try, it may take four to eight weeks to determine its full effectiveness. With some medications, you can take the full dosage immediately. With others, you may need to gradually increase your dose.
If you have no improvement at all in your symptoms after six weeks, it may be time to try a different antidepressant or add a second medication to augment your treatment. You may have to taper off of one medication before starting another, because potentially dangerous drug interactions and withdrawal-like symptoms can occur from an abrupt switch.
In rare cases, antidepressants simply might not work for you. You may need to consider other forms of treatment, such as psychotherapy to help cope with social or other life stressors, or electroconvulsive therapy if your depression is severe or life-threatening.
Finding the right antidepressant and the correct dosage can take time. Talk to your doctor if you're having trouble coping with the wait.
Common side effects of antidepressants
All antidepressants cause some degree of side effects. Most side effects are mild and temporary. In general, the most common are:
Nausea
Sexual dysfunction
Constipation
Bladder problems
Dizziness
Drowsiness
Dry mouth
Changes in sleep patterns
Restlessness
Side effects vary by medication and by person. Your side effects might be more severe or less severe than what someone else taking the same medication experiences.
Side effects often are most pronounced within the first few days of beginning a new medication but then taper off. Side effects can increase or change if you take higher doses or combine antidepressants with other medications, including other antidepressants. Some antidepressants actually have fewer side effects at higher doses rather than lower doses.
Be sure to tell your doctor about your side effects, as some could require medical treatment or changes in your medication.
If an antidepressant is working for you but the side effects seem intolerable, ask your doctor for help dealing with the side effects so that you don't have to discontinue your medication.
New cautions about suicidal thoughts
In some cases, antidepressants may be associated with worsening symptoms of depression or suicidal thoughts or behavior, particularly early in treatment or when you change your dosage.
In October 2004, the FDA began requiring that all antidepressants carry a "black box" warning — the strongest warning it can issue — alerting doctors and the public to a link between antidepressants and suicidal thoughts and behavior in children and adolescents. Each prescription must also provide a medication guide that advises parents and caregivers about risks and precautions.
Although the black box warning itself is directed at pediatric use of antidepressants, the same cautions about suicide also apply to adults who take antidepressants. The FDA has begun reviewing data on whether antidepressants can cause an increased risk of suicide in adults.Antidepressants requiring warnings about a link to suicide
Clomipramine (Anafranil) Tranylcypromine sulfate (Parnate)
Citalopram (Celexa) Paroxetine (Paxil, Paxil CR)
Duloxetine (Cymbalta) Paroxetine mesylate (Pexeva)
Trazodone (Desyrel) Fluoxetine (Prozac, Prozac Weekly, Sarafem)
Venlafaxine (Effexor, Effexor XR) Mirtazapine (Remeron, Remeron Soltab)
Amitriptyline (Elavil) Nefazodone (Serzone)
Escitalopram (Lexapro) Doxepin (Sinequan)
Chlordiazepoxide/amitriptyline (Limbitrol) Trimipramine (Surmontil)
Maprotiline (Ludiomil) Olanzapine/fluoxetine (Symbyax)
Fluvoxamine (Luvox) Imipramine (Tofranil, Tofranil-PM)
Isocarboxazid (Marplan) Perphenazine/amitriptyline (Triavil)
Phenelzine sulfate (Nardil) Protriptyline (Vivactil)
Desipramine (Norpramin) Bupropion (Wellbutrin, Wellbutrin SR, Wellbutrin XL, Zyban)
Nortriptyline (Aventyl, Pamelor) Sertraline (Zoloft)
Note: Some brand-name medications may no longer be on the market.
Source: Food and Drug Administration, October 2004
You may need more careful monitoring at the beginning of treatment with antidepressants or upon a change in dosage, either up or down. It's a good idea to involve family members or friends, who can also watch for signs that your depression is worsening.
Possible signs that depression may be worsening include:
Agitation
Irritability
Anxiety or panic attacks
Insomnia or other sleeping problems
Hostility
Impulsivity
Inability to remain still
Mania or hypomania, such as extreme elation, racing thoughts or rapid talking
Increasing sadness
Mood swings
Decreasing ability to have fun or experience pleasure
Pulling away from relationships
Spending more time alone
If you notice any of these signs, have thoughts of suicide or self-harm, or feel that your depression is getting worse, talk to your doctor right away.
Length of treatment varies by situation
How long will you have to take antidepressants? It can range from several months to a lifetime.
Treatment of depression with medications is often divided into two stages. The initial focus on getting better is called acute therapy. Later, the focus turns to staying well, called maintenance or continuation therapy. In general, your doctor will probably suggest that you continue taking antidepressants for at least six months — and more likely 12 months — even after remission of your symptoms and you feel better. This will help prevent a return of your symptoms.
If your depression is chronic or recurrent, you'll probably have to take medication for years or even for the rest of your life to help control your symptoms and prevent a relapse.
Deciding how long to continue medication treatment includes consideration of:
The length and severity of your depression before treatment started
How difficult the depression was to treat
Whether you've previously had depression
Your family's history of depression
Your stress levels before, during and after treatment
Don't stop taking a medication without consulting your doctor even if you're feeling better. Stopping a medication too soon can make you more vulnerable to a relapse. It can also cause withdrawal-like symptoms if done suddenly.
If you do stop a medication and your symptoms return, talk to your doctor about starting medication again. But be aware that in some cases, if you stop a medication and then restart it, it may no longer be effective.
Although the choices may seem daunting, with some persistence, you have a good chance of finding an antidepressant that works well for you and that has only mild side effects that won't disrupt your lifestyle. The payoff is your ability to enjoy life more fully again.
From MayoClinic.com
For many people, combining medication use with psychotherapy, such as cognitive-behavioral therapy, proves most effective. With scores of antidepressants available, though, finding the right one for your situation can be challenging. Understanding what a treatment plan entails and what goes into determining the right medication for you will help you sort through your options.
