Tag Archives: SSRIs

Concerns About Using Your Antidepressant Long-Term? Talk to Your Doctor

On April 8, 2018, The New York Times published a front-page article titled “The Murky Perils of Quitting Antidepressants After Years of Use.” The day before, the online version, “Many People Taking Antidepressants Discover They Cannot Quit,” was the most-shared article on its website.

In this analysis, Benedict Carey and Robert Gebeloff described a growing trend over the past few decades in which millions of people have been taking prescription antidepressant medications long-term. For instance, they cite data showing that over 15 million Americans have taken antidepressants for 5 years or more.

They go on to attribute this phenomenon mostly to antidepressants causing “dependence and withdrawal,” rather than people needing long-term antidepressants to manage psychiatric illness or choosing to remain on them because of their benefits.

While Carey and Gebeloff do cite a few studies looking at rates of withdrawal after stopping long-term antidepressant use, they only mention one survey from New Zealand that shows that withdrawal is even a common complaint among individuals taking antidepressants. Most of their argument is based on individual stories (i.e., anecdotal evidence) combined with critiques of how antidepressants have been studied.

While the individual stories are compelling and the critiques of research may be valid, this approach makes their case linking long-term antidepressant use to supposed widespread withdrawal circumstantial at best.

Fortunately, several psychiatric care providers and even patients quickly responded to counter this somewhat misleading article. To be fair, the authors do point out that antidepressants have greatly helped millions of people, and they quote psychiatrists who are expert in treating depression, such as Dr. Peter Kramer.

However, overall, the piece uses logically and scientifically shaky arguments to trigger suspicion and fear of antidepressants among the general public and mental health patients alike. Given that depression and other mental illnesses that antidepressants treat (e.g., anxiety disorders) are very common, highly impairing, sometimes dangerous, and exceedingly undertreated, this type of journalism is risky.

The fact is, antidepressant medications are effective, especially for moderate to severe depression, and while all medications have side effects, newer antidepressants such as selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are far more tolerable than older versions. In addition, the past few decades have seen a growing consensus that depression (and many other mental illnesses) is a chronic condition requiring long-term treatment, like diabetes and hypertension. (No one would say that millions of people are on long-term blood pressure medications for hypertension because of fear of withdrawal.)

Therefore, many psychiatrists recommend (and many patients readily choose) long-term antidepressant treatment to avoid relapse once a person has had more than one depressive episode. “Withdrawal” from antidepressants — actually called discontinuation syndrome — is in fact a well-known and not-rare phenomenon. However, it is usually very mild and can be managed with a slow taper in the medication’s dose.

For the relatively rare, more severe cases, a good psychiatrist can almost always reduce or eliminate it with various interventions such as adding low-dose Prozac (fluoxetine) for a while (due to its long half-life) and/or using other prescription drugs in a time-limited manner to treat discontinuation symptoms.

Just like in any medical specialty, not all psychiatric care providers are attentive, responsive or skilled enough to avoid or successfully manage discontinuation syndrome, but that’s a different problem that can’t be solved by avoiding antidepressant treatment to begin with. So, rather than an inability to stop meds due to “withdrawal,” doesn’t it seem much more likely that growing numbers of people are on antidepressant treatment long-term either because they need the medication to prevent symptoms from returning and/or choose to remain on the medication because of low side effect burden and protection against relapse?

The article does make some valid and important points. The research on antidepressants mostly involves relatively short-term studies, so there is a great need to examine the longer-term efficacy and adverse effects of these prescription drugs. And the discontinuation syndrome has received far too little research attention.

These deficits in the science are indeed likely due to pharmaceutical companies having little incentive to investigate prescription drugs that have gone generic or to emphasize problems with the products they produce and market. However, it is unfortunate that these valid critiques were packaged into a misleading and highly public message that has the potential to discourage people from seeking treatment for mental illness and encourage patients to stop their medications.

Here’s some advice from this psychiatrist: Discuss your goals for treatment and any problems with medications with your healthcare provider before changing or stopping them on your own. No one – not even your doctor – can force you to stay on a medication that you no longer want to take, but only an experienced professional can help you to change medications in a safe and healthy way.

This article was first published by JustCareUSA.com. Reprinted by permission.

Can Cannabis Control Depression?

Untreated and inadequately controlled depression is a big problem. In 2016, 16.2 million American adults experienced at least one major depressive episode, according to the National Institute of Mental Health. Approximately 37% did not receive any kind of professional treatment –- no counseling, no antidepressants, no mental health evaluation. That’s nearly 6 million people living, working and parenting under a cloud of depression.

Additionally, somewhere between 10 and 30% of those who receive treatment for depression do not improve or only improve partially. Many eventually quit their antidepressant medication and therapy due to frustration.

Could cannabis help these patients? At least one doctor thinks so. Jordan Tishler, MD, a Harvard-trained internal medicine physician who currently serves as the president of the Association of Cannabis Specialists and treats patients via his private practice, Inhale MD, recommends cannabis as a substitute for or adjunct to prescription antidepressants.

“Cannabis can be a good substitute [for medication], but only under certain circumstances,” Dr. Tishler says.

Marijuana & Mood: What We Know – and What We Don’t

To date, scientific research regarding the effects of Cannabis sativa (marijuana) on mood have been mixed. Some studies suggest that marijuana usage has a negative impact on mood; that cannabis use over time can cause or worsen depression. Other studies suggest that cannabis can alleviate depression.

The problem with the research is that it’s incomplete. Under US federal law, marijuana is still a Schedule I drug and therefore subject to strict rules. Researchers can’t, for instance, give subjects cannabis. “The best they can do,” Dr. Tishler says, “is have them bring their own cannabis or talk about their cannabis use.”

