How I Healed my Depression

Destroy Depression

Destroy Depression is written by James Gordon, a former sufferer of depression from the United Kingdom who was unhappy with the treatment he was being given by medical personnell to fight his illness. Apparently, he stopped All of his medication one day and began to search for answers on how to cure himself of depression in a 100% natural way. He spent every waking hour researching all he could on the subject, making notes and changing things along the way until he had totally cured his depression. Three years later, he put all of his findings into an eBook and the Destroy Depression System was born. The Destroy Depression System is a comprehensive system that will guide you to overcome your depression and to prevent it from injuring you mentally and physically. Read more here...

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The Etiology of Major Depression

Most cases of recurrent major depression, bipolar I disorder, and bipolar II disorder are idiopathic and probably genetic in origin. These illnesses run in families and often present generation after generation in varying degrees of severity. The concordance rate for major depression is 70 percent for identical twins and 15 percent for first-degree relatives. There appear to be multiple genetic subtypes, and inheritance seems polygenic. Many cases of major depression are symptomatic rather than idiopathic that is, they occur in the setting of clear brain pathology, endocrine disturbance, or adverse drug effects. The existence of such symptomatic cases, indistinguishable in their syndromic presentation from idiopathic major depression, gives credibility to the conceptualization of major depression as a disease of the brain. One-quarter of patients hospitalized for acute stroke develop major depression in the weeks after their cerebrovascular accident. These poststroke depressions are...

Tricyclic Antidepressants

The tricyclic antidepressants (TCAs) have been available for decades and seem to act by blocking presynaptic reuptake of norepinephrine and serotonin in the brain. These agents also cause, to varying degrees, orthostatic hypotension (due to alpha adrenergic blockade), anticholinergic effects (secondary to antagonism of muscarinic receptors), sedation (from antihis-tamine action), and slowed cardiac conduction (a quinidine-like mechanism). In therapeutic doses, they do not affect cardiac output. Despite their potential side effects, TCAs are not difficult to use if the best-tolerated agents are chosen and doses are increased gradually. Before the development of the newer antidepressants, TCAs were the treatment standard and were successfully employed with appropriate precautions even for elderly or medically frail persons. Although most patients require 50-100 mg of nortriptyline hydrochlo-ride per day to attain therapeutic serum levels, the occasional patient will need as little as 10...

Explaining Major Depression and Its Treatment

Whichever antidepressant is chosen, the physician must always reassure patients of his or her assessment of the illness and the prospects for recovery. Tell patients, in a straightforward manner, that major depression is a medical condition it is not, in any sense, a character flaw or a weakness of personality. Antidepressant agents are medical treatments, not psychological crutches. Although patients are responsible for cooperation in their treatment and for reasonable behavior during their recovery, they are by no means responsible for their psychiatric illness. Discuss prognosis in openly optimistic terms because the great majority of patients with major depression recover with appropriate treatment. Recurrences can often be prevented or diminished in intensity or frequency. Such a prognosis is certainly better than that of most chronic medical conditions, and depressed patients are reassured to hear it. Until recovery occurs, reassurances are well worth repeating. Finally, the...

Psychiatric Referral of Depressed Patients

There are several situations in which the primary care physician should immediately refer patients with major depression to a psychiatrist. Patients with suicidal intent or a plan to kill themselves must be evaluated by a psychiatrist on an emergent basis to assess the need for psychiatric admission. If they refuse such a referral, procedures for involuntary commitment to a psychiatric hospital must be undertaken to prevent suicide, and the primary care physician should contact psychiatric colleagues for advice on how to proceed. Although uncooperative patients may be angered by such measures or may resist them, they may be grateful when they have recovered.

Tricyclic antidepressants 315

In addition, tremors may appear as a side effect of certain drugs (such as amphetamines, antipsychotics, ANTIDEPRESSANTS, CAFFEINE, or LITHIUM) or as a sign of withdrawal. Alcohol withdrawal also may trigger tremors, indicating the presence of alcohol dependence. These morning shakes occur as the blood alcohol level falls the tremors disappear when more alcohol is consumed. (See also INTERNATIONAL TREMOR FOUNDATION Appendix I.) tricyclic antidepressants A class of antidepres-sants named for their three-ring chemical structure that have been used to treat depression ever since the 1950s. Tricyclics include amitriptyline, amoxa-pine, clomipramine, despiramine, doxepin, imipra-mine, nortriptyline, and pro trip tyline. They are sometimes used for other disorders in addition to depression, including obsessive compulsive disorder, panic disorder, and (in the case of imipramine) bedwetting. The tricyclic antidepressants work by raising the brain's level of the neurotransmitters...

Major Depression

The varieties of sadness described above are not the most serious faced by primary care physicians in everyday practice. Sad moods may also occur as part of a psychiatric disorder in which such moods are regularly accompanied by many other morbid psychological symptoms. These symptoms unite to form a clinical state potentially devastating in its consequences. In years past, this entity was called melancholia or endogenous depression in the most recent psychiatric nomenclature, it is called major depression. It is vital that every primary care physician be skilled in the recognition of major depression because it is common, usually goes undiagnosed, causes great emotional suffering, is associated with marked social and occupational impairment, sometimes provokes suicide, and is very responsive to treatment.

Antidepressants

Physicians increasingly prescribe antidepressant medications to patients with insomnia, usually at a lower dose than would typically be used to treat depression. While benzodiazepines were the most commonly prescribed sleep medications in the 1980s, doctors changed their patterns during the 1990s, and by 2002, three of the top five most frequently prescribed sleep medications were antide-pressants. This occurred even though antidepressants are neither FDA approved for nor proven effective for treating insomnia. Several factors influenced this trend. Some doctors have the perception that antidepressants have fewer side effects and are safer for long-term use than benzodiazepines and that all insomnia is related to depression. None of these beliefs is supported by convincing evidence. Another factor is that there are fewer regulatory restrictions for antidepressants than for benzodiazepines, so they're easier to prescribe. Despite the lack of research on their effectiveness against...

Hallucinations Illusions and Delusions

Hallucinations and delusions are rare among people living in the community, and their presence should lead the physician to consider disorders such as delirium, dementia, manic-depressive illness, schizophrenia, and drug abuse. Hallucinations are perceptions without stimuli and can occur in any sensory modality. Auditory and visual hallucinations are the most common types, and the physician can ask about them while reviewing the patients hearing and vision (e.g., Have you been hearing noises or voices that people who were with you couldn't hear Have you been seeing things with your eyes open that people who were with you couldn't see ). Remember that hallucinations are experienced as real perceptions, so questions such as Did you ever hear see feel something that wasn't there may not elicit an accurate response.

Mental Health of Hispanics in the United States

The Los Angeles area was the only site for the ECA study where significant numbers of Hispanics were interviewed and assessed, and most of these Hispanics were Mexican American. The results showed that the prevalence of major depression was similar in Mexican Americans and non-Hispanic whites (Burnam et al. 1987). The ECA data also showed a higher lifetime prevalence for DSM-III dysthymia, panic disorder, and phobia among Mexican American women older than 40 years compared with both non-Hispanic white women older than 40 and Mexican American women younger than 40 years (Karno et al. 1987). This higher vulnerability of Mexican American women older than 40 years to phobias and depressive disorders may be related to numerous psychosocial stressors, which include low educational levels, high unemployment rates, social isolation, financial and domestic strain, stresses of immigration, acculturation issues, and low socioeconomic status. The ECA data also reported that Mexican Americans...

Interpretation of PCC Data

Some drugs, perhaps cardiac drugs in particular, are taken by patients whose health may already be significantly compromised. It may be difficult to sort out a symptom as being due to drug overdose or the patient's underlying condition. Even if the patient is actually experiencing an adverse drug reaction, the morbidity associated with the reaction is likely to be intensified by the patient's pre-existing poor health. Some drugs, therefore, appear to cause greater toxicity as a function of the type of patient who is using them. Another example of this phenomenon would be tricyclic antidepressants. Such drugs are manifestly dangerous. Their toxicity, however, is probably overstated because they are used by depressed patients many of whom are suicidal.