How antidepressants work
Precisely how antidepressants work to treat depression remains speculative. Scientists do know that antidepressants can influence brain activity through the effects they have on mood-related brain chemicals called neurotransmitters and certain nerve cell receptors. Nerve cells release neurotransmitters to communicate with other nerve cells in the brain. Neurotransmitters transmit signals across a gap (synapse) between the nerve cells.
Neurotransmitters associated with depression are serotonin (ser-oh-TOE-nin), norepinephrine (nor-ep-ih-NEF-rin) and possibly dopamine (DOE-puh-mene). Research suggests that people with depression have lower levels of one or more of these neurotransmitters.
Nerve cells send a signal and then reabsorb (reuptake) the neurotransmitters after they've communicated with other nerve cells. Antidepressants interfere with this reuptake. This results in a greater quantity of a particular neurotransmitter remaining in the synapse. This can change the activity of certain nerve cells and influence brain activity. Maintaining a higher level of neurotransmitters improves neurotransmission — the sending of those nerve impulses — which, in turn, improves your mood.
In addition, a type of antidepressant called alpha-2 receptor blockers is thought to work by preventing neurotransmitters from binding with the nerve cell receptors called alpha-2 receptors. This indirectly increases the levels of norepinephrine and serotonin in your brain.
Numerous types of antidepressants available
Dozens of antidepressants are available, each affecting neurotransmitters in a different way. Antidepressants are typically grouped into categories, either based on when the medications came into use, their chemical structure or how they affect brain chemistry.
Here are the antidepressants that have been approved by the Food and Drug Administration (FDA) specifically to treat depression, with their generic names followed by available brand names in parentheses, and grouped by how they affect brain chemistry.
Selective serotonin reuptake inhibitors (SSRIs)
Citalopram (Celexa)
Escitalopram (Lexapro)
Fluoxetine (Prozac, Prozac Weekly)
Paroxetine (Paxil, Paxil CR)
Sertraline (Zoloft)
Serotonin and norepinephrine reuptake inhibitors (SNRIs)
Duloxetine (Cymbalta)
Venlafaxine (Effexor, Effexor XR)
Norepinephrine and dopamine reuptake inhibitors (NDRIs)
Bupropion (Wellbutrin, Wellbutrin SR, Wellbutrin XL)
Alpha-2 receptor blockers
Mirtazapine (Remeron, Remeron Soltab)
Combined reuptake inhibitors and receptor blockers
Trazodone (Desyrel)
Nefazodone (Serzone)
Maprotiline
Tricyclic antidepressants (TCAs)
Amitriptyline
Desipramine (Norpramin)
Doxepin (Sinequan)
Imipramine (Tofranil)
Nortriptyline (Aventyl, Pamelor)
Protriptyline (Vivactil)
Trimipramine (Surmontil)
Monoamine oxidase inhibitors (MAOIs)
Phenelzine (Nardil)
Tranylcypromine (Parnate)
Isocarboxazid (Marplan)
Off-label use of drugs
The FDA normally approves a drug to treat a specific condition in a particular population. Many drugs used to treat depression in adults have been FDA approved specifically for that use.
But doctors may also prescribe drugs to treat depression that haven't actually been approved to treat depression — a practice known as off-label use. For instance, doctors often prescribe clomipramine (Anafranil) because it may improve depression even though it's FDA approved for obsessive-compulsive disorder. The same may be true of other psychiatric drugs, as well.
Finding the right medication for you
So among the dozens available, which antidepressant should you take?
Finding the right one might take time. Each medication has its own pros and cons, and until you try one, you won't know how it'll affect you or how well it'll work. You may need to try several antidepressants before finding the one, or the combination, that's most effective for you with the fewest side effects.
Consider your health profile
Your family doctor or psychiatrist will take into account your symptoms and their severity, your health history, other illnesses you have and lifestyle factors when determining which antidepressant to prescribe.
Your doctor will also consider your age, sex, weight and diet, mostly because of concerns about side effects. Older adults, for instance, generally tolerate the side effects of the newer antidepressants better than the side effects of the older tricyclic antidepressants. However, for some people, the older medications are more effective in treating depression.
Pregnancy is also an issue. Some psychiatric medications may pose a risk to the developing baby. Other medications may be excreted in breast milk to infants.
If any close relatives, such as a brother or sister, have taken antidepressants, their experiences could predict how well a medication will work for you or what side effects you may experience. Tell your doctor if any of your close relatives have taken antidepressants.
Make your personal preferences known
How you take an antidepressant may also influence your medication choice. Some medications come in pill form, while others come as solutions or injections. You may not be comfortable taking an antidepressant that must be injected, for instance. Or you may prefer a once-a-week medication, while someone else doesn't mind taking several doses a day.
Cost is also a consideration. Some antidepressants are available in a generic form, which is generally cheaper than a brand-name version. Newer versions of a drug are sometimes more expensive than the original. But watch out — those newer versions aren't necessarily more effective.
Trying the medications
Once you and your doctor have selected an antidepressant for you to try, it may take four to eight weeks to determine its full effectiveness. With some medications, you can take the full dosage immediately. With others, you may need to gradually increase your dose.
If you have no improvement at all in your symptoms after six weeks, it may be time to try a different antidepressant or add a second medication to augment your treatment. You may have to taper off of one medication before starting another, because potentially dangerous drug interactions and withdrawal-like symptoms can occur from an abrupt switch.
In rare cases, antidepressants simply might not work for you. You may need to consider other forms of treatment, such as psychotherapy to help cope with social or other life stressors, or electroconvulsive therapy if your depression is severe or life-threatening.
Finding the right antidepressant and the correct dosage can take time. Talk to your doctor if you're having trouble coping with the wait.
Common side effects of antidepressants
All antidepressants cause some degree of side effects. Most side effects are mild and temporary. In general, the most common are:
Nausea
Sexual dysfunction
Constipation
Bladder problems
Dizziness
Drowsiness
Dry mouth
Changes in sleep patterns
Restlessness
Side effects vary by medication and by person. Your side effects might be more severe or less severe than what someone else taking the same medication experiences.