Such studies don’t allow researchers to control or compare strains of cannabis, and make it difficult to accurately assess dosage. That’s a problem because “that’s exactly where the devil lies in this particular discussion,” Dr. Tishler says.

The only source of marijuana approved for medical studies is under control of the National Institute for Drug Abuse (NIDA) at the University of Mississippi. And it requires researchers to complete a mountain of paperwork just to have NIDA consider such a request.

One researcher who requested marijuana from NIDA — and was approved — is Sue Sisley, MD, the president and principal investigator at Phoenix’s Scottsdale Research Institute, arguably the nation’s foremost private research institute investigating medicinal uses of marijuana.

Sisley echoed Tishler’s concerns. Speaking at a panel on marijuana at the American Psychiatric Association Annual Meeting in New York City earlier this month, she mentioned one problem with NIDA’s marijuana once it arrived at her offices. The marijuana had not only the leaves, but stems and other parts that are considered non-therapeutic. In other words, much of the marijuana sent to her via FedEx was useless.

But that wasn’t the worst of it. Sisley added that she suspected the marijuana was bagged years ago and not stored under proper conditions in Mississippi, because mold was present.

A 2007 study published in the Journal of Neuroscience examined the impact of cannabis on rats, concluding that tetrahydrocannabinol, or THC, cannabis’ psychoactive chemical, has antidepressant effects at low doses. High doses of THC, however, can worsen depression, at least in rats.

Data on cannabis’ effect on human mood is sparse. “We don’t have clean data in patients with depression. We have data from people who suffer from multiple sclerosis or other diseases, such as epilepsy,” says Gabriella Gobbi, MD, PhD, CSPQ, a psychiatrist in the Mood Disorders

Program at the McGill University Health Centre in Montreal. In other words, some researchers who were assessing the effectiveness of marijuana to treat multiple sclerosis, epilepsy and other diseases asked subjects about the drug’s impact on their mood, but no one has formally studied cannabis as a treatment for depression.

“We need to do randomized clinical trials in people with depression,” Dr. Gobbi says. Such trials would compare cannabis versus a placebo, and assess the treatment’s effect on depressive symptoms.

Available human and animal studies suggest that adolescents and adults respond differently to cannabis. “In animal experiments, it’s very clear: Cannabis given during adolescence every day increases the risk of developing depression in adulthood,” Dr. Gobbi says. “If you start cannabis later in life, this risk to develop depression is less important.”

The Risks & Benefits of Using Cannabis to Treat Depression

Although cannabis is known for inducing euphoria, “it’s a relatively weak antidepressant,” Dr. Tishler says. Therefore, it’s not likely to be an effective stand-alone treatment for many people with depression. Cannabis can also trigger mania or psychotic episodes in people with bipolar depression or a family history of psychosis or bipolar depression.

Other risks of cannabis use include “the acute risk of impaired judgment and driving,” says Kevin Hill, MD, MHS, director of the Division of Addiction Psychiatry at Beth Israel Deaconess Medical Center and author of Marijuana: The Unbiased Truth About the World’s Most Popular Weed. Risks from chronic use, he says, include “worsening depression or even addiction.”

Dr. Tishler tries to control risks by carefully selecting patients for treatment. “If a patient comes in and says, ‘Doc, I’m on a starter dose of Zoloft (sertraline), 25 milligrams, and it’s working but I want to get off it because of side effects,’ then I think cannabis is reasonable substitution,” he says. “But if somebody is on a high dose – 100 milligrams or more –- then I don’t think it’s reasonable or responsible to try to do a substitution.” Instead, he might suggest cannabis as an adjunct to prescription antidepressant medication.

“Adding cannabis on top of a selective serotonin reuptake inhibitor (SSRI) can let some of the joy of life come back,” Dr. Tishler says. “The other thing we should mention is that SSRIs, generally speaking, are terrible for one’s libido. Cannabis is good for libido.”

Medical professionals agree that it is not a good idea to self-treat depression with cannabis. Dr. Tishler says that patients who are considering using cannabis should consult with a physician. “Even physicians who don’t know very much about cannabis, assuming they are open-minded to it, still know more about human biology and healthcare” than the clerk at the nearest weed shop, he says.

Dr. Hill says it’s critical for patients to discuss their mood openly with their physicians. “Decisions about how to treat depression should be made as part of a conversation between a patient and a doctor who knows them well,” Dr. Hill says. “Patients should collaborate with their physician to make sure that evidence-based treatments have been given a chance to work before turning toward treatments like cannabis that have no evidence behind them.”

Quick Hits: Pregnant Moms and Antidepressants, Deaths Linked to Parkinson’s Drug & More

Mothers-to-be who take common SSRI antidepressants, such as Lexapro (escitalopram) and Prozac (fluoxetine), may unknowingly alter the brain development of their unborn child. Researchers from Columbia University Medical Center examined brain scans of nearly 100 newborns. Some of those babies were born to mothers who took SSRIs (selective serotonin reuptake inhibitors) while pregnant. The scans revealed that babies who were exposed to certain antidepressants while in the womb had alterations in both the gray and white matter of their brains. Researchers indicated that these alterations could ultimately increase the child’s risk of depression and anxiety. Alarmingly, the changes identified were “much greater than the brain changes or abnormalities associated with psychiatric disorders” that the researchers usually detect in children or adults. The study did not demonstrate cause and effect and did not test long-term consequences of the brain changes linked to antidepressant use during pregnancy. Posted April 9, 2018. Via JAMA Pediatrics.

