Tag Archives: depression

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.

Jonathan Block
Jonathan Block

Jonathan Block is MedShadow’s content editor. He has previously worked for Psychiatry Advisor, Modern Healthcare, Health Reform Week and The Pink Sheet.

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.

Jonathan Block
Jonathan Block

Jonathan Block is MedShadow’s content editor. He has previously worked for Psychiatry Advisor, Modern Healthcare, Health Reform Week and The Pink Sheet.

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.

Jonathan Block
Jonathan Block

Jonathan Block is MedShadow’s content editor. He has previously worked for Psychiatry Advisor, Modern Healthcare, Health Reform Week and The Pink Sheet.

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.

Jonathan Block
Jonathan Block

Jonathan Block is MedShadow’s content editor. He has previously worked for Psychiatry Advisor, Modern Healthcare, Health Reform Week and The Pink Sheet.

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.

Jonathan Block
Jonathan Block

Jonathan Block is MedShadow’s content editor. He has previously worked for Psychiatry Advisor, Modern Healthcare, Health Reform Week and The Pink Sheet.

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.

Jonathan Block
Jonathan Block

Jonathan Block is MedShadow’s content editor. He has previously worked for Psychiatry Advisor, Modern Healthcare, Health Reform Week and The Pink Sheet.

‘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.”

Heather Boerner
Heather Boerner

Heather Boerner is a healthcare and medical journalist based in Pittsburgh. Her work has appeared in The Washington Post, The Atlantic, TheBody.com and the Daily Beast. Her book, Positively Negative: Love, Pregnancy, and Science’s Surprising Victory Over HIV, came out in 2014.

Many Children At Risk for Serious Drug-Drug Interactions

Nearly 20% of children have taken at least 1 prescription medication in the last month, and 7.5% took 2 or more, according to a new study. Researchers note that many children taking multiple drugs are at risk for major drug-drug interactions.

The study looked at data from the 2013-14 period of the National Health and Nutrition Examination Survey. The data was based on prescriptions for more than 23,000 children and adolescents. Prescription drug use was highest in adolescent girls (28%) followed by boys between the ages of 6 and 12 years old (26.5%), the researchers reported in the journal Pediatrics.

Overall, in adolescents between 13 and 19 years old, about 23% had taken a prescription drug in the last 30 days. In the 6-to-12 age group, 21% of children reported using a medication.

Respiratory drugs, such as those used for asthma and allergies, were the most commonly prescribed to children, followed by psychotherapeutic agents, which include drugs such as stimulants for ADHD (attention deficit/hyperactivity disorder) and antidepressants.

Researchers noted that 8.2% of children and adolescents taking more than 1 drug were at risk for a potentially serious drug-drug interaction, and the majority of those interactions were because of antidepressants. Put another way, 1 in 12 children face a potentially dangerous drug-drug interaction.

Data indicated that the percentage of children taking a prescription drug in the last 30 days has actually been declining since the 2005-06 period, when it was just over 25%.

Jonathan Block
Jonathan Block

Jonathan Block is MedShadow’s content editor. He has previously worked for Psychiatry Advisor, Modern Healthcare, Health Reform Week and The Pink Sheet.

Treating Children with Depression: How Will History Judge Us?

By Jeremy Howick
Oxford Empathy Programme

An investigative report by the BBC recently found that the number of antidepressant prescriptions to children under 12 in England, Scotland and Northern Ireland has risen 24% over the past 3 years (from 14,500 to almost 18,000 prescriptions).

Drugs may not be the most effective way to treat depression (more of which later), but pity the children who were treated for depression before antidepressants were invented.

From Bloodletting to Lobotomies to Overprescriptions

Bloodletting was the standard treatment for “melancholia” in ancient Greece. This was followed by burning in medieval Europe and locking people up during the so-called “age of enlightenment” in Europe.

Last century, Sigmund Freud improved things a bit when he introduced psychoanalysis as a treatment for depression. The problem was that he thought cocaine was a good way to treat his own depression.

Then things got worse again. In the 1950s and 60s depression was sometimes treated by lobotomy (removing part of the brain) and electroconvulsive therapy or ECT (an electric shock that can be so strong it induces a seizure in the patient). ECT is still used today as an effective therapy (together with agents that prevent seizures) for some cases of treatment-resistant depression, where the patient is at imminent risk of harm.

Looking back at these (mostly bonkers) therapies, you might feel a little shocked yourself. Today things seem more scientific. Now we have psychological therapies, such as cognitive behavioral therapy, and antidepressant drugs. These are much better than lobotomies and burning.