Side effects often are most pronounced within the first few days of beginning a new medication but then taper off. Side effects can increase or change if you take higher doses or combine antidepressants with other medications, including other antidepressants. Some antidepressants actually have fewer side effects at higher doses rather than lower doses.
Be sure to tell your doctor about your side effects, as some could require medical treatment or changes in your medication.
If an antidepressant is working for you but the side effects seem intolerable, ask your doctor for help dealing with the side effects so that you don't have to discontinue your medication.
New cautions about suicidal thoughts
In some cases, antidepressants may be associated with worsening symptoms of depression or suicidal thoughts or behavior, particularly early in treatment or when you change your dosage.
In October 2004, the FDA began requiring that all antidepressants carry a "black box" warning — the strongest warning it can issue — alerting doctors and the public to a link between antidepressants and suicidal thoughts and behavior in children and adolescents. Each prescription must also provide a medication guide that advises parents and caregivers about risks and precautions.
Although the black box warning itself is directed at pediatric use of antidepressants, the same cautions about suicide also apply to adults who take antidepressants. The FDA has begun reviewing data on whether antidepressants can cause an increased risk of suicide in adults.Antidepressants requiring warnings about a link to suicide
Clomipramine (Anafranil) Tranylcypromine sulfate (Parnate)
Citalopram (Celexa) Paroxetine (Paxil, Paxil CR)
Duloxetine (Cymbalta) Paroxetine mesylate (Pexeva)
Trazodone (Desyrel) Fluoxetine (Prozac, Prozac Weekly, Sarafem)
Venlafaxine (Effexor, Effexor XR) Mirtazapine (Remeron, Remeron Soltab)
Amitriptyline (Elavil) Nefazodone (Serzone)
Escitalopram (Lexapro) Doxepin (Sinequan)
Chlordiazepoxide/amitriptyline (Limbitrol) Trimipramine (Surmontil)
Maprotiline (Ludiomil) Olanzapine/fluoxetine (Symbyax)
Fluvoxamine (Luvox) Imipramine (Tofranil, Tofranil-PM)
Isocarboxazid (Marplan) Perphenazine/amitriptyline (Triavil)
Phenelzine sulfate (Nardil) Protriptyline (Vivactil)
Desipramine (Norpramin) Bupropion (Wellbutrin, Wellbutrin SR, Wellbutrin XL, Zyban)
Nortriptyline (Aventyl, Pamelor) Sertraline (Zoloft)
Note: Some brand-name medications may no longer be on the market.
Source: Food and Drug Administration, October 2004
You may need more careful monitoring at the beginning of treatment with antidepressants or upon a change in dosage, either up or down. It's a good idea to involve family members or friends, who can also watch for signs that your depression is worsening.
Possible signs that depression may be worsening include:
Agitation
Irritability
Anxiety or panic attacks
Insomnia or other sleeping problems
Hostility
Impulsivity
Inability to remain still
Mania or hypomania, such as extreme elation, racing thoughts or rapid talking
Increasing sadness
Mood swings
Decreasing ability to have fun or experience pleasure
Pulling away from relationships
Spending more time alone
If you notice any of these signs, have thoughts of suicide or self-harm, or feel that your depression is getting worse, talk to your doctor right away.
Length of treatment varies by situation
How long will you have to take antidepressants? It can range from several months to a lifetime.
Treatment of depression with medications is often divided into two stages. The initial focus on getting better is called acute therapy. Later, the focus turns to staying well, called maintenance or continuation therapy. In general, your doctor will probably suggest that you continue taking antidepressants for at least six months — and more likely 12 months — even after remission of your symptoms and you feel better. This will help prevent a return of your symptoms.
If your depression is chronic or recurrent, you'll probably have to take medication for years or even for the rest of your life to help control your symptoms and prevent a relapse.
Deciding how long to continue medication treatment includes consideration of:
The length and severity of your depression before treatment started
How difficult the depression was to treat
Whether you've previously had depression
Your family's history of depression
Your stress levels before, during and after treatment
Don't stop taking a medication without consulting your doctor even if you're feeling better. Stopping a medication too soon can make you more vulnerable to a relapse. It can also cause withdrawal-like symptoms if done suddenly.
If you do stop a medication and your symptoms return, talk to your doctor about starting medication again. But be aware that in some cases, if you stop a medication and then restart it, it may no longer be effective.
Although the choices may seem daunting, with some persistence, you have a good chance of finding an antidepressant that works well for you and that has only mild side effects that won't disrupt your lifestyle. The payoff is your ability to enjoy life more fully again.
From MayoClinic.com
Seasonal affective disorder treatment: Choosing a light therapy box
A light therapy box is a small, portable device that contains fluorescent bulbs or tubes and is used mainly in the treatment of seasonal affective disorder, a type of depression. You can purchase a light box over-the-counter, without a prescription.
Commercial outlets offer a wide variety of light boxes and other light devices for seasonal affective disorder treatment. You can buy light boxes on the Internet and at some drugstores and hardware stores. But not all of these products are safe or effective for seasonal affective disorder treatment, so check with your doctor before buying one. To avoid complications, use light boxes only under your doctor's guidance.
Features to look for in a light therapy box
Here are some considerations when buying a light therapy box for seasonal affective disorder treatment:
Intensity. Look for a light box that allows you the right intensity of light at a comfortable seating distance. Some light boxes offer 10,000 lux only when you're within a few inches of the box, while others can reach a distance of nearly two feet.
Minimal UV exposure. Some light boxes use full-spectrum light bulbs that give off ultraviolet (UV) light, which can cause eye and skin damage. Look for devices that produce as little UV light as possible at high intensity or that carefully shield the UV rays they produce.
Light direction. Light should come from above your line of sight, not at it or below it. Make sure the light box you want can be positioned appropriately.
Blue light. Exposure to the blue light spectrum should be minimal because it may mens sexual health cause vision problems, such as glare or sexual health macular degeneration.
