Tag Archives: depression

Quick Hits: Medical Treatment Adverse Event Death Drop and Antidepressant Tapering With Psychotherapy

Deaths related to the adverse events of medical treatments fell between 1990 and 2016. Researchers examined the causes of death listed on death certificates as well as data from the Global Burden of Diseases, Injuries and Risk Factor tool. Overall, the mortality rate due to adverse events declined by 21.4% from 1.46 per 100,000 people to 1.15 over the time period. However, researchers noted that age was a significant factor in mortality. The mortality rate for those aged 70 and over was nearly 20 times higher than for those between 15 and 49. Location also influenced the rate, with California having the lowest and Mississippi the highest. The most common reason for an adverse event from medical treatment was surgery and post-operative complications. Posted January 18, 2019. Via JAMA Network Open.

Tapering off antidepressants is more successful and a person has a lower risk for relapse if it is done along with psychotherapy. Researchers conducted a meta-analysis of 15 studies and found that after two years, the risk for relapse was between 15% and 25% for cognitive behavioral therapy and tapering compared to 35% to 80% with just regular clinical visits and tapering. The study’s authors note that in western countries, antidepressant prescriptions have doubled over the last decade. In addition, the average length of time on an antidepressant in the US is five years, and the medications are often prescribed by a primary care physician, not a psychiatrist. Posted January 22, 2019. Via Annals of Family Medicine.

Areas of the country where drugmakers spent more money marketing to doctors are linked to higher rates of opioid use, according to a new study. Researchers say that counties that had the most opioid marketing from pharmaceutical companies to healthcare providers subsequently had the highest rates of opioid prescribing and opioid overdose deaths. Between August 2013 and December 2015, drug companies spent about $40 million on opioid marketing to more than 67,000 physicians. The Northeast US had the highest marketing and the Midwest the lowest, the study found. Also, for every three additional payments made to doctors per 100,000 people in a county, opioid deaths increased 18%. Posted January 18, 2019. Via JAMA Network Open.

MedShadow’s Top 10 Stories of 2018

What were the most popular stories we published in 2018? Our Top 10 includes two stories on drugs that have become popular among opioid abusers, as well as articles dealing with drug interactions, a controversial class of antibiotics and a first-person story on an herbal supplement that has come under attack from the FDA, among others. Here are excerpts of the stories with the highest readership.

1. Gabapentin’s Secret: The Drug Opioid Abuser’s Crave

By Ronni Gordon

For many people who take gabapentin – a drug prescribed to treat seizures and pain caused by shingles – side effects such as sedation can be a challenge, as those who take it off-label for neuropathic pain told MedShadow in the past.

But an increasing number of opioid abusers crave that side effect, reporting a calm feeling when combining gabapentin – developed by Pfizer under the brand name Neurontin – with opioids, muscle relaxants and anxiety medications. Some also get a marijuana-like high and an enhanced euphoria. But when overused or abused, it can cause significant organ or brain damage. Read more →

2. Managing Eczema: Are New Treatments Like Eucrisa Worth It?

By Madeline Vann

Eczema (atopic dermatitis) can feel like a moving target for people who live with it. They get control over one flare, only to have eczema redden and irritate another patch of skin. For some patients, changing their bathing and beauty habits along with a thick moisturizer and topical corticosteroid ointments are enough.

“Steroids are the mainstay of treating atopic dermatitis. They’ve been around for decades. They are generally inexpensive, and for the vast majority of patients, that’s how we start treatment,” explains dermatologist Amy Paller, MD, director of the Northwestern University Skin Disease Research Center in Chicago. American Academy of Dermatology (AAD) guidelines recommend using emollient moisturizers, lifestyle changes to avoid triggers, and corticosteroids at first. Read more →

3. How Imodium Became Appealing to Opioid Addicts

By Padma Nagappan

A sports injury from playing squash in high school lead to a herniated disc for Bob Johnson (name changed to protect his privacy), who was initially given codeine for his pain, and then bumped up to hydrocodone, which is more powerful and used to treat severe pain.

He stopped taking the drugs once he began recovering. All was well until he left for college in Philadelphia and started playing on the squash team — and his back began hurting again. He found it was easy to get access to drugs and began buying OxyContin (oxycodone) from a dealer. Read more → 

4. What is the Best Way to Treat Heat Rash?

By Dave Walker, RPh

Question: It’s summer and I’m going to be spending a lot of times outdoors. I’m susceptible to heat rash. What is the best treatment for it?

I remember anticipating summer vacation as a kid. We were always busy planning and participating in neighborhood sporting activities, biking, hiking, fishing and camping trips. The neighborhood moms always had a ready supply of Band-Aids, Bactine and antiseptic cream to take care of those expected and inevitable scratches, scrapes, cuts and insect bites along the way. Read more →

5. 4 Drugs That Interact with Anxiety Meds

By Christy Huff, MD

If you suffer from anxiety, panic disorder or insomnia, your doctor may have prescribed you a tranquilizer belonging to a class of drugs known as benzodiazepines.