Examining the Patient

When patients report their mood as depressed, the physician should ask them whether it is like sadness they have experienced after disappointments or losses in the past. Many patients readily characterize the mood of major depression as both quantitatively and qualitatively distinct from that of ordinary sadness. Thus, they may say not only that their low mood is more pervasive and less responsive to external conditions, but also that it has a painful or oppressive quality absent from ordinary sadness. Self-Attitude. Most patients with major depression have diminished self-esteem. One way for the physician to elicit such thoughts is to ask Sometimes when people are depressed they become very self-critical or self-doubting. I don't mean you should be having such thoughts, but I was wondering whether you are. The examiner should also ask about the patient's sense of success in his or her most prized social roles. Some patients deny diminished self-esteem on screening inquiry but later...

Hyperactivity inattention and impulsivity

Stimulants such as methyphenidate, dextroamphetamine, metamphetamine, pemoline), Clonidine, and tricyclic antidepressants (desi-pramine, nortriptyline) preoccupations, rituals, and compulsions antidepressants (fluvoxamine, fluoxetine, clo-mipramine) anxiety antidepressants (sertraline, fluoxetine, imipramine, clomipramine, nortriptyline)

Selective Serotonin Reuptake Inhibitors

The selective serotonin reuptake inhibitors (SSRIs) are now commonly used initially in the treatment of major depression. They have a potent and selective blocking effect on the reuptake of serotonin by CNS presynaptic nerve terminals. They have weak, if any, effect on noradrenergic, dopaminergic, histaminergic, and muscarinic cholinergic receptors. Moreover, they do not have a quinidine-like effect on cardiac conduction.

Do You Wish To Know When And How You Will

FJ - It seems to me that what is truly difficult is knowing when one will die. But obviously, predictions in this area are difficult to make. AFL - Indeed. But if we grant that someone can know if she has a predisposition factor, for example, to diabetes or manic depressive disorders, does this ruin her life Is this kind of knowledge unbearable for people, in personal terms, and independently of consequences such as insurance It is clear, besides, that knowledge is sometimes an advantage to know that one is predisposed to diabetes allows one to take precautions. In many cases, it is probably more of a hope than of a concrete reality. For instance, we hope that stem-cell research will be able to address a variety of pathologies. But often, it is genuinely useful to know that one has a predisposition to a particular condition. One can avoid transmitting the illness to one's children, ask for pre-natal diagnoses, etc. This is quite important. Isn't there something disconcerting about the...

Generalized Anxiety Disorder

Approximately two-thirds of patients with GAD have a concurrent psychiatric disorder, and over 90 percent of patients with a lifetime diagnosis of GAD have at least one other lifetime psychiatric diagnosis. The most common comorbid illnesses include phobias, panic disorder, and depressive disorders. Controversy exists as to whether GAD is an independent entity, a prodrome to another disorder, or a residual form of a previous illness.

Center for Hyperactive Child Information A

Central nervous system depressants A group of drugs that cause sedation or diminish brain activity. These drugs include alcohol, aminoglutethimide, anesthetics, anticonvulsants, antidepressants, anti-dyskinetics (except amantadine), antihistamines, apomorphine, baclofen, barbiturates, benzodiazepines, buclizine, carbamazepine, chloral hydrate, chlorzoxazone, clonidine, cyclizine, difenoxin and atropine, diphenoxylate and atropine, disulfiram, dronabinol, ethchlorvynol, ethinamate, etomidate, fenfluramine, flavoxate, glutethimide, guanabenz, guanfacine, haloperidol, hydroxyzine, interferon, loxapine, magnesium sulfate, matprotiline, mecli-zine, meprobamate, methyldopa, methyprylon, metoclopramide, metyrosine, mitotane, molin-done, opiod (narcotic) analgesics, oxybutynin, par-aldehyde, paregoric, pargyline, phenothiazines, pimozide, procarbazine, promethazine, propi-omazine, rauwolfia, scopolamine, skeletal muscle relaxants, thioxanthenes, trazodone, trimeprazine, and trimethobenzamide.

Cultural Models of Health and Illness

Cross-cultural differences in presentation of symptoms have been linked to differential rates of somatization, to posttraumatic stress disorder in immigrants and refugees, and to clinical depression (Castillo et al. 1995). Latinos may be at risk for misdiagnosis or inappropriate interventions because of a lack of sensitivity by medical professionals to culturally based somatoform symptoms. Furthermore, Latinos tend to associate a stigma with certain illnesses such as cancer (Perez-Stable et al. 1992b). Recommendations regard

Referral to Mental Health Professionals

Several types of mental health professionals are available, including psychiatrists, psychologists, social workers, and nurse therapists. The nature of the clinical problem should determine which of these is most appropriate to treat an anxious patient. For example, prompt referral to a psychiatrist is indicated if the patient has severe symptoms that impair daily functioning or are associated with suicidal thoughts. A psychiatrist should also be selected when there is diagnostic uncertainty when advice is needed about medications when the patient has complicated medical comorbidity when another psychiatric condition, such as major depression, substance abuse, or personality disorder, is present and when the anxiety is due to OCD or posttraumatic stress disorder. In addition, psychiatrists should be able to design pharmacologic treatments for patients whose disorder has failed to respond completely to initial medication trials by primary care physicians.

The Structure Of Clinical Toxicology Testing

What are the criteria to be considered when making a decision about the importance of offering a particular test within one's laboratory A critical principle in laboratory medicine must be kept in mind here. If a test result alters therapy in a critical way, then that test is, by necessity, a critical one. Another factor is lethality of the toxin. If exposure to a substance causes only minor symptoms then we can feel free to exclude that test from our menu. A second consideration is the availability of an antidote. If an effective antidote or other treatment is available, then the knowledge that a patient's symptoms are due to a specific toxin is of great value because it directly guides the physician's intervention. A third factor is the relative informational content supplied by the patient's presentation. This refers to the ability of the history, physical examination, etc. to guide the patient's care without any help from the laboratory. If the patient has a severe cardiac...

The Treatment of Noncognitive Symptoms

Approximately two-thirds of patients with Alzheimer disease will experience a hallucination or delusion at some point in the illness. About 20 percent will have symptoms of major depression. Other common noncognitive symptoms include wandering, pacing, physical aggression, apathy, and sleep disturbance. The treatment of these noncognitive symptoms should begin with a careful assessment. If the physician can identify a psychiatric syndrome such as major depression, then he or she should consider pharmacotherapy as an initial approach. More often, no specific psychiatric syndrome is identified, but particular behavior problems, such as not sleeping at night, physical overactivity, and verbal or physical threats directed toward others, are present. When this is the case, most experts recommend nonpharmacologic therapy as the first approach unless the behaviors are dangerous or causing significant distress to the patient or others.

Development of the brain

One reason behind the antidepressants' lag time could be that antidepressants may cause a decrease in number of available receptors. When this happens, it could trigger an increase in the production of neurotransmitters. importantly, these changes do not happen right after antide-pressant treatment begins the changes in the receptors typically can take up to several weeks. This receptor change has been reported in almost all anti-depressant drug treatment and also in Major Depression While symptoms differ from one person to the next, major depression is almost always characterized by general feelings of sadness and a total loss of pleasure in things that once brought joy. There might be sleep and eating problems or a sense of worthlessness, a lack of interest in sex, with apathy or suicidal thoughts. As many as 90 percent of people with depression can be successfully treated, usually in 12 to 14 weeks, with a combination of antidepressant medication and counseling.

Electroencephalography

While many believe the origins of ECT lie in the ancient Roman tradition of applying electric eels to the head as a cure for madness, mild electric shocks had been used since the late 1700s to treat illness. A machine using weak electric currents was used in Middlesex Hospital in England in 1767 to treat a range of illnesses, and London brain surgeon john Birch used his machine to shock the brain of depressed patients.

Differential Diagnosis

Prior to undergoing biochemical testing, patients with a strong clinical suspicion for pheochromocytoma should be taken off medications that may have physiological or analytical interferences.15 Tricyclic antidepressants (TCAs), levodopa, and significant physical stress (e.g., hypertensive stroke) may elevate concentrations of metanephrines. If clinically feasible, these medications should be discontinued at least 1 week before collection. The LC-MS MS method is not affected by the interfering substances that affected the previously utilized spectrophotometric (Pisano reaction) method (i.e., diatrizoate, chlorpromazine, hydrazine derivatives, imipramine, MAO inhibitors, methyldopa, phenacetin, ephedrine, or epinephrine). This method is also not subject to the known interference of acetaminophen (seen with the plasma metanephrine high-performance liquid chromatography HPLC-EC method).