Cost. Prices vary greatly, from about $200 to $500. Health insurance plans don't always cover the cost of light therapy boxes. Check with your insurance company to see if your benefits will cover the cost.
Style. Some light boxes look like upright lamps, while others are small and rectangular. You can even purchase a light therapy device attached to a visor, which would allow you to receive light therapy while remaining active. However, keep in mind that scientific evidence about the effectiveness of light visors is lacking.
Convenience. Some light boxes are bigger than others, which can make them less portable. Find one that you can move health easily and that fits the desired location in your home or office.
From MayoClinic.com
Commercial outlets offer a wide variety of light boxes and other light devices for seasonal affective disorder treatment. You can buy light boxes on the Internet and at some drugstores and hardware stores. But not all of these products are safe or effective for seasonal affective disorder treatment, so check with your doctor before buying one. To avoid complications, use light boxes only under your doctor's guidance.
Features to look for in a light therapy box
Here are some considerations when buying a light therapy box for seasonal affective disorder treatment:
Intensity. Look for a light box that allows you the right intensity of light at a comfortable seating distance. Some light boxes offer 10,000 lux only when you're within a few inches of the box, while others can reach a distance of nearly two feet.
Minimal UV exposure. Some light boxes use full-spectrum light bulbs that give off ultraviolet (UV) light, which can cause eye and skin damage. Look for devices that produce as little UV light as possible at high intensity or that carefully shield the UV rays they produce.
Light direction. Light should come from above your line of sight, not at it or below it. Make sure the light box you want can be positioned appropriately.
Blue light. Exposure to the blue light spectrum should be minimal because it may mens sexual health cause vision problems, such as glare or sexual health macular degeneration.
Cost. Prices vary greatly, from about $200 to $500. Health insurance plans don't always cover the cost of light therapy boxes. Check with your insurance company to see if your benefits will cover the cost.
Style. Some light boxes look like upright lamps, while others are small and rectangular. You can even purchase a light therapy device attached to a visor, which would allow you to receive light therapy while remaining active. However, keep in mind that scientific evidence about the effectiveness of light visors is lacking.
Convenience. Some light boxes are bigger than others, which can make them less portable. Find one that you can move health easily and that fits the desired location in your home or office.
From MayoClinic.com
Saturday, September 15, 2007
Antidepressants: Test shows which may be your best bet
Figuring out which antidepressant may be best for you has been a matter of trial and error to some extent. To be sure, doctors could make a pretty solid choice based on your medical history, your symptoms and even how your relatives may have responded to the same antidepressant.
But they couldn't predict how the antidepressant would affect you — if you'd wind up with nausea, insomnia or some other side effect, for instance. And you might take a certain antidepressant for several weeks, only to realize your symptoms haven't improved. Doctors also couldn't predict that. So you may have been stuck trying out several different medications over a period of months or even years to find one with the fewest side effects and biggest benefits.
Now the process of choosing an antidepressant may be easier. A relatively new genetic test may help end the sometimes frustrating process of trial and error. This test, called the cytochrome P450 (CYP450) genotyping test, may help you find out how an antidepressant will affect you before you ever swallow the pill.
Testing how your body reacts to antidepressants
The CYP450 test is among a handful of tests that can analyze specific genes that play a role in how your body metabolizes certain medications. It's part of an emerging field called pharmacogenomics, or personalized medicine.
Each of your body's cells contains genes. These genes instruct your body to produce enzymes that control how cells process (metabolize) the medications you take. The CYP450 test identifies the genes responsible for producing enzymes that play an important role in processing certain antidepressants and other medications.
Not everyone processes the same medications the same way. This processing difference is what makes you react differently to an antidepressant than does someone else.
Processing antidepressants too slowly
Your genes may produce enzymes that metabolize an antidepressant too slowly. This means that the medication stays in your body longer than it should. As a result, the medication can build up in your body, possibly leading to intolerable side effects or even a toxic reaction. This, of course, may prompt you to stop taking the medication.
Processing antidepressants too quickly
Your genes may produce enzymes that metabolize an antidepressant too quickly. In this case, the medication is eliminated from your body before it has a chance to work fully. This means that you may not see much improvement in your depression symptoms.
Achieving a balance with antidepressants
If your doctor knows in advance how your body is likely to process an antidepressant, he or she can make a better selection for you or adjust your dose appropriately — before you ever start taking the antidepressant. Your medication choice is personalized to your body's genetics. For instance, if you process an antidepressant too slowly, your doctor may suggest taking a lower dose so that it doesn't accumulate in your body and cause severe side effects.
CYP450 test helps predict reactions to antidepressants
This is where the CYP450 test may help. The test checks to see if two specific genes produce normal enzymes or variants of these enzymes. Which ones you have determine how your body processes certain antidepressants.
Figuring out which antidepressant may be best for you has been a matter of trial and error to some extent. To be sure, doctors could make a pretty solid choice based on your medical history, your symptoms and even how your relatives may have responded to the same antidepressant.
But they couldn't predict how the antidepressant would affect you — if you'd wind up with nausea, insomnia or some other side effect, for instance. And you might take a certain antidepressant for several weeks, only to realize your symptoms haven't improved. Doctors also couldn't predict that. So you may have been stuck trying out several different medications over a period of months or even years to find one with the fewest side effects and biggest benefits.
Now the process of choosing an antidepressant may be easier. A relatively new genetic test may help end the sometimes frustrating process of trial and error. This test, called the cytochrome P450 (CYP450) genotyping test, may help you find out how an antidepressant will affect you before you ever swallow the pill.
Testing how your body reacts to antidepressants
The CYP450 test is among a handful of tests that can analyze specific genes that play a role in how your body metabolizes certain medications. It's part of an emerging field called pharmacogenomics, or personalized medicine.
Each of your body's cells contains genes. These genes instruct your body to produce enzymes that control how cells process (metabolize) the medications you take. The CYP450 test identifies the genes responsible for producing enzymes that play an important role in processing certain antidepressants and other medications.