The Parkinson’s disease drug Nuplazid may be responsible for hundreds of deaths. Nuplazid (pimavanserin), manufactured by Acadia Pharmaceuticals in San Diego, was created to regulate Parkinson’s disease psychosis. A CNN article reports that more than 700 patients have died after they started taking Nuplazid. A report from the non-profit Institute for Safe Medication Practices indicated that 244 patients who took the drug died between the drug’s launch in 2016 and March 2017. The FDA approved Nuplazid in 2016, and the agency classified the drug as a “breakthrough therapy” and granted a “priority review,” which sped up the review process. Posted April 9, 2018. Via CNN.

Increasing cigarette prices would curb extreme poverty and poor health around the world. According to an analysis, low-income people would benefit from the price increase the most. After examining 500 million male smokers in 13 countries, researchers discovered that a 50% price increase in cigarettes would lead to 67 million men abandoning cigarettes. Also, the price increase would allow 15.5 million men to dodge catastrophic health spending in the 7 out of 13 countries without universal health coverage. “A higher price would encourage cessation, lead to better health, and save money much more strongly for the poor than the rich,” said lead researcher Prabhat Jha, MD, DPhil, director of the Centre for Global Health Research of St. Michael’s Hospital. Posted April 11, 2018. Via BMJ.

Combining Migraine Meds With Antidepressants Safe

Taking certain migraine medications in combination with antidepressants does not increase the risk of serotonin syndrome, according to a new study published in JAMA Neurology. In 2006, the FDA issued an advisory about triptan migraine drugs being associated with serotonin syndrome when combined with selective serotonin reuptake inhibitors (SSRIs) and selective norepinephrine reuptake inhibitors (SNRIs), which are both a common class of antidepressants. However, researchers are suggesting that the advisory should be reconsidered based on new findings.

Over the course of 14 years, researchers analyzed over 47,000 people who were prescribed triptan migraine drugs. Out of that demographic, 21% to 29% of people took antimigraine meds and antidepressants at the same time.

The results indicated that serotonin syndrome was rare in patients who took antimigraine drugs in combination with SSRIs and SNRIs. Serotonin syndrome was suspected in 17 patients. Only 2 patients were classified as having definite serotonin syndrome, while 5 patients were classified as having possible serotonin syndrome. Based on the new findings, the researchers believe that the 2006 FDA advisory is invalid.

Antidepressant Use Not as Risky for People with Heart Disease

In a surprising finding, researchers at Canada’s McMaster University have concluded that antidepressants can cause cardiovascular problems in people who are otherwise healthy, but seem to have no serious effects on patients who already have heart disease.

The researchers did a meta-analysis of data from 17 studies and found that in the general population, antidepressant use increased the risks of mortality by 33% and new cardiovascular events by 14%. But among those already diagnosed with heart problems and diabetes, the risk did not increase. The difference held true whether the type of antidepressant was an SSRI, such as Prozac or Zoloft, or a tricyclic such as Norpramin or amoxapine.

The researchers theorize that because antidepressants have blood-thinning properties, they don’t have a negative impact on patients with heart problems, but can create serious health problems for people without heart problems or diabetes.

A Man’s Guide to Overactive Bladder

They are problems that many men don’t want to talk about out of potential embarrassment. Still, many men have to contend with overactive bladder and urinary incontinence — in layman’s terms, when control over urination is lost — which can be an indication of bigger problems. Just as important, it can lead to emotional issues and impact a man’s social life.

There are treatment options available for the condition, though many doctors will first turn to prescription medication, especially if the leakage is the result of an overactive bladder. Drugs such as Ditropan XL (oxybutynin), Detrol (tolterodine), VESIcare (solifenacin), Avodart (dutasteride) and Flomax (tamsulosin) are just some of the ones used. But did you known that there are a host of side effects that are associated with them?

If taking medication doesn’t sound like a great prospect to you and the possibility of wearing pads makes you anxious, don’t panic. The good news is there are plenty of non-pharmacological treatments available that have good outcomes with fewer side effects. One of them is even a simple exercise you can do at home. (More on that later.)

But before we get into treatments, let’s start with a primer on urinary incontinence and what could put you at risk for suffering from it.

How Common Is Urinary Incontinence?

Losing bladder control doesn’t commonly occur in younger men, but if you’re an older man — especially over the age of 60 — your chances of developing urinary incontinence increases  (odds around 11-34%) due to associated prostate issues. The National Institutes of Health reports that between 11% and 34% of older men experience incontinence at least occasionally and 2-11% report it is a problem daily.

It can affect your everyday life because if you strain physically, or even sneeze or cough, you could find yourself with leakage in your pants. As a result, you might stop doing things you enjoy, such as socializing or sporting activities. Even sexual encounters can be affected, as position and pressure during intercourse can cause bladder spasm or leakage.

Types of Urinary Incontinence

Urgency incontinence, also known as overactive bladder, is involuntary urination or a very strong desire or urgency to urinate.

Stress incontinence is a weakness of the bladder or sphincter muscles.

Overflow incontinence, also known as after-dribble, is a consequence of not emptying the bladder properly.

Functional incontinence happens when you know you need to urinate, but due to mental or physical reasons, such as dementia or impaired mobility, cannot make it to the bathroom in time.

Risk Factors for Men

Men with certain health conditions or medical histories are at a higher risk of developing incontinence. Not surprisingly, having any kind of prostate problem greatly increases the chances of having incontinence. This includes having a prostatectomy, a procedure involving the partial or complete removal of the prostate due to prostate cancer.

In addition, radiotherapy, a type of treatment for prostate cancer, can also lead to incontinence. Any irregularities with your urinary tract are also a potential cause.

If you are overweight, you are also at a higher risk. All that extra weight is putting extra pressure on the muscles around the pelvis, weakening them. This can then lead to accidental urine leakage.

Neurological conditions that influence the brain or spine can also spur incontinence. Alzheimer’s disease, multiple sclerosis, Parkinson’s disease and stroke can damage the brain’s ability to control certain functions well, such as urination. If this happens, it is known as neurogenic bladder.