Drugs such as Xanax (alprazolam), Valium (diazepam), Ativan (lorazepam), and Klonopin (clonazepam) are some of the most-prescribed medicines – more than 133.4 million such prescriptions were filled in the US in 2014. As with any medication, drug interactions can occur if you take a benzo with another medication, and in certain cases, may be life-threatening. Read more → 

6. Why Aren’t Seniors Getting the Shingles Vaccine?

By Rita Colorito

Nearly 12 years after the FDA approved Zostavax, the first vaccine to prevent shingles in adults 60 and older, the vast majority of seniors still haven’t received it. Only 30.6% of adults age 60 and older reported getting the shingles vaccine, according to the latest CDC (Centers for Disease Control and Prevention) assessment of vaccine coverage.

Since it became available, Zostavax has faced numerous barriers in terms of getting seniors vaccinated, the assessment found. In October, the FDA approved a new shingles vaccine, Shingrix, for people age 50 and older. Less than a week later, the CDC’s Advisory Committee on Immunization Practices (ACIP) recommended Shingrix as the CDC’s preferred shingles vaccine for adults age 50 plus due to Shingrix’s better efficacy and fewer side effects compared to Zostavax. Read more → 

7. Floxed! The Painful, Life-Lasting Effects of Some Antibiotics

By Suzanne B. Robotti

Last week, we ran a news story on antibiotics causing “rare” damages to people. We had a very passionate response from more than 75 people who all claimed to be harmed by a particular type of antibiotics. More than 60,000 people have complained to the FDA about them. It begs the question, how unusual are these “rare” harms.

The side effects and adverse events associated with Cipro, Levaquin and other fluoroquinolones (FQs) can be significant and life altering. Yet many people who have been damaged by fluoroquinolones complain that there are too few warnings. Many claim that doctors don’t believe that their new illnesses have come from the FQs. Worse, sometimes FQs are prescribed when other, less risky — and just as effective — antibiotics are available. Read more →

8. The FDA Has It Wrong on Kratom: How the Herb is Helping People Like Me

By Andrew Turner

Some may ask who are the consumers of kratom, an herb used to treat pain, depression and anxiety that has been the subject of controversy lately in the news. It’s complicated.

We can be anyone. We are your neighbor, the veteran in the supermarket, your college professor and even your best friend. There’s a lot of misconceptions about kratom, how it’s used to treat certain ailments and its potential for addiction. Read more →

9. Can An Opioid Addiction Drug Treat Autoimmune Disorders

By Deborah Lynn Blumberg

A slew of drugs, both new and old, are used to treat autoimmune disorders like multiple sclerosis (MS), lupus and Crohn’s disease. Most of them come with side effects, some of them serious. But research and experience from patients and doctors are mounting that a drug used to treat substance abuse, when used in lower doses, can effectively treat autoimmune conditions with few side effects.

The drug is naltrexone, which was first approved in the 1980s to treat heroin addiction. In recent years, it has been prescribed more and more at a low dose for patients with autoimmune disorders. But is this off-label use (yet to be approved by the FDA) safe and effective? Read more →

10. Pros and Cons: Prednisone

By Tori Rodriguez

If you visit the doctor from time to time for anything other than a routine checkup, it’s likely that at some point you’ve received a prescription for a type of drug called corticosteroids. These are among the most commonly prescribed medications in the US, and they are used in almost every medical specialty.

In a study published last year, researchers at the University of Michigan found that 1 in 5 American adults with commercial health insurance had been prescribed a corticosteroid at least once over a 3-year period. Read more →

2018: A MedShadow and FDA Year in Review

When the end of the year comes, many use it as a time of reflection. I am no different. I’d like to use my blog this week to reflect on some of the accomplishments MedShadow has achieved in 2018, as well as some observations about the FDA this year.

MedShadow’s Top 3 Achievements of 2018

1. The first thing to highlight about 2018 is that it was another year of growth in terms of people visiting the site and reading our content. We already have more than 1.3 million site visitors year-to-date, and we hope to make it to 1.4 million by Dec. 31. As far as content, we added the bi-weekly “Ask the Pharmacist” column from Dave Walker, who also happens to be on our MedShadow Medical Advisory Board. Also, this column, originally called FDA Watch, became known as Health Pulse and instead of running every other week, comes out weekly.

2. MedShadow also held its first-ever public event in November, Raising Awareness About the Side Effects of Medicines. It brought together patients, patient advocates, healthcare workers and political leaders to listen to medical professionals. The purpose was to improve efforts to inform the public about medications to improve their health care, as well as increase MedShadow’s exposure.