Psychosexual Dysfunction

Multiple studies have examined the potential etiologic role of psychosexual factors (45-51). Women with VVS experience greater psychological distress and sexual dissatisfaction than healthy controls (46). Although some investigators propose that the syndrome has a purely psychogenic origin (52), others dispute this, pointing to evidence of pain relief by surgical excision of affected portions of the vestibule (53). Studies of the prevalence of psychological distress fail to distinguish whether such impairment is predisposing, precipitating, perpetuating, or simply the result of having an unmitigated pain syndrome. Qualitative research, which examines patients' commentary as an adjunct to standardized psychological profiling, suggests that sexual dysfunction and psychological distress are the consequences of, rather than the cause of, VVS. For example, when asked about the impact of the disease, VVS sufferers reported dramatic negative effects on sexuality, intimate relationships, and...

Central Nervous System

Among the many toxicants that cause convulsions are chlorinated hydrocarbons, amphetamines, lead, organophosphates, and strychnine. There are several levels of coma, the term used to describe a lowered level of consciousness. At level 0, the subject may be awakened and will respond to questions. At level 1, withdrawal from painful stimuli is observed and all reflexes function. A subject at level 2 does not withdraw from painful stimuli, although most reflexes still function. Levels 3 and 4 are characterized by the absence of reflexes at level 4, respiratory action is depressed and the cardiovascular system fails. Among the many toxicants that cause coma are narcotic analgesics, alcohols, organophosphates, carbamates, lead, hydrocarbons, hydrogen sulfide, benzo-diazepines, tricyclic antidepressants, isoniazid, phenothiazines, and opiates.

Means Used to Commit Suicide

Males are four times as likely as females to die by suicide, but females are twice as likely to attempt it. Women may attempt suicide more often because they have a higher rate of major depressive disorder they may succeed less often because they tend to use less lethal means.

Incidence of Mental Illness

In 1996, a large-scale nationwide mental health and substance abuse epidemiological study was conducted by researchers from the University of Antioquia and the University CES of Medellin. Funded by the Ministry of Health and working with a national team of more than 100 interviewers, the researchers interviewed a random sample of 15,046 individuals older than 12 years of age across the country, using the Clinical Diagnostic Inventory II questionnaire, which is based on the DSM-IV classification. This is the most comprehensive mental health study ever conducted in Colombia. The lifetime prevalence of diagnosable disorders was as follows nicotine dependency, 28 major depression, 19.3 alcohol abuse and dependency (combined), 16.6 posttraumatic stress disorder, 4.5 somatization, 4.3 generalized anxiety, 3.8 and schizophrenia, 1.4 . The lifetime use of marijuana was 7.8 and of cocaine 2.5 (Torres and Montoya 1997). Suicide is also a public health problem in 1995, a total of 58,830 suicides...

Suicide and Psychiatric Disorders

When investigators in different countries examine the medical records and interview the family and friends of people who have died by suicide, they find the same result almost everyone who commits suicide had signs of a psychiatric disorder, and about half had sought psychiatric help in the past. The posthumous diagnoses most often are affective disorders (major depression or bipolar disorder), substance abuse disorders, personality disorders, and schizophrenia. At least two-thirds of persons who committed suicide had symptoms of major depression before death. Clinical and community studies reveal that patients with psychiatric disorders have a remarkably high lifetime risk of completed suicide. Major depression has been associated with a 15-20 percent rate of completed suicide in follow-up of hospitalized patients (who are at higher risk for suicide because suicidal thought and self-injurious behavior are strong indications for hospitalization). Individuals with depression diagnosed...

Suicide and Medical Disorders

Medical disorders associated with an elevated risk of suicide are AIDS, cancer (especially head and neck), Huntington disease, multiple sclerosis, peptic ulcer disease, end-stage renal disease, spinal cord injury, and systemic lupus erythematosus. Any serious medical illness can raise the risk of suicide in elderly Caucasian men. In most cases, suicide in the context of a medical disorder occurs in conjunction with a depressive disorder or a history of alcohol abuse, or both.

Screening for Suicidal Thoughts

The first challenge in helping patients who are thinking of suicide is usually to discover that they are having such thoughts. Patients are often reluctant to admit they are suicidal out of shame, stoicism, or fear of being regarded as crazy. It is not practical or necessary to question every patient about suicidal thinking, but all patients who acknowledge depressive symptoms should be asked. If a patient complains of or assents to feelings of sadness, loss, hopelessness, anger, or any other overwhelming, painful emotion, the physician should inquire about suicidal thoughts. If a patient complains of insomnia, loss of appetite or weight, lack of energy, or problems with memory and concentration, the primary care physician should ask about depressive moods, feelings of hopelessness, and suicidal thinking.

Acculturation and Mental Health Symptoms

As the result of migration, some Colombian families tend to present marital conflicts, difficulties in communication with their teenage children, and symptoms of posttraumatic stress disorder. Alcoholism tends to be common in males depression occurs frequently in women (Leon 1993). Colombians also show frequent symptoms of somatization, resulting from postmigration stress. Escobar (1987 Escobar et al. 1983) documented higher somatization indexes among Colombian patients with major depression compared to North American patients.

Psychological Support

Suicidal thoughts sometimes emerge without signs of major depression in patients encountering difficult situations. By the first follow-up visit after these thoughts have been discussed, the physician may find the patient more hopeful and perhaps dismissive of the suicidal remarks previously made. If, on reevaluation, it appears to the physician and family that the patient does not have a depressive disorder, the problem may be over. These patients may or may not benefit from counseling to learn how to avoid another crisis.

Treating Huntingon Disease

Current options for treating Huntington disease are very limited. Anti-dopaminergic agents are used to try to treat the choreiform movements, and antidepressants and antipsychotics help treat the psychiatric manifestations of the disease. Elevated calorie intake helps fight the typical weight loss, and physical therapy provides further assistance with movement problems. However, none of the current treatments can stop the pathologic processes of the disease itself, which advances through an inevitable progression of cell death among neurons in specific regions of the brain that affect movement and cognitive functions. Past efforts to stem disease progression through use of antioxidant therapies have failed.

Techniques for contrasting experimental conditions

Non-switch difference is larger for one task-type than the other. Factors whose measurements and statistical comparisons are made within subjects, as are those described above, are within-subjects factors, and those whose levels contain data from different individuals (e.g., depressed patients vs. controls) are between-subjects factors. Within-subjects factors generally offer substantially more power and have fewer confounding issues (e.g., differences in brain structure and HRF shapes) than between-subjects factors.

Implementation of the Plan

Many patients will seek detoxification simply to gain temporary relief from their withdrawal misery, but not every patient should necessarily be detoxified simply because of an expressed desire to do so. Any patient who has never undergone medical detoxification should be given the opportunity as quickly as possible, as should anyone active in treatment who relapses. Medical detoxification should always be undertaken whenever a patient's alcohol or drug use significantly compromises the treatment of any other disorder (e.g., epilepsy, diabetes, cardiovascular dysfunction, anxiety and depressive disorders). Otherwise, detoxification should be undertaken only when part of a broader, mutually agreed-upon, long-range treatment strategy in order to deter poorly motivated patients from employing revolving door detoxification as a stopgap measure (e.g., when their drug supply has been temporarily interrupted). A bit of clinical skepticism should be exercised with kindness. Alcohol. A history...

Marilyn A Davies Chiaoying Chang and Bryan L Roth

This chapter first describes the structural changes involved in genetic polymorphisms, mRNA editing, and alternative mRNA splicing of 5-hydroxytryptamine (5-HT) receptors. These structural changes lead to modifications in the production and characteristics of 5-HT receptors and affect protein expression. Functionally, they affect radioligand binding, signal transduction, and receptor sensitivity, thus affecting interindividual variation in responses to therapeutic agents, particularly antipsychotics and antidepressants. Studies indicate that genetic polymorphic and post-transcriptional modifications of 5-HT receptor structure contribute also to pathological processes related to irritable bowel syndrome, cardio-pulmonary problems, psychiatric illness (i.e., schizophrenia and mood disorders), Alzheimer's disease, problems involving increased food and alcohol intake, and behavioral problems such as impulsivity, self-harm, and aggression. In the second part of this chapter, the 5HT2A,...