Testing

Male incontinence is usually diagnosed after taking a medical history and conducting a physical exam.

“Usually a urinalysis is performed and, depending on the findings of the history and physical, further testing with either x-ray studies or an urodynamics study may be appropriate,” says Karl Kreder, MD, a urologist with the University of Iowa Hospital and Clinics. Urodynamics testing can determine bladder flow, capacity and function.

Other potential tests include a cystometrogram, which measures the bladder’s ability to store and expel urine, or an electromyogram, which looks at the electrical activity of muscles around the bladder.

In some cases, a cystoscopy might be warranted. This test allows a doctor to see inside your urinary tract and can detect if the neck of the bladder is contracted.

Dealing with Overflow Incontinence (aka After-Dribble)

After-dribble/overflow incontinence is where a small amount of urine leaks out after you’ve finished.

The good news is that this type of incontinence responds well to self-treatment. Here are some tips:

  • Sit down on the toilet to empty your bladder.
  • Make sure elatics, belts or briefs are not tight around your penis and scrotum to ensure the urethra is straightened when urinating.
  • Alternatively, place your fingertips behind the scrotum and apply gentle upward and forward pressure to encourage urine flow.

Medications for Urinary Incontinence

If your problem is overactive bladder, a medical professional will likely prescribe you anticholinergic/antispasmodic medications such as Ditropan XL, Detrol, Enablex (darifenacin), VESIcare, Sanctura (trospium) and Toviaz (fesoterodine). The most common side effects of these are dry mouth, blurred vision, constipation, nausea, dizziness, drowsiness and joint pain.

Avodart and Proscar (finasteride), known as 5-alpha reductase inhibitors, are also commonly prescribed for overactive bladder. However, they are associated with sexual side effects, such as erectile dysfunction. A recent study also found that men on Avodart had a higher risk of developing diabetes and high cholesterol compared to those taking another overactive bladder drug, Flomax, which is known as an alpha blocker.

Although an older class, many doctors look to alpha blockers (alfuzosin, doxazosin, prazosin, silodosin, terazosin) as an initial treatment. However, side effects with them include dizziness, headache, stomach problems and reduced semen during ejaculation.

For stress incontinence, you may be prescribed a tricyclic antidepressant such as Tofranil (imipramine) and Elavil (amitriptyline); or selective serotonin reuptake inhibitors (SSRIs) such as Cymbalta (duloxetine). Antidepressants come with some nasty side effects, from constipation to vomiting, weight changes and decreased sex drive.

Alpha-adrenergic agonists are another option and include ProAmatine (midodrine) and Sudafed (pseudoephedrine), which is available over the counter. Common side effects include loss of appetite, insomnia and skin rashes or itching.

Many men with urinary incontinence or overactive bladder turn to medications first, but there are several non-pharmacological interventions available that have fewer side effects.

Although it is best known for its ability to reduce wrinkles, Botox (onabotulinumtoxinA) is also approved to treat overactive bladder with symptoms of urge incontinence. This is because Botox is actually a muscle relaxant.

Alex Shteynshlyuger, MD, a urologist with New York Urology Specialists, says that Botox may be a good treatment option for people who have failed after trying other drugs. He mentioned one study that found that patients who didn’t benefit or couldn’t tolerate oral medications had an average of 5 urinary leakage episodes daily. After Botox, they experienced just 2 episodes a day.

“For most patients, one procedure will last over 6 months, and may even last the full year,” Shteynshlyuger says.

Glutaraldehyde — a collagen-like substance — is an FDA-approved medication that gets injected into the sphincter via a tube inserted in the urethra at 4 sites to bulk it up and decrease leakage. The short-term success rate is good but treatments need to be repeated, which most men find off-putting. Injectables have a 42% dryness rate and a 13% complication rate. This complication typically involves being unable to empty the bladder completely or urinary tract infections.

All the above medications can have more severe side effects, which is why you may want to explore alternative options.

Alternative Treatments

Pelvic floor exercises, also known as Kegel exercises, involve performing contractions of the urethral sphincter muscle several times a day over a period of at least 3 months. These exercises are easy to do, are the most effective way to regain control over your bladder, and are effective for all types of incontinence except after-dribble.

Kegel exercises have also been shown to hasten the time it takes to regain control after prostatectomy surgery, with 55% fewer leakage episodes compared to men who don’t perform the exercises.

To perform the exercises, imagine you’re urinating and want to stop the flow; you squeeze your internal muscle to stop mid-flow.

You’re simply contracting and relaxing the muscles that control urination, in order to strengthen them, and can perform the exercises while lying down, sitting at a desk or standing up. The contractions should be performed several times per day for at least a few months to see if they have any effect.

“Kegel exercises will benefit patients with stress or urge incontinence and are very worthwhile treatments as they have virtually no side effects and a relatively high degree of success,” adds Dr. Kreder.

The video below explains how to perform these exercises in more detail.

Volume-adjustable balloons provide another possible solution. These balloons are placed at the bladder neck and can be air-adjusted, providing an average 50% dryness in those using them.

In recent years, male slings have become increasingly popular for treatment of urinary incontinence because they are highly effective (around 84-92% dryness) and have a high satisfaction rate as well (4.5 on a 5-point scale). A sling is a surgical procedure that suspends synthetic threads above the rectum and under the urethra to provide extra support and relieve pressure. Slings, however, are not appropriate for after-dribble.

There are several types of slings available for men, including the bone anchored sling (BAS), rectourethral transobturator sling (RTS), adjustable retropubic sling (ARS) and quadratic sling. They also come in adjustable and unadjustable. Slings are appropriate for all types of incontinence, except for after-dribble.

