Best Home Treatment for Depression

Destroy Depression

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

Destroy Depression Overview


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Treatment Of Major Depression

Treatment interventions are divided into two sublev-els (1) case identification, to provide early treatment for cases of major depression that have not been identified previously and (2) standard treatment, which accounts for the bulk of mental health intervention efforts. The need for case identification efforts arises from the underdiagnosis of major depression and other depressive disorders in primary care clinics. Only 20 of individuals who meet criteria for major depression seek mental health services. However, more than 70 of those who meet criteria for major depression do seek health care, generally from a primary care physician. Yet, only about a third of individuals with major depression are so identified by their primary care providers. It is imperative, therefore, that primary care physicians and other health care providers learn to identify cases of depression so that individuals suffering from them may receive appropriate interventions. Major depression is eminently...

Depressive Disorders

The most commonly used diagnostic system in the United States is the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV). Depression is implicated primarily in what are termed the mood disorders. The mood disorders are themselves divided into two major categories the depressive disorders and the bipolar disorders. The depressive disorders are sometimes referred to as unipolar depressions, that is, mood disorders in which changes from normal mood occur in only one direction, toward depressed mood. Bipolar disorders exhibit bidirectional fluctuations, either to depressed mood or to abnormally euphoric (manic) mood states. It is recognized that mood disorders can be the result of general medical conditions as well as the result of the use or abuse of drugs and other substances. Mood disorders caused by drug use or abuse are not considered primary mood disorders. In the following section, the DSM-IV diagnostic criteria for the more common mood disorders are...

Tricyclic antidepressants and anticonvulsants

Tricyclic antidepressants are effective in relieving neuropathic pain. There are no significant differences in efficacy between the different tricyclic antidepressants, though unfortunately, side effects often limit their use. While the evidence for venlafaxine is less strong, its use can be justified, particularly in patients with both neuropathic pain and low mood. There is a lack of high level evidence of the efficacy of selective serotonin reuptake inhibitors (SSRIs) for treating neuropathic pain. There is no measurable difference in the analgesic benefit of the two drug classes (tricyclic antidepressants or anticonvulsants) in neuropathic pain or in the number of patients needed to treat before a minor or major adverse effect occurs. Gabapentin and pregabalin, however, can have fewer side effects in many patients, though systematic examination of this is awaited in patients with cancer pain. Patients with neuropathic pain should have a trial of a tricyclic antidepressant or...

Major Depression

Major depression is the most common of the mood disorders. The key diagnostic criterion for major depressive disorder is the presence of a major depressive episode. There are nine symptoms that define a major depressive episode. Of the nine, at least five must have been present during a 2-week period. They must represent a change from previous functioning and they must cause significant impairment in daily functioning. At least one of the five symptoms must be either the first or the second symptom in the following list


Antidepressants are commonly used in the treatment of functional digestive disorders and appear to be beneficial (Jackson et al, 2000). In a small trial of seven patients, Mertz and colleagues (1998) showed that 50 mg of amitriptyline at bedtime significantly reduced symptoms of nonulcer dyspepsia. Similar results have been seen by Tanum and Malt (1996) with the tetracyclic agent mianserin. Interestingly, a response to this agent is predicted by both results of a fenfluramine challenge and certain personality constructs. These personality traits include low levels ofneuroticism, as well as low levels of hidden aggression. Thus, in contrast to acid suppression, H. pylori eradication, and prokinetics, there are biomarkers that predict a response to antidepressants.At present, there are no published data for selective serotonin reuptake inhibitors in nonulcer dyspepsia, although studies are underway. Paroxitene (Paxil) has been shown to enhance meal-induced relaxation of the fundus, but...

Cohort Influences on Validity

A further problem is that clinical interviews often yield categorical classification, for example, full-blown depression versus none. To the extent that elders, even in clinical interviews, under-report symptoms, then such procedures may underestimate the existence of problems. For example, in 1992 Koenig and Blazer reviewed studies showing that the prevalence of major depression in the elderly, based upon clinical interviews, was about 1 (which is rather less than that reported for younger populations), but some 20 or more of older samples reported problems with negative affect on self-rated inventories, a figure much more comparable to younger samples. This is not to say that different criteria or cutoff points on standardized clinical assessment tools necessarily need to be developed, but rather that much more research is needed into this issue.

Clinical Examples Make It Relevant

Cranial Nerves Fake Brain

Anatomy and Physiology is fundamentally a textbook of the basic science of the human body. However, students always want to know why all the science is relevant to their career aims. Clinical examples and thought questions make it so. Students can see how the science relates to well-known dysfunctions, and why it is important to know the basics. Dysfunctions also provide windows of insight into the basic concepts, such as the insight that cystic fibrosis gives on the importance of membrane ion channels, or that antidepressants give on the synaptic reuptake of neurotransmitters.

Monoamine Reuptake Inhibitors

Nearly all antidepressants currently in use act by increasing the concentrations of the monoamine neurotransmitters serotonin (5-HT), norepinephrine (NE), and or dopamine (DA), primarily by inhibition of reuptake mechanisms (for a review, see Ref. 10 ). Selective serotonin reuptake inhibitors (SSRIs) were introduced in the 1980s and include fluoxetine, paroxetine, sertraline, and escitalopram. Serotonin and NE reuptake inhibitors (SNRIs) include venlafaxine and duloxetine. The atypical antidepressant buproprion has been reported to inhibit the NE transporter (NET) and the DA transporter (DAT). Although new SSRIs continue to be identified, only those possessing additional receptor modulating properties will be discussed in this review (see Section 3).

HT2C receptor modulators

Selective 5-HT2C agonists have shown antidepressant-like effects in several animal models of depression 5 . Of the recently identified 5-HT2C agonists, Ro 60-0175, WAY-161503, and WAY-163909 have been the most extensively characterized in depression models. Results in chronic mild stress and olfactory bulbectomy models of depression suggest a more rapid onset of antidepressant action typical antidepressants require 2-3 weeks of dosing to show effectiveness, while 5-HT2C agonists are active in less than one week in both models.

HT7 receptor antagonists

The 5-HT7 receptor has been postulated to play a role in depression based partly on its distribution in the brain and also on the observation that chronic treatment with antidepressants results in downregulation of this receptor. Additional support for this hypothesis has been gained by a recent study showing that 5-HT7 receptor knockout mice demonstrate antidepressant-like profiles in forced swim and tail suspension tests 33 . The identification of selective antagonist tool compounds has helped add further evidence in support of the hypothesis. For example, SB-269970, 16, exhibits antidepressant-like activity, even though this compound has a rather poor PK profile. SB-656104-A, 17, has been identified as a 5-HT7 antagonist with better PK properties and has been shown to modulate REM sleep in rats in a manner consistent with potential antidepressant-like activity 34 .

Neuropeptide Receptor Modulation 51 Neurokinins

The potential for NK1 antagonists as antidepressants has been the subject of a tremendous amount of research effort over the last decade 35 . At least three compounds (aprepitant, L759274, and CP-122721) showed early evidence of anti-depressant effects in clinical studies. The failure of aprepitant to separate from placebo in Phase III studies was a great disappointment 6 . Nonetheless, NK1 antagonists continue to be of interest for depression therapy since they have been shown to potentiate the activity of SSRIs. The NK1 antagonist vestipitant is currently being evaluated in combination with paroxetine for anxiety and depression. Interestingly, both of these activities have been attained in a single compound, 18, which is both a potent SERT inhibitor (pIC50 8.0) and an NK1 antagonist (pIC50 8.5) 36 . This compound reportedly increased rat 5-HT levels up to 250 of baseline (measured by microdialysis), and was orally active in the isolation-induced guinea-pig pup vocalization test of...