Mental Health of Adults with Epilepsy

Summary Mental Health of Adults With Epilepsy, a chapter in Epilepsy Patient and Family Guide, discusses the mental and behavioral aspects of epilepsy in adult patients. Behavioral disturbances in people with epilepsy may be unrelated to epilepsy, or related to the person's emotional reactions to having epilepsy, the effect of medications, or epilepsy. The chapter discusses (1) personality and epilepsy, (2) depression in epilepsy and in the general population, (3) causes of depression in people with epilepsy, (4) treating depression, (5) anxiety disorders in patients with epilepsy and in the general population, (6)

Classification Of Cardiotoxins

Cardiotoxicity is not amenable to a simple system of classification. Instead, a wide variety of agents may have toxic action on the myocardium. Some of the better known are antidepressants of the tricyclic category antineoplastic agents such as adriamycin, antibiotics, alcohols, anesthetics and heavy metals. Cardiac drugs become cardiotoxins when taken in large doses. Some of the members of this category that have been involved in many cases of toxicity are digoxin (and other digitalis glycosides), quinidine, beta-adrenergic-receptor agonists, beta-adrenergic-receptor antagonists, and some antihypertensive agents. What follows is a discussion of the mechanisms of some cardiac toxins.

Specific Clinical Patterns

Several specific psychopathological patterns are commonly observed clinically. Some have also been systematically observed in other Hispanics. Others have not and are more anecdotal. Escobar (1987) described the tendency to soma-tize in Hispanics, and this certainly occurs in Mexican Americans however, no evidence, clinical or epidemiologic, suggests greater occurrence in the latter group than in other Hispanics. Anecdotally, the occurrence of mild psychotic symptoms accompanying depressive disorders should be mentioned. These symptoms may consist of fleeting shadows or bultos (forms) that occur in the evening and usually are frightening to the patient. They often subside with treatment of the underlying depression or agitation and may not require the administration of antipsychotic medication. The content of delusions may reflect elements of Mexican or Mexican American culture. The Virgen de Guadalupe, the patron saint of Mexico, may figure dominantly in religious delusions, as might...

Audit of volunteer screening procedures

On the basis of information from GPs, four volunteers were rejected for depressive illness, 18 for alcohol dependency, four for drug dependency, and six for neurological disorders (including one case of epilepsy and four of recent head injuries, two of whom had been prescribed prophylactic anti-convulsant drugs). The understated conclusion of the authors is 'Application to the GP for medical information on potential volunteers is an important step in the screening of volunteer subjects for clinical research'.

Neuropsychological test 335

Neuropathic pain Pain caused by damage, injury, or change in ability to function of one or more nerves. It is the type of pain experienced in neuropathy, shingles, and any number of nerve-related or nerve-involved illnesses such as cancer that can constrict or interrupt nerve function. This type of pain responds best to treatment by prescribed antidepressants or antiseizure medications. Treatment can include a variety of different drugs, usually intended to relieve pain, as there is not much that can be done to rebuild diseased or atrophied nerves. If the cause is thought to be a particular drug, then removing the drug from the regimen is the first step. Once the drug is discontinued, the pain often slows and eventually stops over a period of six to nine months. If this does not work or is not the principal cause, then the first line of treatment is currently an antiseizure medication such as Neurontin or Dilantin. If this is not effective, then the next line of treatment is a class...

Issues of Clinical Relevance

John, a 16-year-old boy, was brought to treatment by his mother, who was concerned about her son's habits. She reported that he was reclusive and spent long hours in his room listening to heavy metal music and not participating in family life. She also reported that he wore torn and loose pants. The mother had been born and raised in Nicaragua, was Catholic, and did not agree with all these fads, as she expressed it. On interview, it was clear that John was experiencing a mild depression. He had also begun to smoke marijuana but quit after experiencing two panic attacks. After several weeks of treatment with an antidepressant and psychotherapy, his depressive symptoms remitted, he completely quit smoking marijuana, and his relationship with his parents improved. John reported that even his mother had made changes, becoming more tolerant of his musical choices. He was euthymic at 1-year follow-up.

Relevant Findings Of Preclinical And Clinical Studies

Depressive Symptoms Depressive symptoms may be related to hypocretin effects on several fronts. Sleep disturbances, both hypersomnias and insomnias, are prominent in depression. Hypocretin promotes wakefulness and increases grooming and face washing in rodents, whereas it suppresses REM sleep. A deficit of hypocretin could contribute to fatigue and hypersomnia, and to the shortened delay in REM sleep onset in depression, but is not as readily reconciled with the frequent insomnia. An excess of hypocretin might explain REM disturbances, but the hypersomnia would seem improbable. Appetite in depression can go either way and frequently fluctuates within depressed individuals over time. Increased food intake is observed with icv injections of Hcrt (16,17) and may be related to increased wake time, but this has been argued to be a relatively weak effect, dependent on the circadian time of administration (2). Hypocretin knockout mice have normal weight (18), but ataxin-3 mutants...

Mental Illness and Society

A gradual but sustained penetration of modern notions of mental illness has occurred, even in remote parts of the country. The growth of communication media and the easier access to those remote areas have contributed to this. Likewise, the use of medications (particularly major tranquilizers, anxiolytics, and antidepressants) is a noteworthy factor in the process. The figure of the doctor enjoys universal respect, admiration, and a sense of dependency that may contribute to acceptable degrees of medication compliance. However, this is not a generalized phenomenon, and poverty, inaccessibility of services, lack of professional attention, and chaotic administration of health programs make the follow-up and ultimately the prognosis of mental illnesses somber or, at best, uncertain (Alarcon 1990).

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Reduced either by lowering the dosage (and raising it more gradually) or by taking the medication earlier in the evening. Constipation from tricyclic antidepressants or verapamil can usually be managed with routine measures such as fiber supplementation, or verapamil can be switched to diltiazem. Beta blockers and calcium channel blockers should not be reduced or eliminated simply because of relative bradycardia or hypotension without symptoms or special cause for concern.

Memory For Valenced Material Moodcongruent Memory

The most common criticism of mood-congruence studies using autobiographical memories has been that the mood at encoding is unknown ensuring that one cannot reliably distinguish between SDM and mood-congruent effects. Furthermore, the relative balance of positive and negative memories for a given participant is an unknown. It is therefore not possible to say whether memory effects represent a genuine bias or merely reflect the profile of the embedded material. One way of avoiding this confound is to move away from the autobiographical domain and provide the to-be-learned material in the experiment proper, e.g. Bradley & Mathews (1983) supplied clinically depressed and nondepressed participants with lists of affectively valenced (positive and negative) words. The depressed group showed lower recall of positive material relative to controls. Memory bias effects using variations of this kind of paradigm have been shown in a large number of studies with subclinically (e.g. Gotlib &...

Selective serotonin reuptake inhibitor SSRI A

Drug that blocks the neurons of the brain from reabsorbing serotonin, a neurotransmitter. This leads to the accumulation of serotonin in the brain and increased serotonin stimulation. These medications have replaced older antidepressants because they have far fewer side effects. Increasing serotonin activity when a patient is depressed appears to improve the patient's condition in many cases. Minor side effects include sleep disturbances and appetite suppression.

Ect Treating The Mind With Electricity

Today, psychiatrists turn to ECT as one of the most effective (and safest) treatments available for major depressive disorder. This therapy can also be extremely beneficial for patients suffering from mania, catatonia, schizophrenia, and other neuropsychiatric conditions. During the procedure, the psychiatrist activates the passage of controlled pulses of electrical current through the patient's brain. The stimulation produces a generalized seizure lasting 25 to 150 seconds. Contrary to popular belief, ECT is a brief, painless procedure. It is always administered under general anesthesia with muscle relaxation. Most patients requiring this course of therapy for depression will undergo roughly 6 to 12 treatments given three times per week.

Reflections On Mental Illness And Psychiatry

Mental illnesses are real diseases that affect a person's brain and change the way a person behaves, thinks, and interacts with others. In medicine, there exists an erroneous belief that diagnosis and treatment within psychiatry has no scientific foundation. The latest research, however, demonstrates strong physiologic and genetic components to most mental illnesses. For instance, neuroscientists have shown that patients diagnosed with major depression have lower levels of certain neurotransmitters, like serotonin and norepinephrine. As psychiatry becomes more and more biologically based, and we continue to increase our understanding of the biological basis of behavior, psychiatry will eventually become more integrated with medicine, declared one psychiatrist in academia.