If the problem is sphincter malfunction, you can undergo surgery to have an artificial urethral sphincter implanted. Men treated by this method were shown to have an 82% dryness rate and a 23% complication rate, which can be infection, erosion of the cuff or mechanical failure.

The bottom line: If you do find yourself having bladder issues, don’t be embarrassed to seek help.

Quick Hits: Magnesium Eyed as Depression Treatment and Few Youths Receive Medication Treatment for Opioid Abuse

Taking magnesium is safe for depression and has efficacy comparable to prescription SSRI (selective serotonin reuptake inhibitors) antidepressants. Researchers at Larner College of Medicine at the University of Vermont examined 126 adults who were experiencing mild to moderate depression. The study team found that participants who received 248 milligrams of elemental magnesium per day over 6 weeks resulted in a clinically significant improvement in measures of depression and anxiety symptoms compared to those who received no treatment at all. In addition, positive effects of magnesium were seen in as little as 2 weeks, and the supplement was well tolerated. Most antidepressants can take a month or more for clinical benefits to be seen, and are often accompanied by side effects. Posted June 27, 2017. Via Larner College of Medicine.

Buprenorphine and naltrexone, 2 medications used to treat opioid abuse, have been underutilized in adolescents and young adults. Researchers at Boston University School of Medicine examined health insurance claims for 9.7 million young people (ages 13 to 25) to measure dispensing of buprenorphine or naltrexone and to identify those who received an opioid use disorder diagnosis from 2001 through June 2014. The rate of diagnosis of opioid use disorder increased nearly six-fold from 2001 to 2014. But just 5,580 out of 20,822 young people with opioid use disorder — just 26.8% — were dispensed a medication within 6 months of diagnosis, with 89% receiving buprenorphine and about 11% receiving naltrexone. Researchers did note that use of the 2 medications in these youths increased from just 3% in 2002 to 27.5% in 2014. However, women, black and Hispanic youths were less likely to receive the medications. Posted June 19, 2017. Via JAMA Pediatrics.

The FDA will assign more personnel to review applications for drugs to treat rare diseases to reduce a huge backlog. The agency currently has around 200 applications seeking orphan drug designation for a medication. That designation, given to drugs that treat diseases with fewer than 200,000 patients in the US, provides incentives to drugmakers, such as tax credits for clinical trial costs and longer time on the market before generic competition for the medication. The FDA also said it is making changes to ensure that future applications receive a response within 90 days. Posted June 29, 2017. Via FDA.

Why You Should Consider Acupuncture to Treat Depression

Bob, a 30-year-old real estate agent, had been suffering from insomnia for 6 months before he came to see me. His problem, he told me, was falling asleep. Once he finally got to sleep, he was down for the count, but before that, he would stare at the ceiling for hours, thinking about the day that had passed and worrying about the one to come.

In response to my questions, he also described other health problems, including poor digestion, fatigue and a short fuse. I asked him what other treatments he’d tried and he listed a few over-the-counter supplements and confided that he had started to see a psychotherapist. In fact, it was the therapy that had prompted Bob to find an acupuncturist. His new therapist had told him that he might be depressed, and suggested he try a medication for his condition. But Bob was keen to explore an alternative before taking that step.

He bristled at the idea that he had a “condition,” which felt like a reduction of his entire life to a simple diagnosis. It also sounded very permanent to him, as did a future of being medicated.

We talked and he was surprised to hear that I wasn’t completely opposed to the idea of antidepressants, but only when there is close monitoring and an endgame in mind. Together we explored the conditions that may — or may not — make medication a good idea.

Significant Side Effects Seen With Antidepressant Medications

In 2015, about 16 million American adults experienced at least one depressive episode in the prior year. The number taking medication for it grows each year. The reasons for this increase vary. They range from shifting attitudes about mental health and recognition of depression to expedient overprescribing in an increasingly burdened healthcare system.

Whatever the cause may be, this increase in the use of psychopharmaceutical medications is not a sustainable trend. While medications such as SSRIs (selective serotonin reuptake inhibitors) and TCAs (tricyclic antidepressants) may offer critical relief for some patients, their prevalence also speaks to a larger failure of mental health management. What’s more, there are significant side effects from these drugs that can paradoxically contribute to the very conditions for which patients are seeking help. These include:

  • Low libido and other sexual side effects
  • Increased appetite and weight gain
  • Nausea
  • Insomnia
  • Fatigue

Since depression is often accompanied by anxiety, patients often take a cocktail of medication that can compound these side effects.

At the YinOva Center, we encourage our patients to embrace the best that conventional medicine and traditional Chinese medicine (TCM) have to offer. In the case of depression, TCM has a valuable contribution to make. The therapeutic process of TCM allows us to create a customized treatment for each patient, using a combination of acupuncture, herbs and other adjunctive therapies.

When used in combination with talk therapy, behavioral counseling and other individualized therapies, acupuncture focuses on the patient more than the disease.

Psychotherapy, which offers individualized exploration and counsel, can also play an important role in treatment. Pharmacological intervention, on the other hand, is often less personalized and, from the patient’s point of view, sometimes feels more abstract. This is because medication is often seen as a one-size-fits-all treatment. And with antidepressants, patient response can vary greatly.

There are two questions that I am commonly asked about acupuncture: How long does it take for the treatments to work and how long does it last? These are of particular concern for patients who are struggling with depression, because it has such broad effects on their lives. To approach these questions we consider a few factors, including how long the depression has been an issue, what precipitated it, circumstances that trigger or worsen it, and tools that the patient may already have, including everything from novel coping strategies to medications.

We then come up with realistic goals and clearly defined strategies for reaching them. Commonly, I recommend weekly treatments for 5 weeks as a starting point, with tangible benchmarks. With that we should see some shift and we can make decisions about how to progress.

