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Adjustment Disorder with Depression

// November 20th, 2010 // No Comments » // Depression

Adjustment disorder with depression is the term for the condition commonly referred to as situational depression or reactive depression. Individuals with this malady feel sadness about a loss or a major life change. The sadness, depressed mood, or sense of hopelessness begins within three months of a major stress and is excessive. People with this form of depression may find it difficult to carry on routine activities at home, at work, or at school. The depression gradually disappears once the stress is over and is not usually considered a serious depression, although it may be very uncomfortable. Often the support and advice of concerned friends, loved ones, or a doctor are enough to help sufferers manage until their mood improves following removal of stress or a decrease in its intensity.

Bereavement

// November 20th, 2010 // No Comments » // Depression

Bereavement, or grief, is a normal feeling of sadness that occurs following the loss of a loved one. Uncomplicated grief is believed to advance through a series of stages that, in many aspects, mimic the illness depression, raising questions as to where normal bereavement ends and major depressive illness begins. The initial stage of grief occurs during the first few weeks after the loss and is experienced as feelings of disbelief and shock. It is commonly associated with bouts of crying, loss of appetite, loss of sexual drive, restless sleep or insomnia, lack of energy, and difficulty concentrating. In women, disturbances in the menstrual cycle are common.

The intermediate stage of grief takes place during the first year after the death of the loved one. During that phase, feelings of intense loneliness and sadness are accompanied by persistent thoughts about the death, the events leading up to the death, why it happened, and how it could have been prevented. Limited capacity for pleasure, lack of energy, sleep and appetite problems, and bouts of tearfulness persist to varying degrees.

The recovery phase of grief is the time when people begin to return to their social lives and “get on with life.” That usually begins about the second year following the loss.

Little is known about the actual duration of normal grief. Studies of spouses and parents dealing with unexpected loss point to normal grief processes lasting up to seven years. Sudden death often causes bouts of grief that are more severe and longer lasting than the bereavement following an anticipated death.

Death of a spouse can have significant impact on the health of the surviving partner. Women tend to be at increased risk for health problems within the first three months after the loss. Men whose spouses die are particularly likely to develop emotional or physical problems during the first year after the loss and have an increased mortality rate. Bereaved men who remarry tend to have lower mortality rates than those who do not.

Death of a child is particularly likely to produce severe grief reactions regardless of the age of the parent and child. Bereaved parents experience high levels of psychological distress that are accompanied by changes in physical health, functional activities, and family cohesion, including an increased risk of divorce.

The distinction between “normal” grief and depression can be a difficult one to make. The two states share many similar

physical and emotional symptoms, and the duration of both can be prolonged. Grief can produce a preoccupation with guilt about actions taken or not taken surrounding the death of a loved one and thoughts that the survivor would be better off dead. Experiences of transiently hearing or seeing the deceased loved one can also be a part of the normal grief process, especially in some cultures. Morbid rumination regarding other feelings of guilt, a sense of worthlessness, anticipated death of other loved ones, prolonged decrease in level of function, marked slowness of behavior or speech, reports of unusual beliefs, or persistent or recurring hallucinations should be considered outside the normal grief process and more indicative of a major depressive episode. When symptoms of severe grief extend more than two months beyond the death of a loved one, treatment with antidepressant medication may be needed in addition to supportive psychotherapy.

Grief in young children is most profound when it involves the death of a parent or a primary caretaker. It can produce such behaviors as crying, calling and searching for the deceased loved one, and refusing to be comforted. Emotional withdrawal often occurs and is associated with sad facial expressions, lethargy, and lack of interest in former activities. Eating and sleeping may be disrupted. Children may regress by losing some of their developmental milestones; i.e., toilet-trained toddlers may begin to soil themselves again. Bereaved young children may become detached and lack much facial expression. They often are very sensitive to any reminder of the lost loved one. Grief in young children is generally treated with supportive measures; use of antidepressant medication is usually not required.