3. Last month, MedShadow filed an amicus curiae (“friend of the court”) brief in a US Supreme Court case, Merck v. Albrecht. The case involves the osteoporosis drug Fosamax (alendronate) and women who say their spontaneous fractures of the thigh bones were caused by the drug. At issue is how Merck dealt with updating the label of Fosamax when it became aware of the issue. Yesterday, Suzanne Robotti, MedShadow’s founder and executive director, had an op-ed piece published in STAT, one of the most well-respected health and medical websites that is followed by many in the pharmaceutical industry, about the case. The decision could impact how patients are able to hold drug companies accountable when they are harmed by a drug and seek damages in court.

Top 3 FDA Actions – and Inactions — of 2018

1. The FDA’s biggest offensive this year came in its assault on e-cigarettes amid growing numbers of young people using the devices. Between 2017 and 2018, the number of high school students using e-cigs increased by 78% from 2.1 million to about 3.6 million. Last month, the agency proposed new restrictions on the sale of flavored e-cigs, which are especially appealing to teens. In September, the FDA ordered the 5 biggest e-cig manufacturers to develop plans to curb use of their devices by teens. Earlier this year, the FDA conducted a surprise inspection of the offices of JUUL Labs, the nation’s largest e-cig manufacturer, seizing more than 1,000 documents.

2. Another product that found itself in the FDA’s crosshairs was kratom. The herb has a loyal following among many Americans who use it for its reported pain-relieving properties, as an alternative to opioids, to deal with the effects of opioid-use withdrawal, and even depression and anxiety. The FDA has issued several warnings on kratom this year. In February, the agency warned kratom has opioid-like qualities and can be potentially addictive. Earlier in the year, the agency issued several warnings about kratom products tainted with salmonella. Last month, the FDA said it found high levels of heavy metals in kratom samples it had tested. The FDA has linked at least 44 death to kratom, though kratom supporters say that is misleading as in nearly all those cases, the kratom was either adulterated with other substances or other potent drugs were found in the person’s system. The Drug Enforcement Agency may essentially ban kratom by making it a Schedule 1 substance – the same as heroin, LSD and marijuana – after the Department of Health and Human Services made the recommendation.

3. One area where the FDA could have – and should have – done more is to tighten regulation of the supplement industry. We have reported on many occasions about supplements being recalled for one reason or another. While drugs are also sometimes recalled, supplements do not have to conduct clinical trials to prove they actually say what they do in order to make it onto the market. Americans spend more than $40 billion a year on supplements, and in many, many cases, they are using products that are likely useless, and potentially harmful. It’s time for the FDA to require more rigorous testing of these products so that the claims on their labels are actually backed by scientific evidence.

FDA Finds High Levels of Heavy Metals in Kratom Samples

The FDA, which has already issued numerous warnings on the plant-based supplement kratom, said it found “disturbingly high levels of heavy metals” in kratom products it tested. The agency noted it found levels of lead and nickel in some of the samples tested at levels not considered safe for human consumption.

FDA Commissioner Scott Gottlieb said in a statement that while one-time use of kratom was not likely to lead to heavy-metal poisoning, repeated use could.

FDA scientists tested 26 different kratom products. Although not legally marketed in the US, kratom has grown in popularity due to its purported pain-relieving effects, despite the FDA’s caution that the herb has opioid-like qualities. Anecdotal reports also indicate kratom is being used for depression and opioid withdrawal.

“To date, there have been no adequate and well-controlled scientific studies involving the use of kratom as a treatment for opioid use withdrawal or other diseases in humans,” Gottlieb noted.

Over the summer, the FDA reported of outbreaks of salmonella connected to kratom products. And earlier this year, the FDA warned kratom could be potentially addictive and linked 44 deaths to kratom use.

Many Medications Taken Longer Than Recommended

Many people continue to take prescription drugs months after clinical guidelines recommend, a practice that increases the risk of side effects from individual drugs as well as from drug interactions.

New research examines the issue of legacy prescribing, which is when drugs are taken for longer than needed to treat a condition. A new study, published in the Annals of Family Medicine, examined 50,000 patients in Canada who were prescribed drugs that are typically taken for more than three months but not indefinitely. The drug classes were antidepressants; proton-pump inhibitors (PPIs), which are used to treat heartburn and acid reflux; and bisphosphonates, which treat osteoporosis by stemming bone density loss.

Nearly half of patients on an antidepressant – 46% – were on it for more than 15 months, even though a current recommendation states they should be prescribed it for only six months after a mood episode is resolved. PPIs shouldn’t be taken for longer than three months. However, 45% of patients were prescribed them for longer than 15 months. The recommendation for bisphosphonate prescriptions is 5.5 years, yet 14% of people on those drugs took them for at least six months longer than that.

For example, long-term use of PPIs has been linked to several health issues. In one study, patients who had taken the drugs for at least five years had a higher risk of developing kidney disease than those on another type of acid-reducing medication. Another study found long-term PPI use may be associated with an increased risk for stomach cancer.

