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.
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.
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.
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.
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.
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.
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.
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
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.
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.
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.
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.
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.