Types of Depression

// November 20th, 2010 // No Comments » // Depression

Many different and sometimes complicated systems attempt to classify depressions according to their symptoms, severity, causes, and other characteristics. One reason for these rigorous attempts is the need to conduct research on relatively pure forms of the illness. Such research should result in improved treatment for the various forms of depression.

The two most common systems use similar terms in naming various types of depression. The international version is the ninth edition of the International Classification of Diseases, commonly referred to as ICD-9, which classifies all medical and mental disorders. The system used by most clinicians in the United States is the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, or DSM-IV, produced by the American Psychiatric Association. Further attempts are made to standardize these common classification systems with each new edition.

Depression can take many forms, and these may be of varying degrees of severity with different natural courses. The types of depression commonly diagnosed in the United States include adjustment disorder with depressed mood; dysthymic disorder; major depressive disorder, single episode or recurrent; major depressive episode associated with bipolar disorder; and mood disorder associated with a general medical condition.

Mild mood alterations do not require help and therefore are not matters for diagnosis. For instance, a bad mood is just that— temporary frustration associated with current circumstances. A person exhibiting a somewhat more persistent alteration of mood is often described as being “blue, ” “bummed out, ” or mildly depressed. People with such negative feelings still enjoy their hobbies, family, and friends. Such mild depressions are usually time-limited and unlikely to require treatment.

Moderate-to-severe forms of depression frequently come to the attention of caregivers, although the initial complaint may not be depression. Those are the forms of depression that fall into formal diagnostic categories.

Depression and Suicide

// November 20th, 2010 // No Comments » // Depression

Every 17.3 minutes someone commits suicide in the United States. According to National Institute of Mental Health statistics, suicide is the ninth leading cause of death in Americans and accounts for more than 30,000 deaths every year. More Americans die of suicide than are victims of homicide. Although most people who become depressed do not commit suicide, depression can be a lethal illness. Contrary to popular belief, not everyone who commits suicide is depressed, but the majority of people who commit suicide do so during a severe depressive episode. The suicide risk in people with severe depression ranges between 15 and 30 percent, with approximately seven suicide attempts for every successful suicide. Women are two to three times more likely to attempt suicide, but men are four to five times more likely to be successful in their attempt.

Over 70 percent of all suicides in the United States are committed by white men, and the majority of those deaths involve firearms. The second highest rate in the country is reported in white women, followed by rates for black women. Black men in the United States currently have the lowest suicide rate; unfortunately, it is rising.

Bob T. was a seventy-two-year-old retired government employee who lived alone in a retirement community. He had been the sole caretaker for his wife, who had been bedridden for two years before her death the previous year. Bob was hypertensive and diabetic. Both conditions had been well controlled with diet and medication until the past few months. Despite repeated visits to his physician, Bob did not feel well. He experienced vague stomach discomfort, joint aches, increasing insomnia, and fatigue, which he reported to his doctor on repeated visits. Bob did not discuss with his physician his fear that his memory was failing rapidly and that he might have “old-timer’s disease.” He often thought of his wife in a “happier place” and longed to join her. One Sunday afternoon after attending church services, Bob went home, wrote his name and the current date in the family Bible below the entry noting his wife’s death, and shot himself in the head.

Thoughts of suicide may be intermittent and relatively brief, but they may also be persistent and intrusive, developing into plans for carrying it out. Circumstances that increase the risk for suicide in depressed patients include advancing age, male sex, Caucasian race, living alone, chronic medical illness, a recent major loss, substance abuse, panic attacks, psychotic symptoms, previous episodes of depression, previous suicide attempts, and family history of depression. In addition, people who are depressed and simultaneously have other brain disorders such as schizophrenia, dementia, or brain damage from illness or trauma may be at increased risk for suicide because of impaired judgment and a tendency toward impulsiveness.