Not everyone processes the same medications the same way. This processing difference is what makes you react differently to an antidepressant than does someone else.
Processing antidepressants too slowly
Your genes may produce enzymes that metabolize an antidepressant too slowly. This means that the medication stays in your body longer than it should. As a result, the medication can build up in your body, possibly leading to intolerable side effects or even a toxic reaction. This, of course, may prompt you to stop taking the medication.
Processing antidepressants too quickly
Your genes may produce enzymes that metabolize an antidepressant too quickly. In this case, the medication is eliminated from your body before it has a chance to work fully. This means that you may not see much improvement in your depression symptoms.
Achieving a balance with antidepressants
If your doctor knows in advance how your body is likely to process an antidepressant, he or she can make a better selection for you or adjust your dose appropriately — before you ever start taking the antidepressant. Your medication choice is personalized to your body's genetics. For instance, if you process an antidepressant too slowly, your doctor may suggest taking a lower dose so that it doesn't accumulate in your body and cause severe side effects.
CYP450 test helps predict reactions to antidepressants
This is where the CYP450 test may help. The test checks to see if two specific genes produce normal enzymes or variants of these enzymes. Which ones you have determine how your body processes certain antidepressants.
Before prescribing an antidepressant, your doctor may discuss with you the option of having the CYP450 test. If you have the test, you and your doctor may know what to expect before you take certain antidepressants. The test helps predict if you're likely to experience harsh side effects or if the antidepressant has little chance of working for you.
The CYP450 test requires only a simple blood draw from a vein in your arm. You don't need to fast before the test or follow other special preparation procedures. You and your doctor will review the results of the test and see how they factor into your choice of antidepressant medication.
Here's how genetic variations can affect processing of an antidepressant and how you and your doctor can decide how to handle them:
Normal metabolizer Slow metabolizer Fast metabolizer
Genetic variation Your genes produce a typical amount of enzyme. Your genes produce too little enzyme. Your genes produce too much enzyme.
Effects on you The antidepressant helps your depression and causes few side effects. The antidepressant builds up in your body, causing intolerable side effects. The antidepressant is eliminated too quickly, providing little or no improvement in depression.
Treatment options Follow the recommended dosage. Switch antidepressants or reduce your dosage. Switch antidepressants or increase your dosage.
Drawbacks of genetic testing for antidepressants
Although it may be a good start in better personalizing treatment to individual situations, the CYP450 genotyping test does have some drawbacks.
One major drawback is that the test can't actually predict if certain antidepressants will improve your depression symptoms. The test can only show which antidepressants probably won't work.
In addition, the test can be used only for certain antidepressants, not all of them. That's because the test is able to check only for two genes that are responsible for metabolizing certain antidepressants. Other genes affect how your body responds to other antidepressants, and the CYP450 test isn't able to check for them.
Here are the antidepressants the CYP450 test can be used for, with their generic names followed by available brand names in parentheses:
Desipramine (Norpramin)
Fluoxetine (Prozac, Prozac Weekly)
Imipramine (Tofranil)
Nortriptyline (Aventyl, Pamelor)
Paroxetine (Paxil, Paxil CR)
Venlafaxine (Effexor, Effexor XR)
These two genes may also influence your reaction to two other medications that haven't been FDA approved for use in depression but that are often used off-label to treat depression. These medications are:
Clomipramine (Anafranil)
Diazepam (Valium, Diazepam Intensol)
Finally, although the cytochrome P450 test has been FDA approved for certain situations, it may not be available in all communities yet. In addition, not all psychiatrists and other doctors routinely use the test.
Other factors also important in selecting antidepressants
If you opt for testing, keep in mind that the cytochrome P450 genotyping test isn't meant to be the only way to determine which antidepressants to try. A thorough medical and psychiatric evaluation, as well as consideration of your preferences and lifestyle, is still important.
But they couldn't predict how the antidepressant would affect you — if you'd wind up with nausea, insomnia or some other side effect, for instance. And you might take a certain antidepressant for several weeks, only to realize your symptoms haven't improved. Doctors also couldn't predict that. So you may have been stuck trying out several different medications over a period of months or even years to find one with the fewest side effects and biggest benefits.
Now the process of choosing an antidepressant may be easier. A relatively new genetic test may help end the sometimes frustrating process of trial and error. This test, called the cytochrome P450 (CYP450) genotyping test, may help you find out how an antidepressant will affect you before you ever swallow the pill.
Testing how your body reacts to antidepressants
The CYP450 test is among a handful of tests that can analyze specific genes that play a role in how your body metabolizes certain medications. It's part of an emerging field called pharmacogenomics, or personalized medicine.
Each of your body's cells contains genes. These genes instruct your body to produce enzymes that control how cells process (metabolize) the medications you take. The CYP450 test identifies the genes responsible for producing enzymes that play an important role in processing certain antidepressants and other medications.
Not everyone processes the same medications the same way. This processing difference is what makes you react differently to an antidepressant than does someone else.
Processing antidepressants too slowly
Your genes may produce enzymes that metabolize an antidepressant too slowly. This means that the medication stays in your body longer than it should. As a result, the medication can build up in your body, possibly leading to intolerable side effects or even a toxic reaction. This, of course, may prompt you to stop taking the medication.
Processing antidepressants too quickly
Your genes may produce enzymes that metabolize an antidepressant too quickly. In this case, the medication is eliminated from your body before it has a chance to work fully. This means that you may not see much improvement in your depression symptoms.
Achieving a balance with antidepressants
If your doctor knows in advance how your body is likely to process an antidepressant, he or she can make a better selection for you or adjust your dose appropriately — before you ever start taking the antidepressant. Your medication choice is personalized to your body's genetics. For instance, if you process an antidepressant too slowly, your doctor may suggest taking a lower dose so that it doesn't accumulate in your body and cause severe side effects.