Quick Hits: Statins and Seniors, ‘Magic Mushrooms’ As Depression Treatment & More

Almost half of patients 65 and over that are prescribed statins stop taking them within a year — and side effects may be to blame. Researchers looked at 22,340 seniors who started statin therapy and found that 45% stopped taking the medication within a year of receiving the prescription. Results also showed that patients 85 and older were even more likely to stop taking the pills. Some people on statins do experience muscle aches and pains and some studies have indicated that statins are associated with a higher risk of developing diabetes. The researchers noted that having diabetes and anxiety was associated with a higher rate of discontinuation. Posted November 6, 2018. Via British Journal of Clinical Pharmacology.

The FDA has granted “Breakthrough Therapy” status to a drug company’s treatment-resistant depression medication that contains psilocybin, the active ingredient in psychedelic mushrooms. The designation means that the agency will fast-track review of the drug. However, it may be some time before the FDA approves the drug as the company, COMPASS Pathways, has just started to conduct a large-scale clinical trial. In a news release, the company said a 2015 study in which psilocybin was given to 19 patients in a clinical setting “found promising signals on efficacy and safety.” Treatment-resistant depression affects 100 million people worldwide. Posted October 23, 2018. Via COMPASS Pathways.

Some lots of the hypertension drug irbesartan are being recalled because they may contain an impurity that can cause cancer. The irbesartan affected was manufactured by ScieGen Pharmaceuticals and may contain N-nitrosodiethylamine (NDMA), a probable human carcinogen. You can check to see if the irbesartan you are taking is impacted by the recall here. If your medication is on the recall list, do not stop taking it. Instead, talk to your doctor or pharmacist about an alternative treatment. Irbesartan is the second high blood pressure medication recalled because of NDMA this year. Over the summer, the FDA recalled certain lots of valsartan. Posted October 30, 2018. Via FDA.

Let’s Get Real About Antidepressant Side Effects

By Sean Hagey
The Mighty

Your doctor just wrote you a prescription for your depression. You were probably given some info on what the drug is, what they hope it will do for you and (if your situation is like mine) they may have mentioned “some mild side effects” may occur.

Maybe they don’t really know, or maybe they don’t want to frighten you, but I’ve found an alarming amount of doctors don’t inform you on just how common side effects are. In my experience, they certainly don’t tell you about the really intense stuff.

I remember coming back to the doctor after that very first prescription and had this interaction:

Me: I’ve been having a lot of headaches and stomach issues since I started taking that medicine.

Doctor: Yes, that’s unfortunately very common.

I didn’t say it out loud, but I definitely remember thinking, “That would have been good to know before I started taking this!”

Drowsiness and fatigue can also be common, which is wonderful because we depressives already struggle with fatigue and lack of motivation.

Weight gain is reported from many antidepressants. Great, now I have a body image issue to add to the mix. What kind of sick joke is this!

My journey through this valley of cupcakes and rainbows has basically been a cruel game of “Would You Rather?”

Nausea and other gastrointestinal issues are common. Fantastic. Now I can’t even enjoy my damn ice cream without feeling like it’s going to violently come back up.

It’s taboo to talk about, but sexual dysfunction is very common. It’s as high as 50% — or more! — in some studies. For guys, that can mean erectile dysfunction. For men and women, this likely means difficulty or inability to achieve orgasm. As if being depressed wasn’t already bad enough.

And last, but not least, there’s other weird stuff. Dry mouth, lightheadedness, dizziness, agitation and my all-time favorite, “brain zaps.” Yes, I’m talking about this really freaky sensation that I’ve only had when taking a type of antidepressant known as an SNRI (serotonin and norepinephrine reuptake inhibitors, such as Cymbalta, Effexor and Pristiq). My brain says, “You know what would really lighten up the mood around here? An electrical shock!” At that moment, a bolt of lightning starts in my brain and zaps out into my face, hands and feet. It’s like a party — in hell.

My journey through this valley of cupcakes and rainbows has basically been a cruel game of “Would You Rather?”

I’ve pretty much run the whole gamut. I don’t know if there’s some sort of prize for my achievements, but I figure I should at least be considered for the hall of fame of side effects. Perhaps I should start calling myself the Babe Ruth of depressives. Please, no requests for autographs though. I’m tired, nauseous and agitated, with a dry mouth and headache from dealing with these damn brain zaps.

Sometimes you have to laugh about it or else you’ll cry. And I’ve already met my lifetime quota on that. Plus, I’ve already written about how serious, scary and horrible it is to have a major depressive episode here.

Sean Hagey is a physical therapist assistant and technology consultant who writes about his battle with depression. He runs the blog, Mental Health Matters, which focuses on mental health advocacy and education.

This article was originally published on The Mighty. Reprinted with permission of the author.