If, on the other hand, we are not seeing the changes we want, we reevaluate our strategy and also consider other treatments and therapies that may be of help. This can also happen at the same time that a patient is beginning pharmaceutical treatments, which can take weeks or months to show improvements. They are not mutually exclusive, and acupuncture can also help to reduce the dosage of medications needed.

Studies Back Acupuncture for Depression

Medical studies have confirmed the benefit of acupuncture as a treatment option for depression. For example, a 2013 study published in PLOS that enrolled more than 750 people with severe depression found that those who received acupuncture saw their level of depression decline slightly more than those who received just counseling, and much more than patients who received usual care, such as medication. And the benefits of acupuncture lasted as long as 12 months after treatment ended for some patients.

(Incidentally, there is also evidence that acupuncture is effective for other types of mental illnesses, especially addiction.)

The most common thread I see among patients struggling with depression is a sense of disconnection in their lives, which is not helped by their medication. Antidepressants are a tool that can help a patient’s ability to embrace all aspects of their life, but antidepressants also miss the nuance of personal experience. In Chinese medicine, the integration of mental health with physical health and consciousness is fundamental. Not only is this connection essential to making meaningful change, missing it prevents us from fully understanding the individual parts.

The use of TCM that includes acupuncture provides a safe and effective complement in the integrative treatment of depression. When used in combination with talk therapy, behavioral counseling and other individualized therapies, it focuses on the patient more than the disease. In the care of depression, this can make all the difference.

Quick Hits: Yoga, Exercise Can Relieve Cancer Treatment Effects, Pharma Company Freebies Influence Doc Prescribing & More

Yoga and exercise may help reduce the pain associated with cancer treatment. Researchers at the University of Rochester found that patients who practiced yoga slept less but had less fatigue, mostly because they cut down on daytime napping. The result was a 37% reduction in “daytime dysfunction.” A second study from the Tata Memorial Centre in Mumbai, India, found that cancer patients who participated in both yoga and exercise were nearly twice as likely to report improved mood and had less trouble with general activities. The results of both studies were presented at this week’s American Society of Clinical Oncology annual meeting. Posted June 7, 2017. Via The Guardian.

Cancer doctors who receive freebies from pharmaceutical companies are more likely to prescribe drugs manufactured by those companies. University of North Carolina researchers found that doctors were 78% more likely to prescribe a specific drug to treat kidney cancer if they’d received a gift or small payment from that drug’s manufacturer, compared to physicians who didn’t receive any payments. For docs that received payments from a manufacturer of a cancer drug, the average amount of the gift or payments was $566. The researchers also noted that even small payments were enough to sway many physicians. Posted June 6, 2017. Via UNC Lineberger Comprehensive Cancer Center.

Health problems seen in newborns are not connected to antidepressant use by the mother but are likely due to preterm birth. Researchers looked at babies 2 to 4 weeks after birth and determined that preterm birth was the main cause of neonatal signs of agitation, excessive crying, rigidity, tremors and restlessness, typically called Neonatal Discontinuation Syndrome (NDS). They found that the babies of women who had a mood disorder and were taking a selective serotonin reuptake inhibitor (SSRI) antidepressant had rates of NDS that were similar to babies of mothers who had no mood disorders at all or who had mood disorders but weren’t taking any medication. Posted June 1, 2017. Via Northwestern University.

Do Your Psychiatric Drugs Keep You Up at Night?

If you take a medication for a psychiatric condition, you may have experienced troubled sleep — insomnia, daytime sleepiness, or any other numbers of sleep-related disorders. I have treated patients with myriad sleep difficulties who take antidepressants, antipsychotics and even medications to treat attention deficit/hyperactivity disorder (ADHD).

While no one wants to experience a poor night of sleep, it’s important to recognize whether the sleep problem you are having is a result of a side effect of a drug (or drugs) you are taking, or something completely independent of medication. That is why if you are on psychiatric medication – or any drug for that matter – and you find yourself having difficulty catching some Zs, it’s important to talk to your primary doctor, who may change your medication or refer you to a sleep specialist for further evaluation. In many cases, the benefits of a drug may outweigh the sleep-deficit side effects. Your physician can work with you to minimize the impact of them.

However, it’s a good idea to know what some of the sleep-related side effects are that have been reported with different types of drugs which act upon the brain. Let’s start with antidepressants. The most commonly prescribed ones are known as SSRIs (selective serotonin reuptake inhibitors) and have names including Prozac (fluoxetine), Zoloft (sertraline), and Paxil (paroxetine). Complaints of both insomnia and daytime sleepiness have been reported in patients with depression on SSRIs. Prozac’s impact on sleep has been the most widely studied. Interestingly, it has been shown to have both a sedating and energizing effect depending on the individual. Prozac can also cause decreased sleep efficiency, awakenings during the night, and interrupted REM (rapid eye movement) sleep, an important period during the sleep cycle that allows a person to dream vividly.

Antidepressants and Vivid Dreams

Another class of antidepressants, SNRIs (serotonin norepinephrine reuptake inhibitors), are known to cause sleep problems similar to those in SSRIs, as well as vivid dreams. Common SNRIs are Effexor (venlafaxine), Pristiq (desvenlafaxine) and Cymbalta (duloxetine).

Treatment with Effexor has also been associated with a condition known as dyskinesia that is characterized by occasional movement of one’s limbs, repetitive and involuntary movements of the extremities – typically the legs – usually during or just before falling asleep. There have also been cases where these involuntary movements have been seen a week after a person stopped taking Effexor.

One antidepressant, Wellbutrin (bupropion), has been associated with insomnia. However, studies that have examined electrical activity of the brain in patients taking bupropion indicate the drug actually increases REM sleep time.

It’s important to recognize whether the sleep problem you are having is a result of a side effect of a drug (or drugs) you are taking, or something completely independent of medication.