Corticotropinreleasing factor

Corticotropin-releasing factor (CRF) is a well-known regulator of the hypothalamic-pituitary-adrenal (HPA) axis, which is activated in response to stress. Hyperactivity of the HPA axis has been linked to depression in humans, and both the elevation of CRF concentrations in the cerebral spinal fluid (CSF) and an increase in the number of CRF-containing neurons in the paraventricular nucleus have been observed in depressed patients. In addition, some antidepressants (e.g., desipramine and fluoxe-tine) have been shown to decrease CRF levels in the CSF. Furthermore, a number of CRF1 antagonists exhibits anxiolytic and antidepressant activity in certain animal models 37,38 . For example, antalarmin (CP-154,526) produces antidepressant-like responses in the rat learned helplessness and mouse chronic mild stress models of depression. Several CRF1 antagonists have reached human clinical trials, but to date SSR125543, 23, was orally active in the rat forced swim test (30mg kg, p.o.), and...

Triple reuptake inhibitors

Triple reuptake inhibitors (TRIs), which increase DA levels in addition to serotonin and NE, are expected to be as efficacious as monoamine oxidase inhibitors (MAOIs) without being limited by the same side effects and dietary restrictions that accompany MAOI use. The rationale for including DAT inhibition is partially based on the well-established role of dopaminergic systems in motivation and reward. Anhedonia and lack of interest, which are core symptoms of MDD, result from dopaminergic impairment in corticolimbic areas, and depressed patients have been shown to have decreased DA release by nerve terminals in the mesolimbic system

Depression as a Syndrome

Major depressive episode is the most common depressive syndrome. A syndrome is a configuration of symptoms that often occur together and constitute a recognizable condition. Although the presence of a major depressive syndrome is a necessary characteristic of major depressive disorder, it is not sufficient. The syndrome can occur for other reasons. For example, medications or drugs of abuse, as well as general medical conditions, can have direct physiological effects which can trigger the symptoms of a major depressive episode. Similarly, the loss of a loved one can result in this configuration of symptoms. In the latter case, unless the symptoms persist for longer than 2 months, or produce marked functional impairment, suicidality, or psychosis, they are considered to be part of the normal course of bereavement. The implication is that major depressive syndrome is much more prevalent than major depressive disorder. Currently, major depressive disorder is conceptualized as a clinical...

Epidemiology and detection

They often have recurrent depressive disorder and a longstanding difficulty with personal relationships and may misuse substances. There is an association with an emotionally deprived childhood and childhood physical and sexual abuse. Some patients will clearly have general disturbances of personality.

Clinical features and classification

The term depression describes a spectrum of mood disturbance ranging from mild to severe and from transient to persistent. Depressive symptoms are continuously distributed in any population but are judged to be of clinical significance when they interfere with normal activities and persist for at least two weeks, in which case a diagnosis of a depressive illness or disorder may be made. The diagnosis depends on the presence of two cardinal symptoms of persistent and pervasive low mood and loss of interest or pleasure in usual activities. Major depressive disorder refers to a syndrome that requires the presence of five or more symptoms of depression in the same two week period. Dysthymia covers persistent symptoms of depression that may not be severe enough to meet the criteria for major depression, in which depressed mood is present for two or more years. Such chronic forms of depression are associated with an increased risk of subsequent major depression, considerable social...

Psychiatric Comorbidity Alcoholism Mood and Personality

Mood disorders are highly comorbid with eating disorders between 40 to 80 of patients with eating disorders will have an affective disorder during their lifetime (Braun et al, 1994). The presence of major depressive disorder or bipolar disorder complicates the examination and management of the patient with AN or BN. Actively depressed patients may feel hopeless and be more likely to resist treatment. In addition, because starvation is associated with a syndrome of depression, symptoms of eating disorders may mimic depression yet reverse rapidly with refeeding.

The Purpose Of Diagnosis

Assigning a diagnosis using the DSM-IV does not necessarily suggest that the etiology (cause) of the symptoms is known, but only than an individual's symptoms meet the criteria for the particular mental disorder. For example, two individuals might meet the criteria for a diagnosis of Major Depressive Disorder, but might develop these symptoms after a very different set of circumstances one person might experience these symptoms only after a series of troubling setbacks (e.g., financial, legal, and relationship problems) while another might experience these symptoms after an apparently unstressful period. Although one might imagine that the etiology of the depression differs for these two individuals, they would both receive the same diagnosis using the DSM.

Thomas A Widiger And Stephanie Mullinssweatt

The question of whether mental disorders are discrete clinical conditions or arbitrary distinctions along dimensions of functioning is a long-standing issue (Kendell, 1975), but its significance is escalating with the growing recognition of the limitations of the categorical model (Widiger & Clark, 2000 Widiger & Samuel, 2005). Indeed, in the last 20 years, the categorical approach has been increasingly questioned as evidence has accumulated that the so-called categorical disorders like major depressive disorder and anxiety disorders, and schizophrenia and bipolar disorder seem to merge imperceptibly both into one another and into normality . . . with no demonstrable natural boundaries (First, 2003, p. 661). In 1999, a DSM-V Research Planning Conference was held under joint sponsorship of the APA and the National Institute of Mental Health (NIMH), the purpose of which was to set research priorities that would optimally inform future classifications. One impetus for this effort...

Myocardial infarction and depression

About one in six patients who have a myocardial infarction develop major depression. The occurrence of depression has been found to be independently associated with poor outcome, including poor quality of life, increased heart disease, and probably increased mortality. There is some evidence that those who have the severest heart disease are at greatest risk of an adverse outcome attributable to depression. It is in just these patients that depression is most likely to be missed because both doctor and patient understandably focus their attention on the heart disease and its treatment, rather than on psychological factors.

Classic Syndromes Primary Psychiatric Illness

First, dramatic, unlikely or even impossible physical complaints may of course be symptomatic of primary psychiatric illness. somatic preoccupations are common in both schizophrenia and major depression, and may range from a chronic sense of unwellness to the fixed conviction of a dread disease (acquired immunodeficiency syndrome, cancer), to bizarre ideas of infestation, or to deliberate implantation of foreign bodies or devices. The true anorexia of depression, as well as the odd and rigid eating patterns seen in schizophrenia, obsessive compulsive disorder and eating disorders, may lead to weight loss and delayed transit times suggestive of primary medical illness. indeed, some

Healthy Mood Management A Developmental Perspective

There appears to be a substantial genetic component in the more severe forms of depression, such as bipolar disorders and major depression. How this genetic influence is manifested physiologically is not yet known. Several biological abnormalities have been identified in subgroups of individuals exhibiting depression. However, most of them appear to occur during a depressed episode and to subside once a normal mood state is attained. None appear to be universally shared by clinically depressed individuals. Developmental influences also appear to be risk factors for depression, such as being born to a mother who is currently depressed, the loss of parents in childhood, and a high number of stressful life events. Social and environmental factors also have well-documented effects on depression. For example, poverty has been shown to account for approximately 10 of new cases of major depression.

Generalized Psychiatric Samples

Point Verbal superiority for Page and Steffy's group of patients with schizophrenia was reported previously, but these investigators also observed a 7 J4-point V > P profile for 46 patients described as neurotics, although they found a V-P difference of less than 1 point for 108 inpatients with personality disorders. In contrast to these V > P profiles, Hawkins, Sullivan, and Choi (1997) found a P V profile for a mixed psychiatric group of 33 patients (18 with major depression or bipolar disorder, 8 with substance abuse problems, 4 with impulse control disorders, and three with assorted other disorders). The lack of a V > P pattern in Hawkins et al.'s mixed psychiatric group may be related to the diversity of diagnoses in the sample.

General Orientation

Orders that fail to capture the richness and subtlety of any given individual's way of interpreting the social world and constructing relationships with others. For instance, a diagnostic category such as major depression'' merely describes a presumably maladaptive ''mood disorder,'' without conveying any information about the way the person's meaning-making processes have ceased to be viable for construing life's experiences. In contrast, constructivists prefer assessment techniques and working conceptualizations that are idiographic or tailored to each use, which examine both the positive and negative implications (from the client's, family's, or society's standpoint) of clients' ways of construing their lives and problems.