Current Treatment In Human Narcolepsy

For management of narcolepsy symptoms in humans, pharmacological treatment is usually employed (11,27,28). For EDS, amphetamine-like central nervous system (CNS) stimulants or modafinil (a nonamphetamine stimulant with undetermined mechanisms of action) are most often used (Table 2). These compounds possess wake-promoting effects in narcoleptic subjects as well as in control populations, but very high doses are required to normalize the abnormal sleep tendency during the daytime (29). For consolidating nighttime sleep, benzodiazepine hypnotics or y-hydroxybutyrate (GHB) are occasionally used (11,27,28). Since amphetamine-like stimulants and modafinil have little effect on cataplexy, tricyclic antidepressants, such as imipramine or clomipramine are used in addition to control cataplexy (11,27,28) (Table 2). However, these compounds can cause a number of side effects, such as dry mouth, constipation, or impotence. GHB is also used for the treatment of cataplexy its mechanism of action...

About the Automatic Thoughts Questionnaire

They argue that thoughts play a critical role. A number of investigators have collected convincing evidence that certain thoughts, or cognitions, can both initiate and maintain a depressive episode. Hollon and Kendall developed the Automatic Thoughts Questionnaire to assess the sorts of cognitions that are associated with depression. Their goal was to develop a test that would be useful in gauging the progress of psychotherapy, but it can also be useful for those of you who are prone to experiencing these feelings. If you do have such episodes and you had a high score on this test, the odds are excellent that by changing your automatic thoughts you could feel considerably better. Please note that the norms were based on nondepressed college students. So even if your score was above the 85th percentile, it does not necessarily mean that you are seriously depressed. As always, if you suspect that you are, you should consult a mental health professional. This approach to treating...

Acute idiopathic polyneuritis The medical name

Many types of drugs are abused, including marijuana, AMPHETAMINES, HALLUCINOGENS (such as LSD), TRANQUILIZERS, and ANTIDEPRESSANTS. ALCOHOL and tobacco are probably the substances that have addicted the largest number of people. Most drugs, when abused, carry the risk of dependency.

Personalized Medicine for Pain Management

(fluoxetine, paroxetine), and tricyclic antidepressants (amitriptyline, imipramine). CYP2D6 is also induced by a variety of drugs, including dexamethasone and rifampicin. It should be obvious from the preceding list of substrates and common drugs that knowledge of 2D6 allele status may be important in directing therapy with such common drugs as antidepressants and opiates. This patient had decreased CYP2D6 activity and might be at a greater risk for toxicity, since he could not metabolize tramadol as efficiently as someone who was an extensive metabolizer. This was clearly evident by the steady-state concentrations (Css) of tramadol and O-desmethyltramadol. Typically, a patient receiving 200-400 mg day of tramadol has an average Css of 365 mg L.5 However, this patient was taking only one-fourth to one-half of that dosage (100 mg day), but had a similar Css (340 mg L). Therefore, insight into the patient's genetic makeup provided a better understanding and rationale for the...

Myositis and Myopathy

There are several genetic variants of drug-metabolizing enzymes that affect how active they are. For example, approximately 5-10 percent of most Caucasian populations have a variant of CYP2D6 that is either inactive or poorly functional. This means that these people poorly metabolize drugs that are substrates for this enzyme. For example, the activation of codeine to the active morphine metabolite is carried out by CYP2D6. Therefore people with an enzyme that functions poorly do not activate codeine well and do not receive the analgesic benefits of codeine when they take it. The older antidepressants such as amitripty-line and nortriptyline are also metabolized by CYP2D6, but in this case they are inactivated. Therefore people with the inactive enzyme have higher blood levels of these antidepressants and are more likely to have side effects if they are given standard doses of the drugs. The ability to predict how an individual will respond to a drug based on his or her genetic makeup,...

Assessment of Language

B is a 20-year-old Salvadoran male, who was hospitalized on an inpatient psychiatric unit. He identified himself as being bilingual. Upon evaluation by the Spanish-speaking nursing staff, the Spanish-speaking staff who saw him as hypomanic questioned why the English-speaking psychiatrist was planning to treat him with antidepressants. A case conference was held in which the doctor interviewed Mr. B in English. During the interview the patient spoke in slow, halting English his affect was flat, and his thoughts were incomplete. His answers to questions were succinct, and he provided scant information. The psychiatrist's diagnostic impression was that Mr. Martinez was depressed, with a psychotic thought process. When the Spanish-speaking staff interviewed Mr. B in Spanish, there was a dramatic change in his presentation. He became expansive in his responses and was quite delusional and labile. He provided a complete history, including details of having witnessed his brother killed...

Posttranscriptional Modifications

Arias et al. (84) genotyped 159 Spanish patients with major depression and 164 unrelated and healthy controls, they found that those patients carrying the 102C allele had more than five times the risk for attempting suicide than non-carriers (OR 5.50,p 0.01). Finally, several association studies that focused on late-onset AD reported an association between the presence of the C102 allele and the presence of psychosis (85,86), delusions (79), hallucinations (22), and comorbid depression (23).

Bronchopneumonia See pneumonia

Some girls with bulimia also struggle with addictions, including abuse of drugs and alcohol, or compulsive stealing. Many suffer from clinical depression, anxiety, obsessive-compulsive disorder, and other mental health problems. These problems, combined with impulsive tendencies, place them at increase risk for suicide. Counseling may last for about four to six months group therapy is also very helpful for bulimics. Antidepressants may also be effective in treating girls with bulimia. In outpatient treatment, bulimic patients are often asked to keep a food intake diary, making sure they eat three meals a day of moderate caloric intake, even if they are still binge eating. Exercise is limited, and if the girl becomes compulsive about it, is not permitted at all.

Treatment Approach

Masseter Muscle Injection

Nortriptyline, protriptyline, doxepin, and imipramine (tricyclic antidepressants). c. Bupropion, mirtazepine, trazodone, and venlafaxine (miscellaneous antidepressants). Treatment for TTHs follows the same principles as for migraine headache. Acute episodes are treated rapidly to restore patient function and comfort. Medications shown to be effective include analgesics and opiates. TTHs are commonly associated with affective, anxiety, and sleep disorders. Medications demonstrating efficacy for these disorders appear to be effective in the management of TTH. Prophylactic therapeutics commonly prescribed for TTH include tizanidine (a-2 adrenergic agonist), tricyclic antidepressants, selective serotonin reuptake inhibitors, neuronal stabilizing agents, buspirone, and venlafaxine (13).

Of Cataplexy And Excessive Daytime Sleepiness

Monoaminergic transmission is also critical for the control of cataplexy. All therapeutic agents currently used to treat cataplexy (i.e., antidepressants or monoamine oxidase inhibitors MAOIs ), are known to act on these systems. Furthermore, whereas a subset of cholinergic neurons is activated during REM sleep, the firing rate of monoaminergic neurons in the brainstem (such as in the locus coeruleus LC and raphe magnus) is well known to be dramatically depressed during this sleep stage (35,36). Using canine narcolepsy, it was recently demonstrated that adrenergic LC activity is also reduced during cataplexy (37). In contrast, dopaminergic neurons in the ventral tegmental area (VTA) and substantia nigra (SN) do not significantly change their activity during natural sleep cycles (38,39). Since cataplexy in dogs can be easily elicited and quantified, the canine narcolepsy model has been intensively used to dissect the mode of action of currently used anticataplectic medications. The...

Chromium Supplementation And Depression

Relate to insulin sensitivity and depression 79 . A small, double-blind, randomized, and placebo-controlled pilot study in 15 patients with major depression suggested that Cr may be effective in the treatment of atypical depression. Seventy percent of the subjects responded to Cr with no negative side effects 80 . In a second, double-blind, multicenter, 8-week replication study, 113 adult outpatients with atypical depression were randomized to receive 600 g day of elemental chromium in the ratio of 2 1, as provided by chromium picolinate (CrPic), or placebo. Primary efficacy measures were the 29-item Hamilton Depression Rating Scale (HAM-D-29) and the Clinical Global Impressions Improvement Scale (CGI-I). The results of this study suggested that the main effect of chromium was on carbohydrate craving and appetite regulation in depressed patients and that 600 g of elemental chromium may be beneficial for patients with atypical depression who also have severe carbohydrate craving 81 .