Quick Hits: Older Adults Want To Take Fewer Drugs, Talk Therapy Side Effects & More

Two out of three older adults would like to decrease the number of medications they are taking, according to a new survey. Also, nine out of 10 of them would stop taking one or more medicines if their doctor told them it was okay. Researchers based their findings on results from the National Health and Aging Trends Study, which includes adults 65 and older. Almost 50% of seniors take five or more medications. Taking many medications simultaneously, commonly known as polypharmacy, can lead to an increased risk of side effects and drug interactions. The survey also showed that those with chronic medical conditions were more likely to want to cut back on the number of drugs they take. The researchers said the results indicate that doctors should be comfortable bringing up the idea of deprescribing with senior patients. Posted October 15, 2018. Via JAMA Internal Medicine.

Cognitive behavioral therapy (CBT), one of the most popular treatments for various kinds of mental illnesses, is not without unwanted effects, according to a new study. These unwanted effects include distress, strains in relations with family, feelings of guilt and shame and intense emotions. Researchers interviewed 100 therapists and asked them to think about a client they had seen for at least 10 sessions. The therapists were then asked if the client had experienced any of 17 unwanted effects from therapy. Based on the interviews, researchers say about 40% of those undergoing CBT experience at least one unwanted event. They added that the unwanted effects may be an inevitable part of dealing with difficult thoughts and events. Posted October 7, 2018. Via Cognitive Therapy and Research.

Drugmakers would be required to disclose the price of a medication in television drug ads under a new proposal from the Trump administration. The proposed rule would mandate that the ad mention the wholesale or list price for a typical course of treatment, or a 30-day supply if the drug is a long-term medication. This is the price of a drug before insurance coverage picks up at least part of the cost. The administration is pushing the requirement as part of an effort to increase price transparency of drugs. Medications with a list price of less than $35 per month would be exempt from the price disclosure requirement. The top 10 most advertised drugs on television have list prices ranging from $535 to $11,000 per month, according to the Department of Health and Human Services (HHS). Posted October 15, 2018. Via Centers for Medicare and Medicaid Services.

How Antidepressant Side Effects Make You Rethink the ‘Good Life’

By Sonya Vatomsky
SonyaVatomsky.com

Even if you aren’t aware of it, the chances are good that someone you know is taking some sort of psychiatric medicine. According to the most recent research, an estimated one in six adults in the U.S. have a prescription for antidepressants, anti-anxiety pills, or some other drug to help them manage their mental health. And with those drugs, for many of those people, come the side effects — some of which can feel dire enough to become a problem in and of themselves, requiring a second treatment to offset the first.

Many commonly prescribed antidepressants, in particular, can come with a host of side effects that can paradoxically contribute to depression. “Antidepressants saved my life and killed my orgasms,” writer Sofia Barrett-Ibarria declared in Self magazine in 2017; problems with sex are common, as are struggles with weight. Auxiliary medications are often prescribed to mitigate the severe side effects of primary medications, but can come with their own, like tinnitus (ringing in the ears) and digestion issues. The end result is that seeking treatment for mental illness is often a delicate tightrope walk toward health, one that forces patients to consider any number of trade-offs and carefully evaluate exactly what it means to live a good, happy life.

“It’s like, if the side effects make me just as depressed, then what’s the point?” says Melissa, a 38-year-old who currently takes both Zoloft (sertraline) and Wellbutrin (bupropion). With just the sertraline, she says, “I was so, so tired, gaining weight, and still wanting to kill myself occasionally.” Exhaustion and weight gain were contributing to the depression rather than curing it, so her doctor added Wellbutrin into the mix — a medication that can help with side effects of other pills, but isn’t itself risk-free.

“Wellbutrin is considered to be a medication without side effects by most doctors I’ve spoken to,” says Emily, a 26-year-old who finds the drug mostly effective but experiences heightened anxiety, an increased libido (“to the point that it is unpleasant,” she says), abnormal hair growth, headaches, and tinnitus. “Those [last two] aren’t as big of an issue for me,” she confides. “As bad as any other side effect is, weight gain is always worse.”

It’s a statement that resonates with many others whose weight rose or fell dramatically after starting a new medication. While mental illness is private, often invisible to outsiders, weight — especially for women — is highly visible, not to mention highly fraught.

Eleanor, who just turned 33, has started calling it “cheer chub,” to make herself feel better. “I’m thrilled to finally feel like a person again,” she says — her antidepressants are working well, and she found herself able to cook more, exercise, and actually partake in the hobbies she kept buying supplies for. Then she noticed the numbers on the scale didn’t make sense, given her lifestyle changes. “It was really discouraging for a bit,” she says, “since a big trigger for my depression is feeling helpless or unable to control things that are important to me.” “Cheer chub” is an attempt at rebranding, a way of reasserting her sense of control.

For patients who have found something that more or less works, deciding to stick to a treatment can come down to choosing the devil you know. But should it be that way?