Pharmacological Treatment Of

Few trials of neuropsychiatric symptoms have been reported in PSP. In a recent placebo-controlled trial, the cholinesterase inhibitor donepezil did not improve neuropsychiatric symptoms. A slight improvement in memory was noted, but because of worsening of motor symptoms, a worsening of ADL was found in patients receiving donepezil (116). Similarly, a small placebo-controlled trial with RS-86, a cholinergic agonist, did not improve cognition or mood in PSP patients with dementia (115). In a clinical survey, it was reported that some PSP patients responded to antidepressive drugs (77). In a chart review, 7 of 12 autopsy-diagnosed PSP patients responded to a dopaminergic drugs, and 1 of 3 to a tricyclic antidepressant. None of the patients responded markedly, however. The serotonergic agent trazodone, but not the neuroleptic drug thiotixine or carbamazepine, improved agitation in patients with PSP (130). Another case report suggested that electroconvulsive therapy (ECT) could improve...

Extending the cellbrain analogy

When conditions exceed the capacity of the brain to tolerate them, individuals suffer clinical depression, or in some cases catalepsy. Many higher brain functions are down-regulated, though housekeeping activities remain intact. Stress hormones are released, ensuring a continuing glucose supply. This is necessary (though it is unlikely to be sufficient) for restoring normal brain function.

Epidemiology And Implications Of Neuropsychiatric Features In Parkinsonian Disorders

What are the clinical implications of neuropsychiatric symptoms in patients with parkinsonian disorders Again, most research has been performed on patients with PD, and it seems reasonable to extrapolate the findings from these studies to patients with atypical parkinsonian disorders. First, several studies have consistently demonstrated that neuropsychiatric symptoms have strong negative influences on the quality of life, including physical, social, and psychological well-being of patients with PD, even after controlling for motor, functional, and cognitive disturbances. For instance, depression has consistently, and irrespective of instruments used to assess depression, been found to be among the most important independent predictors of impaired quality of life in PD patients (29-31), and a longitudinal study reported that depression and insomnia were the most important factors associated with poor quality of life (32). Although there is overlap between the symptoms of depression...

Pharmacologic Therapy of Chronic Pain

The class of agents that we prescribe most often for chronic abdominal pain is tricyclic antidepressants (TCAs). The efficacy of these drugs has been best validated in patients with somatic neuropathic pain syndromes. Effective analgesic doses are significantly lower than those required to treat depression, and there is reasonable evidence to conclude that the beneficial effects of antidepressants on pain occurs independently of changes in mood. However, in this regard, diminution of anxiety and restoration of mood and sleep patterns should be considered desirable even if they represent primary neuropsychiatric effects of the drug. There are details on psychotropic medications in a separate chapter on functional GI disorders (see Chapter 43, Psychotropic Drugs and Management of Patients with Functional Gastrointestinal Disorders). patients with functional constipation as they can increase bowel movements and even cause diarrhea. However, they have been less well evaluated in the...

Treatment Of Huntington Disease

Currently, only symptomatic therapy is available for HD.96 The major goals of symptomatic therapy are to control psychosis, treat depression and suicidal tendencies, and possibly control the severity of chorea and other motor manifestations. Dopaminergic and serotonergic receptor blockade with typical and atypical antipsychotics have been the major source symptomatic therapy for HD patients. Among the drugs that are commonly used are haloperidol, risperidol, quetiapine, olanzapine, and clozaril.97-100 Anti-dopaminergic agents appear to be ineffective in the treatment of chorea. However, long-term use of typical antipsychotics may also complicate the course of the disease by inducing either drug-induced Parkinson's disease and or tardive dyskinesias and tardive dystonia. Severe depression is treated with SSRIs and other antidepressants.

Psychological treatment

Cognitive behaviour therapy, interpersonal therapy, and problem solving have all been shown to be effective for treating depression, although there has been only limited evaluation of their effectiveness in physically ill populations. Although time consuming by comparison with drug treatment, psychological treatment may reduce relapse rates and may be cost effective in the long run. Some patients may require preliminary treatment with drugs to enable them to make best use of psychological treatment.

Labour and delivery

There is a need for a high level of awareness amongst all healthcare professionals involved in intrapartum and postnatal care. Symptoms and signs suggestive of depressive illness must be treated promptly. Tri- and tetracyclic antidepressants, the selective serotonin reuptake inhibitor group of antidepressants and MAOIs may all be necessary in the treatment of both non-pregnancy-related and postnatal depression. Electroconvulsive therapy may also be indicated.

Supplemental Reading

An evidence-based approach to the management of irritable bowel syndrome in North America. Am J Gastroenterol 2002 97 S7-26. Camilleri M, Northcutt AR, Kong S, et al. Efficacy and safety of alosetron in women with irritable bowel syndrome a randomized, placebo-controlled trial. Lancet 2000 355 1035-40. Creed FH, Fernandes L, Guthne E, et al. The cost-effectiveness of psychotherapy and SSRI antidepressants for severe irritable bowel syndrome. Gastroenterol 2001 120 A619. Hawkes ND, Rhodes J, Evans B. Naloxne treatment for irritable bowel syndrome a pilot study. Gastroenterol 2002 122 A552. Horwitz BJ, Fisher RS. The irritable bowel syndrome. N Engl J Med 2001 344 1846-50.

Neurobiology Of Depression

Neuroscientists have known for more than 30 years that antidepressant drugs acutely increase the synaptic levels of norepinephrine and serotonin. This finding led to the idea that depression results from a decrease in the availability of one or both neurotrans-mitters. Lowering their levels in normal subjects does not produce depression, however. Recall, too, that antidepressant medications increase the level of norepinephrine and serotonin within days, but it takes weeks for drugs to start relieving depression. Various explanations for these results have been suggested, none completely satis factory. Ronald Duman (2004) reviewed evidence to suggest that antidepressants act, at least in part, on signaling pathways, such as on cAMP, in the postsynaptic cell. Neu rotrophic factors appear to affect the action of antidepressants and, furthermore, neu rotrophic factors may underlie the neurobiology of depression. Investigators know, for example, that brain-derived neurotrophic factor is...

Torsade de pointes T de P s ee also

It is now known that, in addition to anti-arrhythmic drugs, there are a number of noncardiac drugs that provoke T de P. They share a common feature in that they block one component of a particular type of potassium channel, resulting in lengthening of the QT interval (Yap & Camm 2000).These noncardiac drugs include terfenadine, astemizole, some macrolide antibiotics, tricyclic antidepressants, neuroleptics such as haloperidol and thioridazine, cisapride, and pimozide.

Therapeutic principles of management

For most patients the management of cachexia requires insight and enthusiasm from the physician, surgeon, general practitioner, nurse specialist, and dietician with whom the patient may come into contact. Cachexia is a chronic problem for which there is no quick fix and which requires repeated reevaluation as the clinical condition of the patient changes. Once signs of cachexia are evident patients generally have two to six months to live. Early recognition and prophylactic measures are better than trying to reverse an advanced situation. Good clinical judgment is paramount to identify all reversible factors that may be contributing to the patient's wasting syndrome. In particular, if nausea and vomiting can be controlled with regular antiemetics (or surgery if there is a defined mechanical obstruction), malabsorption treated with enzyme supplements, constipation treated with laxatives, pain well controlled with the minimum of sedation, and depression treated with antidepressants then...

Further nonspecialist treatment

There is good evidence that antidepressants often help, even when there are no clear symptoms of depression. Practical advice is needed, especially on coping effectively with symptoms and gradually returning to normal activity and work. Other useful interventions include help in dealing with major personal, family, or social difficulties and involving a close relative in management. Other members of the primary care or hospital team may be able to offer help with treatment, follow up, and practical help.

Learning Memory Attention and Related Cognitive Disorders

There is a wide variety of cognitive conditions that deleteriously affect learning, memory, and attention but that do not involve other psychopathology. For example, Attentional Deficit Disorder with and without hyperactivity (ADHD and ADD), senile dementia, and Alzheimer's disease are familiar to the public. Each of these conditions can have profound negative effects on daily living and quality of life. Psychopharmacologic treatment for these conditions is an active, current topic of interest with modest success to date. For example, ADHD is treated with stimulants (including dextroamphetamine, methylphenidate Ritalin , and pemoline), antidepressants (including imipra-mine, desipramine, and nortriptyline), and clonidine. Memory deficit-related conditions are an area of great interest and experimental investigations are examining various medications, including drugs that act as do-paminergic agonists, a-2 adrenergic agonists, cholin-ergic agonists, general cerebral metabolic...