Antidepressant Therapy

As discussed in Chapter 2, patients with major depression should be started on antidepressant medication. It is essential for the primary care physician to keep in mind two risks inherent in treating the suicidal patient with major depression. First, many of the older generation of antidepressants (tricyclic antidepressants like amitriptyline hydrochloride, imipramine hydrochloride, nortriptyline hydrochloride, and doxepin hydrochloride) can be fatal in overdose. If there is a good reason for prescribing such a drug (e.g., prior response, inability to afford the newer drugs, formulary limitations), it is usually safe to prescribe a week's worth of medication at a time. At low starting doses, this quantity should not provide the means for a potentially fatal overdose. Most of the time it will be preferable to prescribe a selective serotonin reuptake inhibitor (SSRI), such as fluoxetine hydrochloride, paroxetine hydrochloride, or sertraline hydrochloride, which are extremely unlikely to...

Adjustment Disorder with Depressed Mood

Persistent and evidence of a major depression is lacking, the diagnosis of an adjustment disorder with depressed mood is appropriate. Although sympathy and support from primary care physicians will help patients with this form of sadness to regain their equilibrium, formal psychotherapy is usually needed to reduce the risk of future episodes derived from the same vulnerability.

Occipital cortex See visual cortex

In some cases, antidepressants may be used when the pain is particularly severe. other treatments may include local nerve blocks and injections of steroids directly into the affected area. In most people, the pain is eliminated or reduced with treatment and does not interfere with daily activities.

The Prognosis of Anxiety Disorders

Patients with panic disorder have been found to be symptomatic for 16 percent of their lives after the onset of their illness. For panic disorder with agoraphobia, the figure is 29 percent. Despite this relatively good prognosis, the relapse rate in panic disorder is 80 percent within two years after stopping treatment, and up to 20 percent of patients are chronically ill. Patients with agoraphobia, major depression, substance abuse, or personality disorders have poorer treatment outcomes, as do those who discontinue

Selective serotonin reuptake inhibitors SSRIs

A class of antidepressants that prevents brain cells from reabsorbing serotonin, thus effectively raising the levels of this neurotransmitter. A malfunctioning serotonin system has been implicated in the development of depression. The SSRIs include Prozac (fluoxetine), Zoloft (sertraline), paxil (paroxetine), serzone (nefazodone) and Luvox (fluvoxamine). These SSRIs have moved to the forefront of modern psychiatric treatment because they work as well as any of the older antidepressants while causing far less serious side effects. This lack of side effects is primarily due to the fact that they work so selectively in the brain, affecting just one neuro-transmitter system (serotonin) instead of other neurotransmitter systems and receptor sites throughout the brain. This is quite different than the shotgun approach of older antidepressants such as the MONOAMINE OXIDASE (MAO) INHIBITORS or TRICYCLICS, which interfere with neurotransmitters and receptor sites all over the brain.

Schizophrenia and Delusional Disorder Somatic Type

In schizophrenia, the patients complaints center around a delusional belief of ill health. Unlike anxious patients who are fearful of illness, delusional patients (whether with schizophrenia, delusional disorder, or major depression) are convinced they are ill, often with a bizarre or unusual infestation, poisoning, metabolic derangement, or physical malformation. The diagnosis of schizophrenia is suggested by a history of previous episodes of hallucinations or delusions in clear consciousness and by the absence of evidence of coarse brain disease or major depression. The prevalence of schizophrenia in primary care settings is less than 1 percent.

Treatment and Outcome

There are several different treatments for myasthe-nia that can be divided into three groups (1) drugs that increase the concentrations of the neurotrans-mitter acetylcholine (2) drugs that modulate the immune response and (3) surgical removal of the thymus gland. Several drugs such as aminoglyco-side antibiotics, tricyclic antidepressants, and phenytoin can worsen the symptoms of myasthe-nia and should be avoided if possible.

Benefit to Drug Discovery and Development

Understanding the pharmacological profile of a drug contributes to the development of drugs that have improved safety and tolerability over existing therapies for a disease and this provides the pharmaceutical company with a significant advantage over their competitors and benefit to the patients. For example, tricyclic antidepressants (TCAs) were discovered in the 1950s-1960s and were the therapy of choice for depression. TCAs (e.g., amitryptyline) nonselectively inhibit the reuptake of serotonin, noradrenaline, and dopamine and have a range of side effects that are a consequence of the lack of selectivity for the monoamine uptake transporters and activity at a range of receptors such as histamine, muscarinic, and adrenoceptors.9 The therapy of choice for depression nowadays are the selective serotonin reuptake inhibitors (SSRIs) that have similar efficacy, but significantly fewer side effects (e.g., sertraline),10,11 and therefore increased patient compliance. Another example is the...

Selecting the Right Medication

Antidepressants are the second medications to consider. I prescribe these if benzodiazepines don't work or have unacceptable side effects. In addition, I sometimes use antidepressants in special situations, such as for people who have respiratory disease or untreated sleep apnea, a history of substance abuse, or a coexisting emotional problem.

Drug Interactions

Adderall should not be taken with monoamine oxidase inhibitors (MAOI), because serious (even fatal) interactions can occur. At least 14 days must pass between taking MAOIs and Adderall. Acidifying agents such as guanethidine, reserpine, and fruit juices can interfere with the absorption of Adderall, whereas substances such as Diamox (acetazolamide) increase absorption. Tricyclic antidepressants such as Tofranil become more potent when taken with Adderall. Thorazine (chlorpro-mazine), lithium, and Haldol (haloperidol) can interfere with the effect of Adderall.

Personality

Becoming familiar with the patients personality at baseline also allows the physician to ascertain when there has been a change from the established pattern. Such changes may indicate the onset of a psychiatric disorder. For example, the physician should consider major depression as one reason why someone who is usually cheerful and carefree has now become morose and apprehensive.

Amikacin

This class of antidepressants is usually taken over a long period of time amitriptyline should not be taken by people who have HIV ENCEPHALOPATHY because it may cause acute delirium. Additionally, most antidepressants increase the risk of seizures in people susceptible to them. Because seizures are not uncommon in HIV disease, people who are infected with the virus should be cautious about taking all antidepressants, including those in the tricyclic class.

Bipolar Disorder

Most cases of major depression occur in patients whose episodes of illness are recurrent and relatively uniform in presentation. Each attack is similar to the last, and low mood, diminished self-esteem, and decreased energy are characteristic features. Such illnesses are diagnosed as recurrent major depression (or unipolar depression), and they can begin at any age, even in childhood. The average patient experiences four or five episodes in a lifetime, but variation from this mean is great. A minority of patients have episodes of major depression alternating with episodes of mania. Manic illnesses are in every way the mirror image of depressive ones the manic patient has an elated or excited mood, inflated self-esteem, heightened energy, overactivity, diminished need for sleep, racing thoughts, rapid speech, easy distractibility, and excessive interest in pleasurable activities with little regard to their consequences. Hypersexuality, excessive spending, grandiose delusions, and...

Function

One to two litres of saliva are secreted each day and almost all is swallowed and reabsorbed. Secretion is under autonomic control. Food in the mouth stimulates nerve fibres that end in the nucleus of the tractus solitarius and, in turn, stimulate salivary nuclei in the mid-brain. Salivation is also stimulated by sight, smell and anticipation of food through impulses from the cortex acting on brainstem salivary nuclei. Intense sympathetic activity inhibits saliva production, which is why nervous anxiety causes a dry mouth. Similarly, drugs that inhibit parasympa-thetic nerve activity, such as some antidepressants, tranquillizers and opiate analgesics, can cause dry mouth (xerostomia).

Taking a History

In general practice settings, the existence of major depression may be obscured by somatic complaints because insomnia, anorexia, diminished libido, fatigue, and feelings of ill health are common during depressive episodes. When patients have such symptoms, it is therefore important for the physician to inquire about other manifestations of a mood disorder. Moreover, medical illnesses and major depression frequently coexist, and both types of disorder deserve appropriate assessment. Somatic Complaints and Anhedonia. In typical major depression, patients have marked insomnia, usually awakening early in the morning and not being able to fall asleep again. Sleepless hours are often distressing and filled with pessimistic or self-doubting ruminations. Sometimes, however, patients with major depression have hypersomnia they go to bed early and arise, unre-freshed, late the next day. Because these individuals will not complain of difficulty sleeping, the physician should ask all patients...