It’s also the term Eleanor uses when talking about the uncomfortable issue with her friends: “It makes people laugh and relax when you’re talking about a sometimes touchy subject.” She talks about it with her psychiatrist, who she says is well versed in side effects and also willing to consider their emotional impact in a genuine, resourceful way.

For many patients, the physical impact can be just as frustrating. “It’s difficult to be focusing on my mental and physical health and have one negatively impact the other,” says Deidre, a 26-year-old who found her mental state deteriorating even as she stepped up her efforts to improve her health, becoming vegan and exercising more regularly. Gaining weight after starting an antidepressant was a hit to her self-esteem, she says, but she’s determined to double down on her efforts to stay healthy and fit, even if her medication now makes it more of a struggle.

“Many of my patients feel that their antidepressant has pushed them 10 steps ahead, but the side effects can keep them from feeling 100% better,” says psychiatrist Aparna Iyer, an assistant professor at the University of Texas Southwestern Medical Center. When a medication begins showing side effects, Iyer typically adopts a wait-and-see approach; sometimes the problems will dissipate with continued use. If they don’t, she works with the patient to categorize them into one of three buckets: side effects that can be tolerated, side effects that cannot be tolerated and must be managed through some other means, or side effects that cannot be tolerated and must require discontinuation of the medication.

Much of the time, Iyer adds, a patient who has tried several antidepressants and finally finds one that works will be hesitant to discontinue it, regardless of what else it brings. Emily, who has taken various antidepressants for about seven years, has had such a bad track record with side effects that she’s reluctant to try something new. “I feel like I experience every side effect under the sun,” she says. Once, after being prescribed trazodone to sleep, she woke up unable to urinate.

On the other hand, navigating both depression and ineffective treatments can leave a person unable to judge whether a side effect is truly problematic. “I’ve actually been depressed long enough that I don’t even know what my normal sex drive is anymore,” Eleanor says. “I just have no idea what my expectations should be.” For patients who have found something that more or less works, deciding to stick to a treatment can come down to choosing the devil you know. But should it be that way?

Psychiatrist Carly Snyder, who specializes in reproductive psychiatry and women’s mental-health services, argues that the right medication is one that only improves a person’s life, without causing notable negative results. When a patient complains of weight fluctuation, change in libido, or ability to orgasm, Snyder usually recommends exploring other options; the same goes for continued nausea or sleep difficulties.

“The notion that one must suffer through untoward side effects to gather benefits from an antidepressant is unnecessary and unjustified,” she says. “There are many antidepressant options available, and ‘the one’ is a fallacy. I do not believe anyone should have to remain on a medication if it is causing some measure of harm, and endless side effects are a version of harm.”

Snyder recommends pharmacogenomics testing, done in the office via cheek swab, to predict a patient’s response, based on their genetic makeup, to over 300 drug therapies. It’s a relatively new science that’s not yet foolproof, so she always uses the results alongside clinical judgment when making treatment recommendations — but still, she says, it can help a patient make the leap to a potentially better medication by taking out some of the guesswork.

“The topic of helping people balance side effects and efficacy of psychiatric medications is really part of the skill of psychiatry,” says psychiatrist Antonia S. New, a professor at Icahn School of Medicine at Mount Sinai. New encourages patients to share how their side effects are affecting their relationships, their self-esteem, and their overall enjoyment of life.

As with the medications themselves, though, figuring out what to do about side effects isn’t a one-size-fits-all system. Nor, for that matter, is figuring out what you need in order to achieve your desired quality of life. And both processes, as many people on antidepressants can attest, involve plenty of trial and error.

Sonya Vatomsky is a queer, non-binary Russian-American who has written for publications including Rolling Stone, The Atlantic, New York Magazine, Atlas Obscura, Smithsonian Magazine and Mental Floss. She can be reached on Twitter @coolniceghost.

This article was originally published on The Cut/New York Magazine. Reprinted with permission of the author.

Can a Test Take the Guesswork Out of Prescribing Meds?

Here’s the promise: A simple test, taken in a doctor’s office or even a drug store, will predict which medicine is the right one for you. No guessing, no false starts, no terrible side effects.

Here’s the reality: Not yet.

This is the growing area of pharmacogenomic testing, which for medications means predicting which drugs will work well inside of your body based on certain genes you possess. But at the moment, the testing has not demonstrated it is as good as its developers make it out to be.

The testing is of particular interest for those taking psychiatric drugs, where it can often take several tries before a medication that works for a given condition is found. For example, only 40 to 60% of those with depression find success with the first antidepressant prescribed.

Pharmacogenomic tests are becoming more widely available. As an example, back in May, grocery chain Albertsons, which also operates drug stores, began offering pharmacogenomic testing for psychiatric medications for customers at 28 of their pharmacy locations through a partnership with Genomind.