Appropriate Treatment Interventions

Serotonergic antidepressants Serotonergic antidepressants High tryptophan (carbohydrate) diet Cognitive-behavioral therapy Serotonergic antidepressants Cognitive-behavioral therapy Group therapy Psychoeducation Serotonergic antidepressants Support group A second approach is to manage specific psychological symptoms. With respect to severe psychological symptoms, it is crucial first to verify that the woman, despite her discomfort, is sufficiently safe. A woman who is depressed to the point of being suicidal, or who is so angry that she might harm someone else, should be carefully protected. Four psychiatric medicines that address depression and anxiety have been used effectively in some patients with PMS Xanax (benzodiazepine anxiolytic, GABA agonist), buspirone (anxiolytic, serotonin 1a agonist), nor-tryptiline (tricyclic antidepressant, noradrenergic and serotonergic agonist), and fluoxetine, sertraline, and others (antidepressants, selective serotonin reuptake inhibitors). These...

Torsadesde pointes ventricular tachycardia

This is a polymorphic ventricular tachycardia characterised by an ECG appearance of QRS complexes which change in amplitude and polarity so that they appear to rotate around an isoelectric line. It is seen in conditions characterised by a long QT interval. Quinidine, disopyramide, amiodarone, tricyclic antidepressants and digoxin are all reported causes. In addition, pharmacokinetic interactions may cause torsades de pointes with the interaction between cisapride and erythromycin being a recently recognised problem. The treatment is magnesium sulphate in a rapid IV infusion (several minutes) of 25-50 mg kg (up to 2g).

Other Psychotropic Agents

Buspirone (Buspar) is a nonbenzodiazepine antianxiety agent that may take several weeks to achieve benefit. Its action as a 5-HT1a agonist results in increased gastric accommodation, and therefore, it may be beneficial in some patients with functional dyspepsia. In one small study comparing the effect of venlaxafine (Effexor), buspirone (Buspar) and placebo on colonic mechanoelastic properties and perception in IBS patients, buspirone was shown to have no effect on colonic sensitivity. It is relatively non-sedating and is usually well tolerated. The dosage is 20 to 30 mg in divided doses (2 to 3 times per day). This drug also has augmentativeproperties and can be combined with other antidepressants to enhance the treatment effect.

Management Of Neuropsychiatric Symptoms

To our knowledge, only nine randomized, placebo-controlled studies of neuropsychiatric symptoms in parkinsonian disorders have been reported four trials with cholinergic agents in DLB (rivastigmine) (113), PD (donepezil) (114), and PSP (donepezil and RS-86, a cholinergic agonist) (115,116), two trials with clozapine in PD (117,118), and three trials with antidepressants in PD (119-121). The studies have usually included few subjects, with a total number of 356 patients in the nine studies. Further details are provided in Table 2. In addition to the two studies showing efficacy of clozapine in PD with psychosis, rivastigmine improved neuropsychiatric symptoms in DLB (113),

Miscellaneous Approaches

In several examples, simple chemical modifications to existing clinical compounds provided new antiarrhythmic agents. For example, evidence exists that tricyclic antidepressants such as imipramine and chlorpromazine induce self-defibrillation. However, these effects are seen at high doses resulting in therapeutic indices that are too low for use as antiarrhythmic agents. Modification of the side chain of imipra-mine to an amide (e.g. 26) resulted in antiarrhythmic agents that were potent in a cat model of ventricular fibrillation (1-3 mg kg i.v.) 45 .

Management of Unexplained Chest Pain

Nonpharmacologic approaches can be useful in unexplained chest pain, just as in other functional gastrointestinal disorders. Cognitive behavioral psychotherapy, deep muscle relaxation, biofeedback, and other stress reduction techniques, are beneficial for some patients. Transcutaneous electrical nerve stimulation, acupuncture, and other alternative approaches, have had anecdotal success, but the best advice is to learn to maximize the use of antidepressants, particularly TCAs, in this patient group.

Diagnostic Testing

Drugs and intoxicants are important, and common causes of myoclonus (Ghaziuddin et al., 2001 Gordon, 2002 Maiteh and Daoud, 2001 McClain et al., 2001 Mercadante et al., 2001 Zaw et al., 2001). The pharmacologic diversity of agents, which span a multitude of clinical indications from antidepressants to narcotic analgesics, alerts the clinician to search for myoclonus-evoking drugs in every new case. Stopping the offending agent may be sufficient, but symptomatic therapy can be provided if necessary. Although propofol, used as an anesthetic, may occasionally induce myoclonus, for most patients with myoclonic disorders it is an effective agent for procedures (Tate et al., 1994). Intoxi-

Therapeutic Alternatives and Developping Treatments in Refractory Urge Incontinence and Idiopathic Bladder Overactivity

Conservative therapies such as pelvic floor exercises, bladder retraining, electrical stimulation of the pelvic floor and pharmacotherapy involving anticholinergics, antispasmodics and tricyclic antidepressants are primary discussed. The use of pelvic floor muscle training with or without biofeedback for overactive bladder is suggested to inhibit detrusor muscle contraction by voluntary contraction of the pelvic floor at the same time, and to prevent sudden falls in urethral pressure by change in pelvic floor muscle morphology, position and neuromuscular function 17 . Some promising results have been reported, and these treatments are widely used, but there is still a need for high quality randomized trials on the effect of pelvic floor exercises on the inhibition of detrusor contraction. Detrusor over-activity current pharmacological treatment involve use of muscarinic receptor antagonists, but their therapeutic activity is limited by side effects resulting in the non continuance of...

The Prevention Of Depression

A number of outcome studies that examined the efficacy of cognitive therapy for depression found differential relapse rates among those treated with cognitive therapy, with or without medication, and those treated with medication alone. Specifically, it appears that cognitive therapy for depression prevents relapse. Currently, there is no evidence of a preventive effect after termination of antidepressant medication or any other psychotherapy. Interpersonal psychotherapy, another efficacious treatment for depression, appears to reduce risk only as long as it is continued. The Penn Prevention Program used a school-based, cognitive-behavioral intervention to prevent a first episode of depression in 10- to 13-year-old children. The children were identified as being at-risk for depression on the basis of depressive symptoms and their reports of parental conflict. The cognitive-behavioral techniques were designed to teach children coping strategies to use when confronted with negative life...

Recognition and diagnosis

In spite of its enormous clinical and public health importance, depressive illness is often underdiagnosed and undertreated, particularly when it coexists with physical illness. This often causes great distress for patients who have mistakenly assumed that symptoms such as weakness or fatigue are due to an underlying medical condition. All medical practitioners must be able to diagnose and manage depressive illness effectively. This depends on The use of screening questions in those at risk in particular, two questions about low mood and lack of pleasure in life can detect up to 95 of patients with major depression. Depressive disorders

Depression in medical patients

Depressive illness is usually treatable. It is common and results in marked disability, diminished survival, and increased healthcare costs. As a result, it is essential that all doctors have a basic understanding of its diagnosis and management. In patients with physical illness depression may

Depression and anxiety

These are broad terms that cover a continuum of emotional states. It is not always possible on the basis of a single interview to distinguish self limiting distress, which forms a natural part of the adjustment process, from the psychiatric syndromes of depressive illness and anxiety state, which need specific treatment. Borderline cases are common, and both the somatic and psychological symptoms of depression and anxiety can make diagnosis difficult. Psychological symptoms Although these might seem understandable, they differ in severity, duration, and quality from normal distress. Depressed patients seem to loathe themselves, over and above loathing their disease. A useful analogy is that the patient who is sad blames the illness for how they feel, whereas a patient who is depressed blames themselves for their illness. This expresses itself through guilt about being ill and a burden to others, pervasive loss of interest and pleasure, and hopelessness about the future. Attempted...