CYP450 test helps predict reactions to antidepressants
This is where the CYP450 test may help. The test checks to see if two specific genes produce normal enzymes or variants of these enzymes. Which ones you have determine how your body processes certain antidepressants.
Figuring out which antidepressant may be best for you has been a matter of trial and error to some extent. To be sure, doctors could make a pretty solid choice based on your medical history, your symptoms and even how your relatives may have responded to the same antidepressant.
But they couldn't predict how the antidepressant would affect you — if you'd wind up with nausea, insomnia or some other side effect, for instance. And you might take a certain antidepressant for several weeks, only to realize your symptoms haven't improved. Doctors also couldn't predict that. So you may have been stuck trying out several different medications over a period of months or even years to find one with the fewest side effects and biggest benefits.
Now the process of choosing an antidepressant may be easier. A relatively new genetic test may help end the sometimes frustrating process of trial and error. This test, called the cytochrome P450 (CYP450) genotyping test, may help you find out how an antidepressant will affect you before you ever swallow the pill.
Testing how your body reacts to antidepressants
The CYP450 test is among a handful of tests that can analyze specific genes that play a role in how your body metabolizes certain medications. It's part of an emerging field called pharmacogenomics, or personalized medicine.
Each of your body's cells contains genes. These genes instruct your body to produce enzymes that control how cells process (metabolize) the medications you take. The CYP450 test identifies the genes responsible for producing enzymes that play an important role in processing certain antidepressants and other medications.
Not everyone processes the same medications the same way. This processing difference is what makes you react differently to an antidepressant than does someone else.
Processing antidepressants too slowly
Your genes may produce enzymes that metabolize an antidepressant too slowly. This means that the medication stays in your body longer than it should. As a result, the medication can build up in your body, possibly leading to intolerable side effects or even a toxic reaction. This, of course, may prompt you to stop taking the medication.
Processing antidepressants too quickly
Your genes may produce enzymes that metabolize an antidepressant too quickly. In this case, the medication is eliminated from your body before it has a chance to work fully. This means that you may not see much improvement in your depression symptoms.
Achieving a balance with antidepressants
If your doctor knows in advance how your body is likely to process an antidepressant, he or she can make a better selection for you or adjust your dose appropriately — before you ever start taking the antidepressant. Your medication choice is personalized to your body's genetics. For instance, if you process an antidepressant too slowly, your doctor may suggest taking a lower dose so that it doesn't accumulate in your body and cause severe side effects.
CYP450 test helps predict reactions to antidepressants
This is where the CYP450 test may help. The test checks to see if two specific genes produce normal enzymes or variants of these enzymes. Which ones you have determine how your body processes certain antidepressants.
Before prescribing an antidepressant, your doctor may discuss with you the option of having the CYP450 test. If you have the test, you and your doctor may know what to expect before you take certain antidepressants. The test helps predict if you're likely to experience harsh side effects or if the antidepressant has little chance of working for you.
The CYP450 test requires only a simple blood draw from a vein in your arm. You don't need to fast before the test or follow other special preparation procedures. You and your doctor will review the results of the test and see how they factor into your choice of antidepressant medication.
Here's how genetic variations can affect processing of an antidepressant and how you and your doctor can decide how to handle them:
Normal metabolizer Slow metabolizer Fast metabolizer
Genetic variation Your genes produce a typical amount of enzyme. Your genes produce too little enzyme. Your genes produce too much enzyme.
Effects on you The antidepressant helps your depression and causes few side effects. The antidepressant builds up in your body, causing intolerable side effects. The antidepressant is eliminated too quickly, providing little or no improvement in depression.
Treatment options Follow the recommended dosage. Switch antidepressants or reduce your dosage. Switch antidepressants or increase your dosage.
Drawbacks of genetic testing for antidepressants
Although it may be a good start in better personalizing treatment to individual situations, the CYP450 genotyping test does have some drawbacks.
One major drawback is that the test can't actually predict if certain antidepressants will improve your depression symptoms. The test can only show which antidepressants probably won't work.
In addition, the test can be used only for certain antidepressants, not all of them. That's because the test is able to check only for two genes that are responsible for metabolizing certain antidepressants. Other genes affect how your body responds to other antidepressants, and the CYP450 test isn't able to check for them.
Here are the antidepressants the CYP450 test can be used for, with their generic names followed by available brand names in parentheses:
Desipramine (Norpramin)
Fluoxetine (Prozac, Prozac Weekly)
Imipramine (Tofranil)
Nortriptyline (Aventyl, Pamelor)
Paroxetine (Paxil, Paxil CR)
Venlafaxine (Effexor, Effexor XR)
These two genes may also influence your reaction to two other medications that haven't been FDA approved for use in depression but that are often used off-label to treat depression. These medications are:
Clomipramine (Anafranil)
Diazepam (Valium, Diazepam Intensol)
Finally, although the cytochrome P450 test has been FDA approved for certain situations, it may not be available in all communities yet. In addition, not all psychiatrists and other doctors routinely use the test.
Other factors also important in selecting antidepressants
If you opt for testing, keep in mind that the cytochrome P450 genotyping test isn't meant to be the only way to determine which antidepressants to try. A thorough medical and psychiatric evaluation, as well as consideration of your preferences and lifestyle, is still important.
Warning strengthened on Paxil birth defect risks
What happened: Based on the results of two studies, the Food and Drug Administration (FDA) has strengthened its warning on the antidepressant paroxetine (Paxil). FDA stated in a Dec. 8, 2005, public health advisory that Paxil increases the risk of birth defects in women taking the drug during their first trimester of pregnancy. Women who take Paxil during their first three months of pregnancy are nearly two times more likely to give birth to a child with a birth defect — in particular a heart defect — than are women taking other antidepressants, the FDA stated.
What does this mean to you? If you're taking Paxil and you're in your first trimester or are considering getting pregnant, see your doctor about switching to another antidepressant or discontinuing treatment. Don't stop taking Paxil without contacting your doctor first, as side effects may occur after immediate cessation of the drug. Your doctor may recommend a phased withdrawal from the medication or may determine that for you the benefits of Paxil outweigh the risk.