Typical drugs for treating depression are selective serotonin reuptake inhibitors (SSRIs), such as Prozac (fluoxetine) and Zoloft (sertraline). In spite of having been studied extensively, there is controversy about how effective they are — if at all — relative to placebo. Their effects may be higher for people who are severely depressed. Certainly anyone with severe depression should be treated by specialists using the best available interventions. Not treating serious depression may cause serious harm.

Prescriptions for Young People Are Climbing

But not everyone who gets the drugs has severe depression. The drugs are prescribed for 1 in 10 adults in most developed nations, and prescription rates for young depressed people are climbing in the US and UK. Many people getting the drugs don’t have severe depression, and there is even more controversy about how effective the drugs are relative to placebo in children with mild or moderate depression. According to the best evidence currently, there was little evidence that the drugs improved self-rated depression at all, relative to placebo for children with depression.

Worryingly, the drugs are often not being prescribed in an evidence-based way for young people. Whereas guidelines in the UK state that antidepressants should only be prescribed within child and adolescent mental health services (CAMHS), many GPs prescribe them. This means that children are unlikely to be getting the supervision needed to avoid unnecessary harm. And the harms can be serious.

Significant Adverse Effects

Trials show that antidepressant drugs increase the risk of suicidal ideation (i.e. having thoughts about suicide), compared with placebo in young people. Other likely adverse effects include nausea, sexual dysfunction, and sleepiness.

Given the limited benefits and potentially serious adverse effects, why have numbers of antidepressant prescriptions for young people risen so much? We don’t yet have a good answer to this question. It could be that increased loneliness, caused by young people spending too much time staring at screens, is causing more depression that needs to be treated.

Another possibility is that funding is being cut to mental health services, which leaves GPs with the difficult task of having to help young depressed people, but not having the option of sending them to mental health services.

A Gentler Approach

Until we find out why the numbers of antidepressant prescriptions have risen, why don’t we use safer options? Trials show that exercise seems to be as good as the drugs for most mild to moderate depression. And the side effects of exercise are likely to be good things, such as reduced cardiovascular disease and higher sex drive in men and women.

Another safer option is face-to-face socialising. Studies with hundreds of thousands of people show that contact with friends, family and social groups is associated with less depression. (This doesn’t include contact via social media, which seems to increase the risk of depression.) And a side effect of maintaining close relationship is that you’ll live an average of 5 years longer.

So it’s common sense: the right treatment for staring at a screen too much isn’t a pill that increases the risk of suicide, it’s to get some exercise, preferably with friends.

Fifty years from now, are we going to look back at the widespread prescription of antidepressants for mildly depressed young people the same way we look at beatings, lobotomies and cocaine? My guess is “yes.” But I doubt that exercising and hanging out with friends will ever be viewed in a negative light, so if you have mild depression, why not give it a try?

An earlier version of this article was published in The Conversation. Reprinted by permission of the author.

Jeremy Howick
Jeremy Howick

Jeremy Howick, PhD, is the director of the Oxford Empathy Programme at the University of Oxford. As a medical researcher, he has conducted groundbreaking studies about placebos and why we need unbiased experiments. Howick is the author of the book Doctor You.

Early Weight Gain on Antidepressants Predicts Later Weight Gain

People taking antidepressants who gain weight a month after starting treatment are more likely to put on even more extra pounds as they continue to take the medication.

Weight gain is a common side effect with many antidepressants, especially SSRIs (selective serotonin reuptake inhibitors), one of the most popular antidepressant classes prescribed. It also leads many people to stop taking an antidepressant.

Researchers looked at 260 people who were not overweight and were diagnosed with major depressive disorder. At the start of the trial, they began taking an antidepressant. They were examined again for weight gain after 1, 3 and 6 months.

Results, published in the Journal of Affective Disorders, found that after 3 months, 12.4% of participants became overweight. After 6 months, 21.1% were. Patients that had a weight gain of at least 3% after 1 month were much more likely to have a weight gain of at least 15% after 3 months compared to those who didn’t have the early weight gain.

Researchers noted that weight gain of at least 3% after the first month of antidepressant treatment was the best predictor of more significant weight gain after 3 months and 6 months of treatment.

Jonathan Block
Jonathan Block

Jonathan Block is MedShadow’s content editor. He has previously worked for Psychiatry Advisor, Modern Healthcare, Health Reform Week and The Pink Sheet.