Depression as a Symptom

As a continuum one can be more or less depressed. The former conceptualization is compatible with the disorder view of depression, and is covered later. The latter concept has been much used in epidemiologic studies and in clinical studies, particularly in those focused on treatment outcome. The general strategy for measuring the level of depression that an individual is experiencing has been to construct a questionnaire or a structured interview that inquires about several aspects of the depressive state, usually focus ing on duration and or intensity of several symptoms of depression. The questionnaire or interview is then scored, yielding a single continuous variable. Higher scores reflect a greater level of depression. Depression symptom scales have been useful in providing normative data on the experience of depression in community samples and in helping to evaluate the effect of treatment on level of depression. Depression symptom scales are usually not intended to diagnose...

Efficacy Of Antipsychotics In The Acute Phase Of Treatment

Johnstone and co-workers25, showed that pimozide was antipsychotic (i.e. reducing the positive symptoms of psychosis) in patients with 'functional' psychosis, regardless of whether the patients had prominent manic or depressive symptoms or were euthymic. This proved that 'neuroleptics', as they were then popularly called, were truly antipsychotic rather than simply antischizo-phrenic (Figure 4.12).

Clinical Applications of the Emotional Component of Brain Damage

Attention to detail is important to performance on Wechsler's nonverbal tasks such as Picture Arrangement, yet impaired and disordered attention in signal detection tasks has been documented in several investigations of depressed patients (Caine, 1986). Indeed, the V > P that often characterizes the profiles of depressed patients (Gregory, 1987) is opposite to the P > V that is anticipated for people with left-hemisphere lesions. This antagonistic influence on V-P differences may be a primary reason why patients with left lesions have demonstrated such trivial P > V profiles in so many studies of unilateral brain damage on the WAIS and WAIS-R. This hypothesis, however, is mere speculation there are no data to support the contention that depression systematically lowers the P-IQs of patients with left lesions.

Cognitive Therapy And Mental Health

Cognitive therapy was developed in the 1960s by psychiatrist Aaron T. Beck. It is derived from empirical findings from studies of depressed patients. Beck found that depressed patients' thinking is saturated with themes of deprivation, defeat, and loss. Moreover, their judgments are absolute and rigid. Usually, information processing proceeds in a fairly flexible manner, so that initial impressions or primary appraisals may be checked and verified or adjusted. Beck observed that during depression this flexibility is lost, making it extremely difficult for depressed persons to generate alternative interpretations of events, solutions to problems, or new ways of behaving. Cognitive deficits, such as impaired perception, recall, and long-term memory, interfere with reasoning. Errors in logic, or cognitive distortions, become more apparent and create a negative bias to thinking.

Definition And Identification Of Key Neuropsychiatry Symptoms

Apathy consists of lack of motivation with diminished goal-directed behavior, reduced goal-directed cognition, and decreased emotional engagement. Apathy may accompany depression, but it is often an independent syndrome without the sadness, despair, and intense suffering typically experienced by depressed patients (5). Apathy is commonly accompanied by evidence of executive dysfunction.

Clinical Presentations Of Huntington Disease

A feature of HD that investigators have not given serious attention is the significant weight loss invariably noted in all patients with HD.6869 Significant weight loss occurs even in animal models of HD. The mechanism underlying the weight loss is not known and it is not correlated with the severity of chorea, dystonia, depressive mood, or the course of the disease.69'70 An interesting observation is that a loss occurs in 90 of the 60,000 neurons normally found in the lateral tuberal nucleus (LTN) of the hypothalamus.7172 The severity of the neuronal loss in this nucleus appears to be directly correlated with the severity of the disease. HD patients with minimal motor dysfunction have the least number of losses of neurons in this nucleus.72 This nucleus contains high levels of NMDA and AMPA receptors and the neuronal loss may be due to glutamate toxicity that may be associated with Huntington disease.73 In early and recent literature, investigators have extensively reported...

Anovulation Is A Characteristic Feature Of Pcos. It Manifests As Menstrual Disturbance 80 Amenorrhoea Oligoamenorrhea

Peripubital Obesity

Weight gain that is primarily centripetal, especially if associated with extremity wasting, purple striae, easy bruisability, moon facies, and rubor, suggests the presence of Cushing's syndrome, and these patients should be appropriately screened using 24-hour urinary-free cortisol levels or a cortisol level following an overnight dexamethasone suppression test. Other information that should be sought includes the patient's awareness of her body fat distribution, as women with PCOS have a greater prevalence of abdominal obesity (29). Weight gain may also be associated with carbohydrate craving and evidence of postprandial reactive hypoglycemia, particularly in mid-afternoons. For example, Holte and colleagues found that although insulin resistance in obese women with PCOS was reduced by weight loss to similar levels as BMI-matched controls, these patients continued to demonstrate an increased early insulin response to glucose, which could stimulate appetite and persistent weight gain...

Qualityof Life Measurements

Quality of life is a multidimensional concept, which includes, but is not limited to, the social, physical, and psychological functioning of the individual. Validated instruments are supposed to objectively measure the domains of quality of life, and to exclude observer bias. The relevance of quality-of-life assessment in children with ARM was confirmed in an early study by Ditesheim and Templeton 4 , who used a questionnaire scoring system that included items such as school attendance, social relationships, and physical capacities. Today it is well known that children and adolescents with fecal incontinence may suffer from emotional problems, internalizing behavior problems, and depressive symptoms. Various measures of quality of life have been used for quantitative and qualitative scoring of children and adolescents with fecal incontinence and constipation. However, the results presented below are not conclusive and none of the suggested instruments has been generally accepted.

Axis III General Medical Conditions

The second manner in which a general medical condition may be relevant to a mental disorder is that the medical condition may be related to the development of the mental disorder, but not through direct physiological means. For example, an Axis I disorder such as Major Depression or Adjustment Disorder with Depressed Mood might follow in reaction to learning of one is diagnosed with a malignant melanoma (Axis III). Finally, an Axis III medical condition, while not related to the appearance of the symptoms of a mental disorder, might be relevant in the treatment of a disorder. For example, certain antidepressant medications might be ill-advised in the presence of certain cardiovascular conditions. Alternatively, someone with a severe psychosis (Axis I) might have a medical condition (Axis III) that needs careful monitoring or

Rasagiline Parkinsons Disease [7987

Precursor, is a standard line of treatment for PD, many patients begin to experience motor complications after several years of artificial dopaminergic stimulation. As an adjunct therapy, rasagiline treats the fluctuations in motor symptoms. The R-enantiomer exhibits 4-times the potency of the S-enantiomer, so the synthetic method begins with the optical resolution of racemic N-benzyl-1-amino-indan using (R,R)-tartaric acid as the resolving agent. Once isolated, the enantiomerically-enriched salt is submitted to hydrogenolysis to afford 1(R)-aminoindane that is subsequently propargylated to provide rasagiline. It is formulated as its mesylate salt, and the recommended dosage of rasagiline is 1 mg day, with or without levodopa. As an irreversible inhibitor, frequent dosing is not necessary since the duration of action is not driven by half-life regeneration of MAO-B is the critical factor in the duration of action. Rasagiline is rapidly absorbed with a Tmax of approximately 0.5 h and a...

Neurobiological Theories Of Adhd

Recent work in human and animal studies also suggests the involvement of the adrenergic system in ADHD. In rodents, norepinephrine (NE) depletion results in increased distractibility and motor hyperactivity (38), and in nonhuman primates, stimulation of the noradrenergic system has been shown to improve cognitive function and distractibility (39). Noradrenergic projections are particularly dense in the frontal cortex and cingulate gyrus. These regions are involved in mood stabilization and sleep regulation, as well as attention and alertness (40,41). Animals and humans with lesions in the prefrontal cortex show poor attention regulation and disorganized, impulsive, and hyperactive behaviors, similar to those observed in ADHD. Pharmacological studies have demonstrated the clinical usefulness of NE inhibitors (such as desipramine, nortriptyline, and atomoxetine) in the treatment of ADHD (42,43). The mode of action of these antidepressants is to block the reuptake of dopamine and...