‘The Marketing Is Way Out Ahead of the Data’

A recent article in JAMA discussed psychiatric pharmacogenomic testing, interviewing doctors and other health care professionals. The bottom line: Pharmacogenomic testing for psychiatric meds may work, but the evidence so far is limited.

James Potash, MD, with the department of psychiatry and behavioral science at Johns Hopkins, said that the evidence for the tests has come mostly from small trials conducted by the manufacturers. Perhaps that’s why he told JAMA that for some tests, “the marketing is way out ahead of the data.”

A piece published in August in JAMA Psychiatry examined the trials behind 10 pharmacogenomic tests that are marketed to help determine the ideal medication choice for treating major depression. The authors found issues with the way all 10 trials were conducted.

A consensus is growing, according to the JAMA article, that pharmacogenomic testing may be more useful for predicting side effects than for a person’s response to a particular drug. So far, there is no test than can tell you, for example, what the “right” antidepressant is for a given patient, according to Potash.

An American Psychiatric Association task force this year also came to the conclusion that there is not enough evidence to support widespread use of pharmacogenomic testing, though “it may be informative, particularly in predicting side effects.”

There are other concerns. Just because an individual has a gene linked to a particular side effect doesn’t guarantee they will definitely experience that side effect. Along the same lines, lacking that gene doesn’t mean you won’t experience it or other effects. Many genes influence side effects you might experience, as do other health conditions and medications you are taking. In other words, pharmacogenomic tests can complement, not replace, existing clinical tools.

And then there is the cost — pharmacogenomic tests can easily cost hundreds of dollars.

To me, pharmacogenomic testing for drug side effects and efficacy holds great promise, but we are not there yet. If you decide to get a test, understand its limitations.

Quick Hits: FDA Threatens E-Cig Manufacturers, Elderly Polypharmacy and Falls & More

Saying youth smoking of e-cigarettes is reaching “epidemic proportions,” the FDA has ordered the manufacturers of the 5 top e-cigarettes to come up with plans on how to curb use by teens. The agency also threatened to pull flavored e-cigarettes – which are especially appealing to young people – from the market if they can’t demonstrate how they can keep the devices away from children. The manufacturers receiving letters are Juul Labs Inc., Vuse, MarkTen XL, Blu and Logic. Data from Nielsen Research indicates that Juul has more than two-thirds of the e-cigarette market. About 2.1 million middle and high school students used e-cigarettes last year, according to the CDC. Over the summer, the FDA said it issued more than 1,300 warning letters and fines to retailers who illegally sold e-cig products to minors as part of an undercover operation, the largest coordinated enforcement effort in the agency’s history. Posted September 12, 2018. Via FDA.

Elderly people that take several medications for sleeping, pain or incontinence are twice as likely to fall and suffer broken bones compared to those not taking any drugs. Researchers analyzed data on more than 70,000 older adults living in New Zealand. Those who were taking more than 3 Drug Burden Index medications – drugs that sedate or affect one’s cognition – were twice as likely to break their hip than those on no drugs, researchers reported in the Journals of Gerontology. Between 20% and 30% of those who broke their hip died within a year. Lead author Hamish Jamieson, PhD, of the University of Otago, Christchurch, New Zealand, said that multiple medications can cause falls in the elderly because of side effects in each of the medications and drug-drug interactions than can create additional side effects. Posted September 11, 2018. Via University of Otago.

The FDA has issued warning letters to 2 companies for making unsubstantiated medical claims in selling products containing the herb kratom. The agency says that Chillin Mix Kratom and Mitra Distributing make claims that their kratom products can relieve opioid withdrawal and treat conditions including depression, anxiety and high blood pressure. The FDA noted that kratom may contain substances that contain opioids and the plant may have a high potential for abuse. Over the last year, the FDA has issued several public warnings about potential dangers associated with kratom. In February, the agency said it identified 44 deaths associated with the use of kratom. Posted September 11, 2018. Via FDA.

‘It’s a Gamble:’ St. John’s Wort, Depression and Drug Interactions

In my 20s, I wasn’t much for traditional medicine. For one thing, navigating our labyrinthine health care system seemed like a lot of unnecessary work. For another, I was broke. Plus, I used henna to dye my hair. I wanted something natural.

That meant that when I felt down in the winter and was quick to worry and anxiety, I didn’t go to the doctor. I went to the drug store and got myself a bottle of St. John’s wort (Hypericum perforatum).

By the time I started taking St. John’s wort around 2003, the plant had been used to rid the environment of evil spirits in ancient Greece and medicinally to menstrual cramps, heal wounds, and treat kidney conditions in later centuries. Today, it’s primarily used to treat depression.

What those early practitioners didn’t know and what I didn’t, either, was that St. John’s wort can interact with prescription medicines in ways that can be serious. With everything from hormonal contraception to organ-transplant drugs interacting with the supplement, the more you know about the interactions, the better off you are.

Powerful or Placebo

In 1998, St. John’s wort was the second most popular supplement in the US, according to the nonprofit supplement industry group the American Botanical Council.