From MayoClinic.com
What does this mean to you? If you're taking Paxil and you're in your first trimester or are considering getting pregnant, see your doctor about switching to another antidepressant or discontinuing treatment. Don't stop taking Paxil without contacting your doctor first, as side effects may occur after immediate cessation of the drug. Your doctor may recommend a phased withdrawal from the medication or may determine that for you the benefits of Paxil outweigh the risk.
From MayoClinic.com
Monday, September 10, 2007
Seasonal affective disorder drug Wellbutrin XL wins approval
What happened? People who have seasonal affective disorder and experience depression during waning daylight hours may find relief in a medication approved to prevent this potentially debilitating condition.
The Food and Drug Administration (FDA) has approved the antidepressant bupropion hydrochloride extended release (Wellbutrin XL) for prevention of depression in people with seasonal affective disorder (SAD).
With the approval, Wellbutrin XL becomes the first medication approved to prevent SAD, a type of depression characterized by seasonal episodes of depressed mood, loss of energy, social withdrawal, increased sleep and other, sometimes debilitating, symptoms. Wellbutrin XL is already FDA approved to treat depression.
The FDA noted that Wellbutrin XL's effectiveness for preventing SAD episodes was demonstrated in three clinical trials. In the trials, approximately 1,000 people with seasonal affective disorder were randomly chosen to receive either Wellbutrin XL or a placebo beginning in the fall and winter, before the onset of symptoms of depression. Treatment was stopped in the spring.
Pooled results of the three studies showed that 84 percent of people taking Wellbutrin XL were free of depression, compared with 72 percent taking the placebo. All of the studies were funded by Wellbutrin XL's manufacturer, GlaxoSmithKline.
What does this mean to you? Wellbutrin XL is the first antidepressant officially approved by the FDA to prevent seasonal affective disorder. But many other antidepressants are used to treat or prevent SAD.
These other medications are used off-label, a common practice that simply means that a prescription drug is prescribed for a purpose not officially FDA sanctioned. For some people, light therapy is also an effective treatment for seasonal affective disorder.
If you're already being effectively treated for seasonal affective disorder, whether with medication or light therapy, you may not need to change treatments.
As with other antidepressants, Wellbutrin XL poses potential side effects and health risks. Certain antidepressants, including Wellbutrin XL, may be associated with worsening symptoms of depression or suicidal thoughts or behavior.
Before taking an antidepressant to try to prevent symptoms of seasonal affective disorder, carefully weigh the pros and cons with your doctor.
From MayoClinic.com
The Food and Drug Administration (FDA) has approved the antidepressant bupropion hydrochloride extended release (Wellbutrin XL) for prevention of depression in people with seasonal affective disorder (SAD).
With the approval, Wellbutrin XL becomes the first medication approved to prevent SAD, a type of depression characterized by seasonal episodes of depressed mood, loss of energy, social withdrawal, increased sleep and other, sometimes debilitating, symptoms. Wellbutrin XL is already FDA approved to treat depression.
The FDA noted that Wellbutrin XL's effectiveness for preventing SAD episodes was demonstrated in three clinical trials. In the trials, approximately 1,000 people with seasonal affective disorder were randomly chosen to receive either Wellbutrin XL or a placebo beginning in the fall and winter, before the onset of symptoms of depression. Treatment was stopped in the spring.
Pooled results of the three studies showed that 84 percent of people taking Wellbutrin XL were free of depression, compared with 72 percent taking the placebo. All of the studies were funded by Wellbutrin XL's manufacturer, GlaxoSmithKline.
What does this mean to you? Wellbutrin XL is the first antidepressant officially approved by the FDA to prevent seasonal affective disorder. But many other antidepressants are used to treat or prevent SAD.
These other medications are used off-label, a common practice that simply means that a prescription drug is prescribed for a purpose not officially FDA sanctioned. For some people, light therapy is also an effective treatment for seasonal affective disorder.
If you're already being effectively treated for seasonal affective disorder, whether with medication or light therapy, you may not need to change treatments.
As with other antidepressants, Wellbutrin XL poses potential side effects and health risks. Certain antidepressants, including Wellbutrin XL, may be associated with worsening symptoms of depression or suicidal thoughts or behavior.
Before taking an antidepressant to try to prevent symptoms of seasonal affective disorder, carefully weigh the pros and cons with your doctor.
From MayoClinic.com
Mixing migraine, depression drugs poses risk of serotonin syndrome
What happened? Mixing certain medications for migraine and depression might be risky, warn Food and Drug Administration (FDA) officials.
Taking triptans — a common class of migraine medications — along with selective serotonin reuptake inhibitors (SSRIs) or serotonin/norepinephrine reuptake inhibitors (SNRIs) can cause serotonin syndrome, a life-threatening condition that occurs when there's too much of the chemical serotonin in your blood.
All three types of medication increase serotonin levels. If a triptan is taken with either an SSRI or SNRI, the drugs may increase serotonin to dangerous levels. Signs and symptoms of serotonin syndrome may include:
Restlessness
Hallucinations
Loss of coordination
Fast heartbeat
Rapid changes in blood pressure
Increased body temperature
Overactive reflexes
Nausea, vomiting and diarrhea
Serotonin syndrome often resolves within 24 hours of stopping any medication that increases serotonin. Severe cases may require additional medications or hospitalization.
Common triptans include:
Almotriptan (Axert)
Naratriptan (Amerge)
Sumatriptan (Imitrex)
Zolmitriptan (Zomig)
Common SSRIs include:
Citalopram (Celexa)
Escitalopram (Lexapro)
Fluoxetine (Prozac)
Paroxetine (Paxil)
Sertraline (Zoloft)
SNRIs include duloxetine (Cymbalta) and venlafaxine (Effexor).
The FDA has asked manufacturers of all three types of medication to include a warning about serotonin syndrome in their prescribing information.