Antipsychotics are usually prescribed for schizophrenia and other psychotic disorders, though they are also prescribed for bipolar disorder and to supplement antidepressants in the treatment of depression. One of the most popular antipsychotics, Seroquel (quetiapine), has been associated with faster sleep onset and longer overall sleep time. A typical antipsychotic, Clozaril (clozapine) has also been associated with improving sleep onset and sleep time.

RLS (restless legs syndrome) can ruin a good night’s sleep and antipsychotics and antidepressants have been known to lead to cause it. The strong urge that RLS causes to uncontrollably move one’s legs can make it hard to sleep, lead to sleeplessness, irritability and depressed mood. Remeron (mirtazapine), an older, atypical antidepressant, is most likely to cause RLS. A case study found that RLS appeared to be provoked in patients on a low-dose of Seroquel. Interestingly, some evidence has shown that Wellbutrin may actually help to alleviate RLS.

Lifestyle Changes May Help Curb Sleep-Related Side Effects

However, you might find relief from RLS through lifestyle changes and/or taking certain vitamins. For example, going to the bed at the same time every night and getting up at the same time each morning can help. Also, there are some indications that a lack of some vitamins and minerals, such as iron, folic acid, magnesium, and vitamin B, can contribute to RLS.

Not surprisingly, insomnia and delayed sleep onset are associated with stimulants such as Adderall and Ritalin (methylphenidate), that are used in the treatment of ADHD. However, the effect of Ritalin on sleep may depend on the amount of time a child has been on the drug and when the medication is given. There have also been reports of children having difficulty falling asleep as they are being weaned off the medication.

Sleep is an important part of staying healthy and feeling good. Again, if you feel you are experiencing sleep issues as a result of medication, speak to your doctor without delay. Sleep-related side effects due to drugs impact relatively few patients. And if it ends up your sleep problems are not drug-related, the good news is there are steps you can take to rectify the situation. Changes in sleep hygiene and even in your bedroom environment can provide some of the most effective improvements, as can making sure you are getting enough sleep in the first place. As we are in the middle of Sleep Awareness Week, I recommend visiting the National Sleep Foundation’s website for more helpful tips.

This piece is based on an article, Adverse Effects of Psychotropic Medications on Sleep, published in the journal Psychiatric Clinics of North America in 2016.

Who’s Responsible When a Generic Drug Kills?

Common sense wins! Stewart Dolin was prescribed and took a generic version of the antidepressant Paxil. Within 6 days he was dead at 57 — a suicide. His surviving spouse discovered that suicide is a known risk associated with Paxil (paroxetine) and all SSRI-type antidepressants, not just for people 24 years and younger as the drug label stated.

Because her husband took a generic version of Paxil, Wendy Dolin could not bring suit against the generic drug company. Why? Because the drug label (that long package insert that includes what is supposed to be all the information needed by doctor and patient for safe and effective prescribing) is required by the FDA to be a copy of the brand name drug, Paxil. So Dolin sued GlaxoSmithKline (GSK), the original manufacturer of Paxil. And in a unexpected surprise, she won.

Did you know that if you take a generic drug and you suffer from an adverse event — a really bad side effect — that isn’t warned about on the label but should be, you can’t sue? The Supreme Court found that generic companies have no liability because they don’t control what’s in the drug (it’s a copycat of the original) and have no say on what the label states. Putting patients who have been harmed in the middle of a donut hole of liability, the brand name company has gotten off scot-free because they didn’t make the drug that the person who was damaged took. A free pass for industry and a “you’re out of luck” card to patients with nowhere to turn for needed compensation. Thanks to Dolin, that is hopefully changing.

Patient Advocates Righting Wrongs

I met Wendy Dolin a couple of years ago when we took the same training seminar on patient advocacy. Dolin had started a not-for-profit called MISSD (The Medication-Induced Suicide Prevention and Education Foundation in Memory of Stewart Dolin)  while she pursued the legal case. I had just started MedShadow and was fortunately invited to the patient advocacy training program held by National Center for Health Research  (funded by PCORI). There I met about 20 patient advocates all with their own story and a passion for righting wrongs.

The victory in the Dolin case may help to hold brand name pharmaceutical companies responsible when patients are harmed by generic versions of their drugs.

I’d heard of the tragic teen suicide stories linked to antidepressants, but until I met Wendy at the seminar, I was unaware that the suicide risks and akathisia (an uncontrollable feeling of agitation and unease) are high across all age ranges with far too many drugs.

At the same training, I met Kim Witczak who started a nonprofit foundation, Woody Matters,  in response to her husband’s suicide 5 weeks after starting another SSRI antidepressant, Zoloft. Wendy also sued to hold Pfizer responsible for Woody’s death (the claim was both wrongful death and failure to warn). Woody Witczak was taking the branded version of Zoloft (sertraline), so there were no complications identifying liability. Here are the trial transcripts from Witczak v. Pfizer on the Baum Hedlund Aristide Goldman Law website. The same attorneys have been handling the Dolin case.

Informing Doctors About All Drug Risks

Wendy Dolin’s case is Dolin v. GlaxoSmithKline, U.S. District Court, Northern District of Illinois, No. 12-cv-6403.

The Dolin case highlights that pharmaceutical companies must take care to inform doctors about all possible risks associated with drugs. And patients must also be diligent in learning more about powerful meds before and while taking them.

GSK will appeal the ruling and there will be more trials. But out there protecting you and me are these 2 strong women, among many, who are determined to make change and protect innocent people who are seeking help.

Women: How to Deal With Urinary Incontinence Without the Meds

No woman wants to be caught too far from a bathroom, especially when the ability to hold your bladder is a struggle. But if it gets to the point where the thought of coughing or laughing leads to leakage anxiety, or you have to wear pads due to wetting your panties, well, it’s natural to have a few concerns.