That’s when I first heard about it. But what I didn’t know was that, 4 years earlier, passage of the Dietary Supplement Health and Education Act created the category of dietary supplements and prevented the FDA from requiring supplement companies to prove their products were safe, certify levels of active ingredient or produce evidence that they work.

So, I was working with spotty knowledge. I wasn’t the only one.

Research on St. John’s wort was positive early on, but over the years, the findings have been more muddy, said D. Craig Hopp, PhD, deputy director of the Division of Extramural Research, National Center for Complementary and Integrative Health (NCCIH), part of the National Institutes of Health (NIH) . St. John’s wort seems to be associated with a “strong” reduction in depressive symptoms, including lack of interest in once-pleasurable activities, sleep or eating changes, hostility, irritability, and feelings of guilt, worthlessness or helplessness.

“But you get the same response from the placebo,” he said. “It’s not real clear whether it has [any] benefit.”

A 2002 NCCIH-funded study found that neither St. John’s wort nor the antidepressant tested was any more powerful than placebo for major depression. Another study found the same for mild depression.

On the other hand, a 2008 Cochrane review of 29 studies on the herb found that St. John’s wort is as effective as antidepressants in ameliorating mild to moderate depressive symptoms. But there was a catch: In countries where supplements are regulated and prescribed, the results were more positive. Studies conducted in the US had less positive results.

In any case, Hopp added, “St. John’s wort by itself is safe. But when taken in combination with something else, it dramatically influences how well those medicines work.”

Multiple Interactions

That’s because when you’re taking a whole-herb supplement, you aren’t just getting whatever the active ingredient of the herb is — you’re getting everything else that comes with it, too.

It’s unclear what St. John’s wort’s active ingredient is, though researchers have studied 2 components, hyperforin and hypericin. What researchers do know is that St. John’s wort also delivers significant doses of enzymes that help the body break down medications.

Any drug that is broken down by these particular enzymes breaks down a lot faster than it would otherwise. Drugs include the heart medication digoxin, the opioid oxycodone, some HIV medications, cancer drugs like irinotecan, cyclosporine for organ transplants, and the anticoagulant warfarin. That means that the medication exits the body more rapidly.

In the case of HIV medications, that could mean that the virus mutates and develops resistance to the drug so it never works as well again. In the case of heart medicines, it can increase the risk of a cardiac event.

And in the case of organ transplants, it can be fatal.

“Studies have shown that St. John’s wort would clear immunosuppressive medicines 10 times faster,” Hopp said, “That could cause organ rejection and organ failure.”

Plus, because St. John’s wort is unregulated, you don’t know exactly how much active ingredient you’re getting. That limits doctors’ ability to adjust dosages to accommodate St. John’s wort use, said Austin De La Cruz, PharmD, BCPP, a clinical pharmacist who treats mental health disorders. In addition, he teaches psychiatric treatment and over-the-counter medications at the University of Houston College of Pharmacy.

“It is definitely a gamble,” he said. “If you’re taking St. John’s wort with digoxin and switch to a different St. John’s wort brand that has lower amounts of active ingredient, that can lead to significant toxicity with digoxin.”

Birth Control and St. John’s Wort

Notably, since the majority of people reporting depressive symptoms are women, St. John’s wort seems to break down the contraceptive hormone ethinyl estradiol, a component of most estrogen-containing birth control, about twice as fast as when it is taken alone.

“There were also a number of unintended pregnancies because women taking oral birth control were not getting effective doses,” Hopp said of studies on the topic. “This isn’t fatal [the way organ failure is] but it is still a serious adverse event.”

Treating Accurately

For De La Cruz, all of this makes it hard for him to recommend St. John’s wort. He also pointed to a ban on sale of St. John’s wort in France and Ireland, and careful regulation in other countries as evidence of concern.

If people are interested in non-pharmacological approaches to depression, he recommends therapy. Cognitive behavioral therapy has been found to be more effective than antidepressants alone, he said, and carries no risk of side effects.

Then he’ll make sure patients are trying everything that drugs can’t address — like exercise, food and sleep habits — and light therapy lamps if the depression is seasonal.

“It’s important to identify if the depression can be managed by self-care,” De La Cruz said. For instance, a patient may only come in when they feel depressed, but they may also have bouts of mania. Using only St. John’s wort or an antidepressant could exacerbate manic episodes in bipolar disorder.

Besides, he said, 800,000 people die by suicide related to depression every year.

“Depression is a serious illness,” he said. “I have a hard time recommending St. John’s wort.”

NCCIH’s Hopp was less absolute. If you don’t take any of the medications that interact with St. John’s wort, its risk is essentially zero. But because it interacts with so many medications, people should tell their doctors they are taking it.

“It’s not that you can’t take St. John’s wort,” he said. “But it warrants a high level of extra care.”