Vulval Pain Syndromes

Historically, there have been some links made between vulvodynia and sexual and physical abuse. Most relevant studies have failed to demonstrate this link (Edwards et al., 1997). Studies in which patients have more depressive symptoms and somatic complaints than controls do not differentiate between cause and effect (Lotery et al., 2004). James Aikens et al. (2003) showed that increased scores for somatic depressive symptoms were due to a lack of sexual interest and chronic pain, with no significant difference in cognitive affective symptoms or depressive history disorder. antidepressants

Cognitive Model Of Depression

Cognitive therapy also considers the interaction of personality and stressful life events in the onset of depression. Two broad personality types have been identified among depressed patients autonomous and so-ciotropic. Autonomous individuals are most likely to become depressed when thwarted from achieving their goals or when confronted with failure. Sociotropic types are most sensitive to personal rejection or to loss of a relationship. Although these are pure types at opposite ends of a continuum of personality styles, they allow investigation of the relationship between life events and various cognitive vulnerabilities. Current research supports the association between sociotropy and depressive symptoms.

Antidepressant Action in Neurogenesis

A puzzle in treating depression is that, even though there is an almost immediate increase in monoamines in the brains of people who begin taking antidepressant drugs, patients typically must wait from 3 to 4 weeks for the medication to take effect. If low levels of monoamines cause depression, then why does it take so long to see and feel improvement One explanation is that the increased monoamine levels initiate a slow reparative process in their target areas in the brain. In fact, findings from postmortem studies of the brains of depressed people show cell loss in the prefrontal cortex and hippocampus, and some of this loss may be reversed by the antidepressants' actions. Furthermore, exposure to chronic stress can cause cell death and dendritic shrinkage in the hippocampus, changes that likely result from high levels of cortisol. The possibility arises, therefore, that antidepressant drugs act to reverse cell loss, at least in the hippocampus. In fact, there is good evidence that...

What Does Healthy Cognitive Functioning Look Like

Cognitive therapy is derived from research on clinical populations, particularly depressed patients. Characteristics of the diagnostic groups studied are assumed to be extreme manifestations of qualities that are also found in normal people. Among depressed patients, for example, thinking is characterized by cognitive distortions or errors in logic, by cognitive rigidity, and by maladaptive core beliefs. Does this mean that the thinking of nondepressed people is free of distortions or an accurate reflection of reality It does not.

Central anticholinergic syndrome

A term given to a syndrome of blockade of central cholinergic neurotransmission, probably involving muscarinic receptors, which produces a clinical picture similar to that of atropine intoxication (Schneck & Rupreht 1989). It may be caused by any drug that has central anticholinergic actions, sometimes even after normal doses. It occurs most commonly following general anaesthesia, but also after acute intoxication from self poisoning, in association with sedation on the ITU, or during acute withdrawal states.The conscious level is usually impaired, or the patient may exhibit unpredictable behaviour. It has been described in association with a wide variety of drugs including atropine, hyoscine, benzodiazepines, tricyclic antidepressants, phenothiazines, butyrophenones (especially droperidol), cimetidine, phenobarbitone, opiates, and datura stramonium. Patients can vary considerably in their sensitivity to the anticholinergic effects.

Neuropsychiatric Symptoms In Multiple System Atrophy

Several reports have described depressive symptoms in MSA (16,92-95). In a study of 15 patients clinically diagnosed with Shy-Drager syndrome using the BDI, 86 scored in the depressed range (i.e., BDI score 10-15), and 29 scored in the moderately depressed range (BDI score 16-19). The mean BDI score was 14.4. This score is comparable to that reported in a community-based sample of patients with PD, who had a mean BDI score of 12.8, compared to 7.9 in patients with non-neurological chronic disease (diabetes mellitus) and 5.9 in healthy elderly controls (52). Severity of depression did not correlate with disability or ability to perform activities of daily living (ADL) (95). In another study using the BDI, 3 of 15 (20 ) patients had a score over 15, and MSA patients had similar severity of depression as PD patients (94). The importance of depression in MSA is underlined by reports showing that MSA patients may initially present with an affective disturbance (92,96). Fetoni et al....

Depression and Pseudodementia

The essential feature of major or clinical depression is either depressed mood or the loss of interest or pleasure in nearly all activities during a period of at least 2 weeks (APA, 1994). Additional symptoms that may be present include sleep and or eating disturbances, psychomotor retardation or agitation, loss of energy, difficulties in thinking or concentration, and suicidal ideation. Typically, intelligence tests are not used as the primary assessment tool in diagnosing depression however, they can be useful to this end. For instance, many individuals with learning disabilities also have major depression (APA, 1994 Culbertson & Edmonds, 1996). Additionally, it can be difficult, particularly in elderly persons, to determine whether cognitive symptoms are due to dementia or to a major depressive episode (APA, 1994). In fact, the literature suggests that the cognitive symptoms associated with depression are the most common type of pseudodementia and the most easily misdiagnosed...

Factors Affecting Prognosis

May 23 'The blue is there because I feel depressed, through cutting back on the antidepressants the wavy lines are because just as I feel I am safe, a voice from the street guts me emotionally by its ESP of my conditions am so pleased that I have been able to express such a purely mental concept as thought-broadcasting by the simple device of turning the brain into a mouth.'

Axis I Clinical Disorders and Other Conditions That May Be a Focus of Clinical Attention

Major Depressive Disorder, Bipolar I Disorder (aka Manic Depression), Also found for each disorder (other than NOS disorders) listed on Axis I are other sections providing more detailed information that may be of use to clinicians. The Diagnostic Features section provides an overview of the essential features of the disorder, along with examples and definitions of criteria and terms that are part of the criterion set for that disorder. The Subtypes and or Specifiers section delineates subtypes of the disorder (e.g., Catatonic Subtype of Schizophrenia) or specifiers of the disorder (e.g., Post-partum Onset for Major Depressive Disorder), where applicable. The Recording Procedures section includes information to assist in reporting the correct name of the disorder and the associated five-digit code that corresponds to the disorder. These five-digit codes correspond to the codes listed in the International Classification of Disease (9th edition, with clinical modification), the...

Nonstimulant Medications for ADHD

Ety and depressive symptoms that often appear with ADHD and are less likely to be alleviated by stimulants. tified tricyclic antidepressants and buproprion as second-line agents for treatment of ADHD. Clinicians are advised to utilize second-line agents for ADHD only if an individual fails to respond adequately to adequate trials of at least two stimulants and ATX. Tricyclic Antidepressants Tricyclic antidepressants (TCAs) were introduced in the late 1950s as an effective treatment for major depression. Medications in this class include imipramine, desipramine, nortriptyline, and others all act primarily on the noradrenergic system. TCAs remained the primary agents for treatment of depression until the advent of selective serotonin reuptake inhibitors in 1987. Most of the research on use of TCAs for treatment of ADHD has focused on desipramine and nortriptyline.

Appendices to the DSMIV

Dence to include or exclude these entries from future editions of the DSM. The appendix encourages researchers to study refinements in these sets of criteria. Examples of entries in this appendix include Caffeine Withdrawal, alternative descriptions of Schizophrenia and other disorders related to Schizophrenia, other variants of depressive disorders, Premenstrual Dys-phoric Disorder, Mixed Anxiety-Depressive Disorder, a series of Medication-Induced Movement Disorders, and Passive Aggressive Personality Disorder (which appeared as an Axis II disorder in the previous edition of the DSM). The proposed Axes include a scale to measure strategies for coping with emotional states, termed the Defensive Functioning Scale, and two scales modeled after Axis V to measure functioning in specific areas (relationships, and social occupational).

Biological Target Validation

Non-selective sodium channel blockers developed as local anesthetics 26 , an-ticonvulsants, antidepressants, or antiarrhythmics have found application in the treatment of various pain conditions 27 . All of these agents have CNS penetration and have undesired effects and off-target activities. In spite of the fact that these agents are non-selective against Nav1.5, the heart sodium channel, they demonstrate few cardiovascular liabilities. The observed therapeutic index is thought to be a result of their use and voltage-dependent properties as neuronal firing frequencies are often 3-100 fold higher than that of cardiac myocytes.