Using the Laboratory

Major depression is a condition that occurs in clear consciousness. If the patients level of consciousness is altered, delirium is a far more likely diagnosis and the depressive symptoms are almost certainly secondary. The usual clinical and laboratory investigations for delirious states should be undertaken immediately, including searches for toxic, infectious, metabolic, and endocrine abnormalities, as well as structural lesions of the central nervous system (CNS). The electroencephalogram should be normal in idiopathic major depression. Urine screens for drugs of abuse are indicated if the physician suspects drug abuse but the patient denies it. If major depression is diagnostically certain on clinical grounds, the physician should always obtain thyroid function studies. Hypothyroidism (and, more rarely, hyperthyroidism) may present with severe depression and few or no physical findings. Screening tests for other endocrine or metabolic abnormalities are usually not indicated unless...

Treatment

Antidepressant drug therapy is the mainstay of treatment and is usually successful. As noted earlier, 60 percent of patients will respond to the first antidepressant used, and 85 percent respond to one of the first three agents chosen. These outcomes are possible only if medications are given in adequate doses and for an adequate length of time. Insufficient dosage and duration of therapy are the most common causes of treatment failure. Although the dosage depends on the drug, the required duration for a full therapeutic trial is six to eight weeks with most agents. Briefer trials reveal little about the true potential for drug response, and p.r.n. use of antidepressants is useless. This section describes the use of three classes of antidepressants tri-cyclic antidepressants, selective serotonin reuptake inhibitors, and the relatively new agent venlafaxine hydrochloride presented in the order in which they were developed. They are neither the only effective nor the most effective...

Rules of the Road

Bipolar disorder Popularly known as manic depression, this condition is characterized by manic episodes alternating with depression. Mood swings are often dramatic and unpredictable. Almost one-third of six- to 12-year-old children diagnosed with major depression will develop bipolar disorders within a few years. Bipolar disorder, which affects about 1 percent of the adult population of the united States, is in the same family of illnesses (called affective disorders) as clinical depression. Unlike depression, which affects more girls than boys, bipolar disorder seems to affect boys and girls equally. episodes accompanied by one or more major depressive episodes, which usually occur in cycles. Depression (major depressive episode) To be considered a full-blown major depressive episode, a child will feel sad and lack interest for at least two weeks, in addition to exhibiting at least four other symptoms Untreated patients with bipolar disorder may have more than 10 total episodes of...

Summary

Major depression is a common, often severe, and potentially life-threatening syndrome. Typical features include persistent sadness, excessive self-doubt, diminished mental and physical energy, disturbed sleep and appetite, decreased capacity to experience pleasure, and wishes for death or suicidal ideas. Major depression is not simply a more severe form of ordinary un-happiness. Only 50 percent of patients with major depression ever seek treatment for their illness, and only half of those who do are appropriately diagnosed and treated. In many cases, the first opportunity to detect the illness occurs in primary care settings. The diagnosis of major depression should not be made without a thorough examination of the patients mental state and a careful review of his or her past psychiatric history. Information obtained from members of the patient's family can be crucial for accurate diagnosis. Uncomplicated cases of major depression can be treated by primary care physicians. Treatment...

Enhanced Elimination

This technique is also called ion trapping and depends on the fact that charged species are less likely to cross biological membranes. Thus, if the urine is rendered alkaline, an acidic drug such as salicylic acid is converted to a salt within the kidney. This is illustrated by Eq. 3.3. The salicylate anion which carries a negative charge is now more prone to remain in the renal filtrate than to be reabsorbed back into the blood. In other words, it is more rapidly excreted from the body. Converting urine to an alkaline pH is, therefore, an effective means for enhancing the elimination of acids such as salicylates, barbiturates, methotrexate, and others. Conversely, it is possible to increase the acidity of the urine and thereby increase the charged character of drugs which are basic. Basic drugs such as tricyclic antidepressants or phencyc-lidine can be excreted more rapidly by acidifying the urine. This is not recommended, however, because the benefits of improved elimination usually...

Delirium

Ticholinergic compounds (e.g., tricyclic antidepressants, antihistamines, antispasmodics), narcotics, steroids, and antiparkinsonian agents (e.g., L-dopa, bromocriptine mesylate) are the chief culprits. Benzodiazepine, barbiturate, or alcohol intoxication also cause delirium, as can withdrawal from benzodiazepine, barbiturate, or alcohol. The physician should suspect alcohol, benzodiazepine, and or barbiturate withdrawal in hospitalized patients when delirium (especially delirium tremens) develops several days after hospitalization and no other cause is identified.

Dementia

The most common cause of dementia is Alzheimer disease, which accounts for approximately 60 percent of cases. Alzheimer disease is a diagnosis of both inclusion and exclusion. Inclusion criteria are the gradual development of cognitive decline over months or years, impairments in memory, and at least one other cognitive dysfunction (i.e., aphasia, apraxia, or agnosia). The exclusion criterion is that other causes (e.g., cerebrovascular disease, Parkinson disease, major depression, hypothyroidism, pernicious anemia, subdural hematoma) have been ruled out. Potentially curable dementias are rare but should be considered. Chronic subdural hematoma, hydrocephalus (characterized by dementia, gait disorder, and incontinence), major depression, gradually developing renal failure, endocrinopathies (e.g., hypothyroidism, hyperparathyroidism), and chronic central nervous system (CNS) infection (e.g., human immunodeficiency virus HIV , syphilis) can cause partially or fully reversible dementias.

Assessment

Chapter 1 discusses the Mini-Mental State Examination (MMSE) and suggests ways to determine the presence of abnormal mood, illusions, hallucinations, and delusions. A dementia due to major depression is often accompanied by delusions that are characteristic of depression, such as hypochondriacal beliefs (e.g., no bowel movements for many weeks without evidence of constipation), ideas of poverty (e.g., complaints of no money, insurance, or clothing when that is not the case), or guilt and self-blame (e.g., unfounded beliefs that the person has harmed others). Because depressed patients often feel unwell, with insomnia, anorexia, and lethargy, they may present to their primary care physicians with somatic complaints.

Depression 141

Depression A mood disorder characterized by sadness, hopelessness, low self-esteem, fatigue, or agitation. As many as one in every 33 children (and one in five adolescents) may have clinical depression. Recent studies have shown that more than 20 percent of adolescents in the general population have emotional problems, and a third of teens attending mental health clinics suffer from depression. A child who has experienced an episode of depression is at an increased risk for developing another episode of depression within the next five years. In addition, children who experience a depressive episode are five times more likely to become depressed as an adult. indeed, depression in childhood may predict a more severe depressive illness in adulthood. Clinical depression can have a devastating impact on children's school performance, friendships, and family relationships. Because children who are depressed are likely to experience depression in adulthood, treatment of this childhood...

Distribution

Vd is helpful in the context of drug monitoring. It helps to predict whether the practice of drug measurement in blood will have any clinical value. Drugs with high Vd are not present in the blood to any extent and it follows, therefore, that tests on blood specimens may give an inaccurate picture of total body burden of the drug. In other words, one must measure blood content of drug because it is impractical to measure organ content, but the drug produces symptoms depending on the organ content. In actuality, the key feature of drug monitoring from the perspective of correlation between concentration and symptoms is that an equilibrium exists between the drug at the receptor and the drug's concentration in the blood. This equilibrium, furthermore, is more likely to exist for a drug with low Vd drugs with this property, therefore, are good candidates for drug monitoring by measurement of blood concentration. Psychotropic drugs such as tranquilizers, antidepressants, antipsychotics,...

Epidemiology

Somatic symptoms are extremely common. It has been estimated that 60-80 percent of a normal population experience one physical symptom per week and that anywhere from 20 percent to 80 percent of patients presenting to primary care physicians have poorly explained somatic complaints. Culture, personality, and gender may all be predisposing factors in generating unexplained medical complaints. Female sex may be influential in three ways (1) women report more symptoms in general than men do, (2) women visit physicians more often than men do, and (3) the two most common psychiatric disorders that present with prominent somatic symptoms (i.e., major depression and anxiety disorders) occur more frequently in women than in men.