What does this mean to you? If you're taking a triptan with either an SSRI or SNRI, consult your doctor about possible risks. Don't stop taking any of the medications on your own. If your doctor prescribes a new medication, make sure he or she knows about all the other medications you're taking — especially if you receive prescriptions from more than one doctor.
If you and your doctor decide the benefits of combining a triptan with an SSRI or SNRI outweigh the risks, be alert to the possibility of serotonin syndrome. If you develop restlessness, hallucinations or any other signs or symptoms of serotonin syndrome, seek medical attention immediately.
From MayoClinic.com
Taking triptans — a common class of migraine medications — along with selective serotonin reuptake inhibitors (SSRIs) or serotonin/norepinephrine reuptake inhibitors (SNRIs) can cause serotonin syndrome, a life-threatening condition that occurs when there's too much of the chemical serotonin in your blood.
All three types of medication increase serotonin levels. If a triptan is taken with either an SSRI or SNRI, the drugs may increase serotonin to dangerous levels. Signs and symptoms of serotonin syndrome may include:
Restlessness
Hallucinations
Loss of coordination
Fast heartbeat
Rapid changes in blood pressure
Increased body temperature
Overactive reflexes
Nausea, vomiting and diarrhea
Serotonin syndrome often resolves within 24 hours of stopping any medication that increases serotonin. Severe cases may require additional medications or hospitalization.
Common triptans include:
Almotriptan (Axert)
Naratriptan (Amerge)
Sumatriptan (Imitrex)
Zolmitriptan (Zomig)
Common SSRIs include:
Citalopram (Celexa)
Escitalopram (Lexapro)
Fluoxetine (Prozac)
Paroxetine (Paxil)
Sertraline (Zoloft)
SNRIs include duloxetine (Cymbalta) and venlafaxine (Effexor).
The FDA has asked manufacturers of all three types of medication to include a warning about serotonin syndrome in their prescribing information.
What does this mean to you? If you're taking a triptan with either an SSRI or SNRI, consult your doctor about possible risks. Don't stop taking any of the medications on your own. If your doctor prescribes a new medication, make sure he or she knows about all the other medications you're taking — especially if you receive prescriptions from more than one doctor.
If you and your doctor decide the benefits of combining a triptan with an SSRI or SNRI outweigh the risks, be alert to the possibility of serotonin syndrome. If you develop restlessness, hallucinations or any other signs or symptoms of serotonin syndrome, seek medical attention immediately.
From MayoClinic.com
Thursday, September 6, 2007
Antidepressant patch Emsam approved by FDA
What happened: The Food and Drug Administration (FDA) has approved a skin patch to treat depression in adults. The antidepressant medication, called Emsam, is the first skin (transdermal) patch for depression.
Known generically as selegiline, Emsam belongs to a class of antidepressants called monoamine oxidase inhibitors (MAOIs). At its lowest dose, Emsam may offer a way around the strict dietary requirements needed when using oral MAOIs.
You apply a new Emsam patch to your torso, thigh or upper arm each day, allowing the medication to be absorbed into your bloodstream over a 24-hour period. Precisely how MAOIs such as Emsam work isn't fully known. Researchers believe that MAOIs, including Emsam, relieve depression by maintaining high levels of certain mood-enhancing chemicals in your brain.
Emsam is not approved for use in children ages 17 or younger.
What does this mean to you? For some adults, Emsam provides more depression treatment options because at its lowest dose you can use it without the dietary restrictions needed with all oral MAOIs.
MAOIs can cause potentially life-threatening interactions with foods, even common cheeses and luncheon meats. Because of these problems, doctors typically prescribe MAOIs only after trying other antidepressant medications first.
At the lowest dose of the Emsam antidepressant patch — 6 milligrams (mg) daily — there are no dietary restrictions. That may give some people more flexibility in their depression treatment options.
Higher doses of the patch — 9 mg and 12 mg — do pose the same dietary risks as other MAOIs. If you take either of those higher daily doses of Emsam, you must follow the same dietary restrictions as with oral MAOIs.
Like other MAOIs, Emsam has other side effects, as well. And like all other antidepressants, it must carry a warning that its use may be associated with worsening suicidal thoughts and other depression symptoms.
Because of the numerous side effects and interactions, it's not appropriate for everyone. Talk to your doctor or other health care provider to see if Emsam may be right for you.
Known generically as selegiline, Emsam belongs to a class of antidepressants called monoamine oxidase inhibitors (MAOIs). At its lowest dose, Emsam may offer a way around the strict dietary requirements needed when using oral MAOIs.
You apply a new Emsam patch to your torso, thigh or upper arm each day, allowing the medication to be absorbed into your bloodstream over a 24-hour period. Precisely how MAOIs such as Emsam work isn't fully known. Researchers believe that MAOIs, including Emsam, relieve depression by maintaining high levels of certain mood-enhancing chemicals in your brain.
Emsam is not approved for use in children ages 17 or younger.
What does this mean to you? For some adults, Emsam provides more depression treatment options because at its lowest dose you can use it without the dietary restrictions needed with all oral MAOIs.
MAOIs can cause potentially life-threatening interactions with foods, even common cheeses and luncheon meats. Because of these problems, doctors typically prescribe MAOIs only after trying other antidepressant medications first.
At the lowest dose of the Emsam antidepressant patch — 6 milligrams (mg) daily — there are no dietary restrictions. That may give some people more flexibility in their depression treatment options.
Higher doses of the patch — 9 mg and 12 mg — do pose the same dietary risks as other MAOIs. If you take either of those higher daily doses of Emsam, you must follow the same dietary restrictions as with oral MAOIs.
Like other MAOIs, Emsam has other side effects, as well. And like all other antidepressants, it must carry a warning that its use may be associated with worsening suicidal thoughts and other depression symptoms.
Because of the numerous side effects and interactions, it's not appropriate for everyone. Talk to your doctor or other health care provider to see if Emsam may be right for you.
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