Unfortunately, urinary incontinence is yet another health condition that affects more women than men: 25-45% of women aged 30 to 60 years, and 7-39% of women aged 20 to 30 years suffer from the condition. It can be a very embarrassing issue that can affect your self-esteem, confidence and quality of life.

Fortunately, for many women a few adjustments in diet and some exercises will significantly decrease minor incontinence problems.

Even though bladder concerns are an embarrassing issue, don’t be afraid to reach out for help, because, thankfully, there are a range of different treatments that can remedy the problem. So let’s have a grown-up talk about your options.

Types of Urinary Incontinence

There are two main types of urinary incontinence in women — stress urinary incontinence and overactive bladder, also known as urgency incontinence. Many women can experience both types at the same time.

Stress incontinence is characterized by urine leakage due to pressure, coughing, sneezing, laughing or physical activity. This is triggered by physical changes to the pelvic region and weakening of the supporting muscles or weakening of the urethra wall.

Overactive bladder is a strong desire or urgency to urinate that may result in unexpected urination or leakage of urine. This urgency is often triggered by involuntary bladder spasms that occur due to abnormal nerve signals to the bladder from the brain.

Causes of Urinary Incontinence

There are a range of causes in women, including:

  • Urinary tract development problems from childhood
  • Genetics: If other female family members have it, you’re more likely to
  • Ethnicity: Caucasian women are more afflicted than other ethnicities
  • Childbirth and/or pregnancy can damage the muscles and nerves that control urination
  • Menopause: There is a reduction in hormones that keep the urethra and bladder lining strong and healthy
  • Pelvic organ prolapse: The bladder, bowel or uterus sag and shift from their normal positions
  • Neurological problems
  • Lack of exercise
  • Overweight or obesity
  • Older age

Diagnosis

For a diagnosis, you can visit your general practitioner, gynecologist, urologist or a urogynecologist. They will take your medical history, conduct a full physical examination, which includes a pelvic and rectal exam, and will order a range of diagnostic tests such as a urinalysis (standard urine test), urine culture (to test for urinary tract infection), blood test (to assess kidney function or chemical imbalances) and urodynamic testing (to determine bladder flow, capacity and function).

Once they diagnose the issue, they will may prescribe one in a range of medications.

Exercises and Minor Lifestyle Adjustments

If you want to avoid taking meds to deal with incontinence, lifestyle changes are a good place to start and include:

  • Limit bladder irritants — coffee, tea, carbonated beverages, alcohol, tomatoes, spices, chocolate, citrus and high-acid foods
  • Limit water at least 3 hours before bed
  • Lose weight
  • Treat constipation
  • Engage in bladder training, using distraction/deep breathing techniques to help retrain nerve signals and suppress urgency sensations; or retraining of the bladder with scheduled visits to the toilet.

The pelvic floor muscles support the uterus, bladder and bowel in women. And according to research, strengthening these muscles via Kegel exercises is one of the best ways to regain control.

You don’t need any special equipment to perform Kegel exercises. And the best news is, you can perform them anytime — at work, on the train, or in line at the supermarket — because no one will ever know.

To perform the exercises, imagine you’re urinating and want to stop the flow; you squeeze your internal muscle up tight to stop mid-flow.

You’re simply contracting and relaxing the muscles that control urination, in order to strengthen them, and can perform the the exercises while lying down, sitting at a desk or standing up. The contractions should be performed several times per day for at least a few months to see if they have any effect.

Here’s a short video that explains how to do the exercises in more detail.

Medical Devices

It can be difficult for some women to contract the pelvic floor muscles, so vaginal cones are often used. A vaginal cone is a small medical device that’s inserted into the vagina like a tampon. The device acts as an internal weight-training tool for you to squeeze around. As your pelvic floor muscles become stronger, you can increase the weight of the vaginal cone to strengthen the muscles even further.

If leakage continues to be bothersome, you may prefer to use a urethral insert, which is a tampon-like disposable device. It’s inserted into the vagina to prevent leakage and removed when you need to urinate. Another option is a pessary, a ringed device that presses against the urethra to decrease leakage.

Electrical Stimulation

Some electrotherapies such as electroacupuncture and electro current to the pelvic floor muscles show improvement in some women.

Medications

If your problem is overactive bladder, a medical professional will likely prescribe you anticholinergic/antispasmodic medications such as Ditropan XL (oxybutynin), Detrol (tolterodine), Enablex (darifenacin), VESIcare (solifenacin), Sanctura (trospium) and Toviaz (fesoterodine). The most common side effects of these are dry mouth, blurred vision, constipation, nausea, dizziness, drowsiness and joint pain — none of which are pleasant.

For stress incontinence, you may be prescribed a tricyclic antidepressant such as Tofranil (imipramine) and Elavil (amitriptyline); or selective serotonin reuptake inhibitors (SSRIs) such as Cymbalta (duloxetine). Antidepressants come with some nasty side effects, from constipation to vomiting, weight changes and decreased sex drive.

Alpha-adrenergic agonists are another prescription option and include ProAmatine (midodrine) and Sudafed (pseudoephedrine), with common side effects such as loss of appetite, insomnia and skin rashes or itching.

All the above medications can have more severe side effects also, which is why you may want to explore alternative options.

Surgery

As a last resort, you may opt for surgical intervention. Research shows 73-83% of women are more than satisfied with the results of these surgical procedures.

Retropubic suspension involves surgical insertion of synthetic threads to lift up the bladder neck and urethra for additional support. Internal slings are another option and involve insertion of a man-made sling to cradle the bladder neck and urethra.

The most important thing is, don’t let your urinary incontinence go unchecked. Yes, it is an embarrassing thing to talk about, but we are all grown-ups here.