Depression

Treating depression leads to improvement in memory and other cognitive functions, often within a few months. Michael's experience was fairly typical. The combination of psychotherapy and medication for his depression and sleep disturbance successfully treated these problems and led to the full return of his cognitive function within six months.

Hysteria

Case Example A single young man was hospitalized with a one-month history of weakness of his legs and difficulty walking. Neurologic evaluation was unremarkable, yet the patient persisted in a fearful worry that he had multiple sclerosis. His present illness had started acutely, after he had begun a new job where he felt fearful of his boss, who was critical and demanding. The final straw came after he had begun dating a woman from his office. Although he saw their relationship as casual and platonic, she had begun pressing him for more of a commitment. After a distressing discussion with her one night, he awoke the next morning feeling weak in his legs and unable to walk. By temperament he was a dramatic, perfectionistic, and self-centered person. Examination of the patients mental state did not reveal evidence of major depression, an anxiety disorder, or schizophrenia. His behavior was understood as motivated by both fears of dealing with situations he wished to avoid and a desire...

Dermatitis

Withdrawal from activities usually found to be pleasurable. It may also cause sleep disturbances and changes in eating patterns and energy levels it may range in intensity from a general feeling of the blues to major clinical depression. The term depression is used to describe various conditions, including transient moods, mild but persistent sadness, and clinical illness. Clinical depression is defined as a cluster of symptoms that occur together daily over a certain period. The main forms of depressive disorder are major depression, which is often episodic, and dysthymia, which is a milder chronic condition. The diagnosis of major depression, as defined in current psychiatric standards, requires the presence of at least five of nine specific symptoms during one two-week period. These must include either the first or the second of the following depressed mood, markedly diminished interest or pleasure in almost all activities, significant unintentional weight gain or loss, insomnia or...

Skin Symptoms

In many cases the skin exhibits evidence of exposure to toxic substances. The two main skin characteristics observed as evidence of poisoning are skin color and degree of skin moisture. Excessively dry skin tends to accompany poisoning by tricyclic antidepressants, antihistamines, and belladonna alkaloids. Among the toxic substances for which moist skin is a symptom of poisoning are mercury, arsenic, thallium, carbamates, and organophosphates. The skin appears flushed when the subject has been exposed to toxic doses of carbon monoxide, nitrites, amphetamines, monsodium glutamate, and tricyclic antidepressants. Higher doses of cyanide, carbon monoxide, and nitrites give the skin a cyanotic appearance (blue color due to oxygen deficiency in the blood). Skin may appear jaundiced (yellow because of the presence of bile pigments in the blood) when the subject is poisoned by a number of toxicants, including arsenic, arsine gas (AsH3), iron, aniline dyes, and carbon tetrachloride.

Symptom Relief

Low-dose tricyclic antidepressants have been employed on the basis of their effectiveness in treating dysesthetic vulvodynia. These agents are indicated for efficacious pain reduction rather than for their effects on mood. In a series of 230 VVS patients, a three- to six-month course of low-dose amitriptyline resulted in a 60 positive response rate after five years of follow-up (3).

Dyspepsia

Dysthymia A term used by the American Psychiatric Association to refer to a mild but generally chronic form of depression. It is not the same as major depression. Both conditions do occur in the same people. Major depression is episodic, meaning it is usually a time-specific episode. Dysthymia affects people over a long period, when they never feel good about their lives. Dys-thymia tends to run in families. It has been shown to respond well to treatment with antide-pressants, but marked improvement may take longer. Dysthymia may be the term used to describe someone who is suffering from an ongoing bereavement reaction, as occurred during the years when AIDS deaths were far more numerous in the United States.

Study Size

In many situations, the description of the single group of a cross-sectional study may contain within-group comparisons. For example, in patients with schizophrenia, differences in mean latency of the auditory P300 between males and females may be examined. However, these comparisons are secondary to the main objective which is to describe the group as a whole. In a truly comparative study, two or more groups of subjects are identified and the examination of differences between them is the primary objective of the study. Thus Weir, Fiaschi and Machin (1998) wished to compare patients with schizophrenia with those having major depressive illness. This comparison provides the major research question and any secondary variable, such as the gender of the patients, may then be used as a covariate to see if taking this into account modifies the observed differences between groups with respect to the measures taken.

Fluid retention

Fluoxetine hydrochloride An antidepressant that is approved for treatment of major forms of depression. It is also used to treat obsessive-compulsive disorder, bulimia nervosa, and premenstrual dys-phoric disorder (commonly referred to as PMS). Fluoxetine works by slowly restoring normal levels of a nerve transmitter (serotonin). Possible side effects are decreased appetite and weight loss. Some patients have reported conversion of depression to mania in manic-depressive (bipolar) disorders, but this effect is rare. Although press reports suggested fluoxetine caused major depression and suicidal ideation in many people who used it, a review of literature on this subject reveals that development or intensification of suicidal thoughts during treatment (regardless of the severity of depression) has been documented for many anti-depressant drugs in use. Fluoxetine is a selective serotonin reuptake inhibitor (SSRI), referring to its family of drugs. (Trade name is Prozac.)

Cholestasis

This term refers to the blocking of the flow of bile. It may arise on a microscopic basis from disruption of the normal hepatic architecture which occurs when hepa-tocytes die. Alternatively, it may occur from a macroscopic abnormality such as a hepatic tumor. In any case, the outcome is some degree of jaundice (yellow discoloration of the skin) and the disruption of normal biliary flow. Many drugs including some tranquilizers, antidepressants, and hormones are capable of causing cholestasis.

Emotion

Astrom et al. (1993) found major depression in 25 of stroke survivors, which rose to 31 at 3 months post onset, fell to 16 at 12 months, and increased again over the next 2 years to 29 . Some workers take the position that drugs should be avoided, but others suggest incorporating drugs and psychotherapy, with drugs perhaps being more appropriate at early stages to counter direct effects and psychotherapy and counseling more appropriate later, when the individual is more ready to deal with the future. Individual and group counseling are effective, and aphasic people themselves have recently become involved as counselors.

In the Workplace

Neurotransmitters are made from the protein in food this protein is first broken down in the stomach and intestines into smaller substances called amino acids. These amino acids enter the blood, where they are absorbed by the brain, which uses the amino acids to make neurotransmitters. it is the correct balance of the neurotransmitters in the brain that is responsible for proper function. Any deficiencies in nutrients will upset the level of certain neurotransmitters and interfere with the behaviors or actions for which they are responsible. On the other hand, a problem (such as depression) can be corrected by altering the balance of the neu-rotransmitters this is precisely what antidepressant medication is designed to do. Different neurotrans-mitters are manufactured by different nutrients in the diet therefore, too much or too little of any one nutrient may lead to an abnormal level of neu-rotransmitters in the brain.

Adverse Effects

Isotretinoin is an extremely effective anti-acne preparation, but in a small number of patients (less than 1 percent) it may be associated with symptoms of a major depressive episode. In these cases, symptoms resolve rapidly (within two to seven days) after stopping the medicine. After a period off medication, treatment can begin again at a lower dose.

Liposuction

Lithium carbonate A drug that is particularly useful in treating the manic phase of manic-depressive illness. Given orally, it is readily absorbed and eliminated at a fast rate for five to six hours and eliminated at a much slower rate over the next 24 hours. It is essential to monitor the blood level of the drug in patients on this therapy. Side effects including fatigue, weakness, fine tremor of the hands, nausea and vomiting, thirst, and polyuria (the passing of an excessive quantity of urine) may be noticed in the first week of therapy. If these are mild, most will disappear, but the thirst, polyuria, and tremor tend to persist. (Trade names are Eskalith, Lithane, Lithonate, and Litho-tabs.)

Mandatory reporting

Mania Any mental disorder, especially when characterized by violent, unrestrained behavior. When used as a suffix, a morbid preference for or an irrepressible impulse to behave in a certain way. The term also refers to one of the two major forms of manic depressive illness. The manic form of manic-depressive psychosis is characterized by an elated or euphoric, although unstable, mood increased psychomotor activity, restlessness, agitation, etc. and increase in number of ideas and speed of thinking and speaking, in which in more severe forms proceed to flight of ideas (rapid shift

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