Differentiating Depression from Dementia

Some depressive symptoms mimic cognitive impairment, especially in the elderly. In particular, psycho-motor retardation and memory lapses in the elderly are usually attributed to dementing processes, but actually may reflect depression. Pseudodementias can result from a wide variety of disorders, including nutritional deficiencies, prescribed medications, alcohol and substance abuse, and surgical procedures. Thus, assessment of the occurrence of problems of this type may be an important component in elders presenting with cognitive impairment. In turn, dementia is often associated with difficulty concentrating, loss of en In 1992, Newman and Sweet identified a number of different features which may distinguish depression from dementia. Depression often has a rapid onset while dementia often has a gradual one. In addition, there may be differences in both patient and familial awareness of the problems, with recognition greater in depression-related cognitive impairment than in problems...

Psychiatric Aspects Of Dementia With Lewy Bodies

DLB is characterized clinically by dementia, visual hallucinations, and fluctuating consciousness in addition to parkinsonism. Neuropathological characteristics include alpha-synucleinopathy, such as Lewy bodies and Lewy neurites in the brainstem, particularly the substantia nigra, subcortical structures, limbic cortex, and neocortex. Some amyloid deposition is also found in most patients. Neurochemically marked cholinergic deficits are reported in addition to a moderate nigro-striatal dopaminergic, and monoaminergic deficits have also been reported. It is estimated that at least 80 of DLB patients experience some form of neuropsychiatric symptoms (23), such as visual hallucinations, auditory hallucinations, delusions, delusional misidentification, and depression. These visual hallucinations are consistently reported to be more frequent in DLB than in AD, also in samples diagnosed at autopsy, and constitute one of the key diagnostic features of the disorder. Although rates vary from...

Disorders of Arousal and Motivation

The chronic, low-grade depressive symptoms shown by Charles are characteristic of dysthymia, a less dramatic but significantly impairing form of depression that has been described by Hagop Akiskal (1997). Charles was able to do most of what he was required to do, but found virtually no pleasure or satisfaction in most of life.

Lack of Adequate Resources for Assessment and Treatment

Clinicians tend to interpret each patient's presenting complaints within the framework of diagnoses they know well. If they have been trained to recognize and treat depression and anxiety, but lack adequate training to identify and treat ADHD, clinicians are likely to interpret pa

Treating Behavioral Disorders with TMS

The results of controlled clinical studies of drug-resistant patients show that daily stimulation of the left dorsolateral prefrontal cortex may produce significant reductions in depressive symptoms compared with sham TMS treatment (e.g., George et al., 1997). One difficulty is that the relief may be transient, possibly because the stimulation does not reach deeper regions of the hemisphere, such as the limbic cortex.

Localization Studies For Pheochromocytoma

False-negative scans occur in about 15 of both benign and malignant pheochromocytomas. False-negative scans are more common in patients who, within 6 weeks, have taken tricyclic class drugs, for example, antidepressants or cylcobenzaprine (Flex-eril). Other drugs can cause false-negative scans if taken within 2 weeks amphetamines, cocaine, phenylpropanolamine hydrochloride, haloperidol, phenothiazines, thiothixene, reserpine, nasal decon-gestants, and diet pills. Labetalol causes some decreased uptake, but the scan can still be done with reasonable sensitivity (Table 9-3).

Psychological consequences

Depression is a response to perceived loss. A diagnosis of cancer and awareness of associated losses may precipitate feelings similar to bereavement. The loss may be of parts of the body (such as a breast or hair), the role in family or society, or impending loss of life. Severe and persistent depressive disorder is up to four times more common in cancer patients than in the general population, occurring in 10-20 during the disease.

Depression Applied Aspects

Treatment of Major Depression Depressed Mood A feeling state consisting of dejection, sadness, and demoralization, usually accompanied by diminished reaction to pleasurable events. Depressive Disorder A condition in which an individual exhibits a specified number of depressive symptoms of enough severity and duration to meet well-delineated and widely accepted diagnostic criteria. Emotion A noticeable subjective feeling, usually lasting on the order of minutes, in reaction to internal or external stimuli.

Neuropsychiatric Symptoms In Corticobasal Degeneration

In 14 patients with a neuropathological diagnosis of CBD selected from the research and neuro-pathological files of seven medical centers, the presenting symptom was dementia in 21 , frontal behavior (i.e., apathy, disinhibition, and irritability) in 21 and depression in 7 . Subsequently, dementia and depression had developed in 30-40 , and at the last visit, 58 showed frontal behaviors (84). Dementia as a presenting symptom in CBD was also reported in another postmortem study (85). A high prevalence of frontal behaviors was also reported in one of the few prospective studies reported. Kertesz et al. followed 35 patients with a clinical diagnosis of CBD and included a structured evaluation of language, cognition, and personality changes (Frontal Behavioral Inventory or FBI see ref. 86), which was specifically designed to assess the spectrum of apathy and disinhibition in frontotemporal dementias (87). They found two groups of patients according to the initial presentation 15 (43 )...

Ventricular Fibrillation And Pulseless Ventricular Tachycardia

These arrhythmias are uncommon in children but may be expected in those suffering from hypothermia, poisoning by tricyclic antidepressants and with cardiac disease. The protocol for ventricular fibrillation and pulseless ventricular tachycardia is shown in Figure 6.6. During the resuscitation the underlying cause of the arrhythmia should be considered. If the VF VT is due to hypothermia then defibrillation may be resistant until core temperature is increased. Active rewarming should be commenced. If the VF has been caused by an overdose of tricyclic antidepressants then the patient should be

Albert Ellis and Rational Emotive Therapy

Remarkably similar to Ellis' cognitive orientation is Aaron Beck's cognitive therapy. Beck's technique has been proved to be as effective for treating some depressive disorders as is medication. Beck's method has also proved to be more effective than medication for preventing recurrences of those depressive disorders it therefore prevents the unhealthy medical side effects of long-term drug treatment. See Cognitive Therapy.


The World Health Organization estimates that depression will become the second most important cause of disability worldwide (after ischaemic heart disease) by 2020. Major depressive disorder affects 1 in 20 people during their lifetime. Both major depression and dysthymia seem to be more common in women. Depressive illness is strongly associated with physical disease. Up to a third of physically ill patients attending hospital have depressive symptoms. Depression is even more common in patients with Criteria for major depression* Criteria for major depression*

Drug treatment

Antidepressants have been shown to be effective in treating major depressive disorder irrespective of whether the mood disturbance is understandable. There have been far fewer trials of antidepressants in patients who are also physically unwell, but the available evidence is in keeping with the treatment of depression generally.

Depressed Mood

Depressed mood states appear to be a normal part of human subjective experience. Most individuals have a personal understanding of depressed mood, in contrast with, say, psychotic experiences or addictions. Depressed mood states usually involve the emotion of sadness, a subjective lack of energy, reduced motivation to engage in formerly pleasant activities, reduced desire to have positive interactions with other people, and a belief that one's lot in life is difficult. Such states color one's reactions to external events, but they can themselves be modified by such events. Normal states of depressed mood last hours or days. Once they become more chronic and start affecting one's ability to function, they are often conceptualized as part of a pathological process, which can ultimately meet criteria for a diagnosis of a clinical depressive disorder. The role of mood states in the development of psy-chopathology has yet to be adequately elucidated. It is well known that prior to having a...

Bipolar Disorder

Depressed mood and a major depressive episode may be part of bipolar disorders. However, what characterizes bipolar disorders is the occurrence of one or more manic episodes. The DSM-IV criteria for manic episode include a period of abnormally elevated, expansive, or irritable mood lasting at least 1 week, plus three or more of the following seven symptoms most of the time for at least 2 years. Both depressive and bipolar disorders include residual categories called, respectively, depressive disorder not otherwise specified'' and bipolar disorder not otherwise specified.'' In both cases, the disorders do not meet the full criteria for either depressive or bipolar diagnoses.

Attributable Risk

Many factors have been linked to depression. Some of them are demographic factors that cannot be changed for the individual, such as sex, death of a parent during early childhood, or a family history of the disorder. Therefore it is important to focus on modifiable risk factors, especially those with a high level of attributable risk. From a preventive standpoint, one possible risk factor that is related to later episodes of major depression is the evidence of deficits in mood regulation. A potential strategy, therefore, is to identify individuals who have high symptom levels of depression, but who do not meet the criteria for a depressive disorder, and to teach such individuals methods to manage their moods. Such methods can come, for example, from cognitive - behavioral techniques that have been found to be useful in the treatment of depression. Some studies have already shown that de pressive symptoms can be reduced in nonclinical populations that nevertheless show high depressive...

Mood Disorders

Mood disorders are manifested as either depressive or manic episodes. Among the most serious of the mood disorders are major depressive disorder or unipolar depression, in which a patient only experiences depressive episodes, and bipolar disorder, in which a patient experiences both manic and depressive episodes or only manic episodes. The history and current use of pharmacological agents to treat these separate mood disorders differ. With regard to unipolar depression, amphetamines were first used in the late 1930s. In the 1950s, the tricyclic and tetracyclic antidepressants (TCAs) (e.g., imipramine, amoxapine) and MAOIs (e.g., phenelzine) were serendipitously discovered to elevate depressive moods. These prototypal compounds, however, affect many systems indiscriminately, have a slow action of onset, and produce numerous unwanted side effects that deter patient compliance. The largest new drug class of antidepres-sants includes SSRIs (e.g., fluoxetine). In general, the SSRIs are no...

Tourette Syndrome

Report evaluating 100 children and adolescents, 76 met the criteria for mood disorder and 67 the criteria for non-obsessive-compulsive anxiety disorder.53 Depressive symptoms are thought to be more severe in older female patients with TS who have echo phenomena. Some investigators believe that early onset and longer duration of tics correlates positively with depression, whereas others find no correlation between the two. Genetic studies show that major depressive disorder (MDD) is genetic but that TS and MDD are unrelated.54


Dysthymia differs from major depression in that it is generally more chronic and is defined by fewer symptoms. The DSM-IV criteria for dysthymic disorder include a depressed mood for most days for at least 2 years in adults or at least 1 year in children and adolescents. In addition, two or more of the following six symptoms must be present poor appetite or overeating, trouble sleeping or sleeping too much, low energy or fatigue, low self-esteem, poor concentration or difficulty making decisions, and feelings of hopelessness. The initial 2-year period must not have included a major depressive episode and the 2-year period of depression must not have been broken by a period of normal mood lasting more than 2 months.

Emotional Disorders

As detailed in Chapter 7, a highly disruptive emotional disorder is major depression, characterized by abnormal regulation of feelings of sadness and happiness. A depressed person feels severely despondent for a prolonged time. Depression is common in our modern world, with a prevalence of at least 10 percent of the population. The strongest evidence supporting a biological cause of depression comes from the fact that about 70 percent of depressed people can be treated with one of several anti-depressant drugs. This success rate has made antidepressants among the most widely prescribed classes of drugs in the world. As summarized in Table 11-2, antidepres-sants act on synapses (especially noradrenaline- and serotonin-containing synapses) by increasing the amount of available transmitter at them. The major projections of noradrenaline- and serotonin-containing cells to the limbic system imply that the activity of limbic regions, including the prefrontal cortex, is abnormal in...

Risk factors

Anxiety, sadness, and somatic discomfort are part of the normal psychological response to life stress, including medical illness. Clinical depression is a final common pathway resulting from the interaction of biological, psychological, and social factors. The likelihood of this outcome depends on such factors as genetic and family predisposition, the clinical course of a concurrent medical illness, the nature of the treatment, functional disability, the effectiveness of individual coping strategies, and the availability of social and other support.


The third large segment of mental health interventions identified by the Institute of Medicine is the area of maintenance. Even though the treatment of acute episodes of depression and other disorders may be quite effective, relapse or recurrence of such an episode can be not only as disruptive as the first experience of clinical depression, but, at times, even more demoralizing. The fear that this painful condition will recur can have a major impact on a person's outlook. Approximately 50 of persons who have had one major depressive episode have a second 70 of those with two have a third and 90 of those with three have a fourth. These figures suggest two important goals for the mental health field preventing the first episode (as described earlier) and, if the first episode occurs, providing interventions that will maintain a healthy mood state, thus forestalling relapse and recurrence. Current convention uses the terms relapse and recurrence in relatively well-defined ways. When...


Treating, and caring for, the elderly is a complex endeavor. Older people are usually suffering from several simultaneous disorders that, because of the patient's age, cannot be treated with the drugs or therapies that are routine for younger individuals. Drug therapies assume a clearance time (physiological deactivation of the drug), made possible by a healthy liver that may not exist in an older patient. Drugs that are safely used to treat depression or cardiovascular disease in young patients can have devastating effects on the elderly. Accurate medical histories are often difficult to obtain from elderly patients, either because of poor memory or because of psychological compensation by which the patient ignores and minimizes danger signs and symptoms. Growing old is often a time of loss lost physical abilities, lost friends, the patient's spouse may have passed away, and the family home may have been given up for a room in a nursing home or hospital ward. All these elements...


By far the best-studied pharmacologic agent in the treatment of AN is fluoxetine (Prozac and generics). The data for treatment of acutely ill, underweight patients are mixed, and there is at least some evidence that suggests if patients are treated in a sufficiently intense, multidisci-plinary inpatient setting, fluoxetine does not add additional benefit (Strober et al, 1999). The APA's Practice Guidelines recommend the use of antidepressants as agents Studies of the pharmacotherapy of BN have demonstrated efficacy for several classes of antidepressants, including tricyclic antidepressants (TCAs) (eg, nortriptyline Pannelor , amitriptyline Elavil ), monoamine oxidase inhibitors, and selective serotonin reuptake inhibitors (SSRIs) (eg, fluoxetine and related compounds). There is some evidence that treatment with fluoxetine (Prozac) is more effective at 60 mg daily than at 20 mg daily. There are few data on the use of other SSRIs or newer agents, such as venlafaxine (Effexor XR), and...


Tricyclic antidepressants produce a worthwhile response in about 80 of patients but have considerable anticholinergic side effects in the doses necessary for a therapeutic response and therefore are not routinely indicated in palliative care settings. Selective serotonin reuptake inhibitors such as sertraline (50 mg daily) or paroxetine (20 mg daily) have few anticholinergic effects, are non-sedative, and are safe in overdose. They may, however, cause nausea, diarrhoea, headache, or anxiety. The newer antidepressants, such as mirtazapine, seem to be better tolerated. Other treatments The use of drugs such as lithium or combinations of antidepressants should be prescribed and managed in consultation with a psychiatrist. Psychostimulants can be used but care needs to be taken regarding doses.

Gastric stasis

Reduction in gastric emptying may be caused by opioids, mucosal inflammation (NSAIDs, stress, tumour), anticholinergic drugs (including side effects of tricyclic antidepressants and antipsychotics), raised intra-abdominal pressure (ascites, hepatomegaly), or occasionally by encroachment of tumour on the gastric outlet (such as gastroduodenal tumours, mass in head of pancreas).


To treat patients successfully with antidepressants, doctors must be able to show their patient that they have understood the patient's problems, considered the issues, and are advising the best available treatment (see previous chapters). Before starting treatment, patients should be given an explanation of side effects and be reassured that side effects tend to be worse during the first two weeks of treatment and then diminish. They need to be warned that they are unlikely to feel benefits from treatment in the first four weeks. They should be given follow up appointments during this period in order to encourage compliance.


Drugs are reviewed with regard to need and route of administration. Previously essential drugs such as antihypertensives, corticosteroids, antidepressants, and hypoglycaemics are often no longer needed and analgesic, antiemetic, sedative, and anticonvulsant drugs form the new essential list to work from. The route of administration depends on the clinical situation and characteristics of the drugs used. Some patients manage to take oral drugs until near to death, but many require an alternative route. Any change in medication relies on information from the patient, family, and carers (both lay and professional) and regular medical review to monitor the level of symptom control and side effects.

Beat Depression Now

Beat Depression Now

Let me be up front. My intention is to sell you something. Normally, it's not wise to come out and say that. However, I can do so because I have such an incredible deal for you that you'd be crazy to pass on it.

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