Common methods of suicide include gunshot wound to the head or chest, overdose of over-the-counter or prescription medications, overdose of street drugs, laceration of neck or wrists with a sharp object such as a razor blade or a knife or broken glass, asphyxiation by hanging or from the breathing of a toxic gas such as natural gas or carbon monoxide from an automobile exhaust, and purposeful “accidents, ” such as car crashes against trees or off bridges. In the past, women were reported to choose less violent means of suicide, such as overdose or asphyxiation by gas, while men chose more violent means, such as guns. Now, however, suicide by firearms is the most common method for both men and women, accounting for over half of all suicides. Unfortunately, depressed people intent on suicide can be very creative in choosing their method of death, despite the efforts of their doctors and their loved ones to prevent the tragedy.

The risk for suicide, ironically, may be greatest when the sufferers have passed the lowest point in the course of their illness and have begun to recover. The reasons are not clear but may relate to the observation that recovery from depression often begins with an increase in energy level without immediate improvement in mood. When such is the case, depressed people in the early stages of recovery have regained enough energy to plan and carry out a long-desired suicide. It may also be that once seriously depressed individuals finally make the decision to escape the anguish of illness through death, they feel a temporary reprieve from their symptoms.

Suicide may occur without warning, but 80 percent of people who attempt or commit suicide do give some indication of their intent by means such as voicing despair and world-weariness, expressing suicidal thoughts, threatening to harm themselves, increasing the use of alcohol or drugs, or writing suicide notes. Rehearsing suicide or seriously discussing specific methods may also indicate a determination to go forward with it. More often the hints are subtle behavioral changes that may serve as red flags. Such warnings perhaps indicating that the despondent individual is putting his or her house in order may include making out a will, reviewing life insurance coverage, purchasing cemetery plots, giving away valued possessions, or getting in touch with close relatives. Contrary to popular understanding, most people do not leave notes.

Once someone has decided to commit suicide, it may be impossible to prevent the tragedy. Although many suicide attempters are ambivalent about their course of action until the last moment, others are determined to die and give few clues ahead of time.

Symptoms of Depression

// November 20th, 2010 // 1 Comment » // Depression

There is no blood test for depression. The diagnosis is based on the reports of sufferers about how they feel and on observations of how they look and behave made by doctors and by people who know them well.

John D. was a forty-five-year-old, self-employed, successful businessman when he suddenly initiated negotiations to sell his company. For months preceding the decision to sell, John had experienced increasing fatigue and decreasing ability to concentrate, which he attributed to the pressures of work. He quit meeting his friends for golf on Sunday afternoons, preferring to sleep in front of the television, but then had problems going to sleep at night. John’s appetite, energy level, and sex drive gradually diminished, while he experienced a growing sense of restlessness, irritability, and futility. John’s wife became concerned when she learned of her husband’s recent purchase of additional life insurance and of his revision of his will. She convinced John to see his family physician for a “good physical.”

The symptoms of depression fall into four categories: mood, cognitive, behavioral, and physical. In other words, depression affects how individuals feel, think, and behave as well as how their bodies work. People with depression may experience symptoms in any or all of the categories, depending on personal characteristics and the severity and type of depression.

Depressed people generally describe their mood as sad, depressed, anxious, or flat. Victims of depression often report additional feelings of emptiness, hopelessness, pessimism, uselessness, worthlessness, helplessness, unreasonable guilt, and profound apathy. Their self-esteem is usually low, and they may feel overwhelmed, restless, or irritable. Loss of interest in activities previously enjoyed is common and is usually accompanied by a diminished ability to feel pleasure, even in sexual activity.
As the illness worsens, the cognitive ability of the brain is affected. Slowed thinking, difficulty with concentration, memory lapses, and problems with decision-making become obvious. Those losses lead to frustration and further aggravate the person’s mounting sense of being overwhelmed. The sufferer longs for escape, and thoughts of death intrude, sometimes taking the form of wishful thinking, as in “I wish God would just take me” or “I wish I could vanish, ” and often involving ideas of suicide.

In its most severe forms, depression causes major abnormalities in the way sufferers see the world around them. They may become psychotic, believing things that are not true or seeing and hearing imaginary people or objects.

Ann H. was forty years old when her husband took her to the family physician after she began crying daily and begging her husband to take good care of their teenage daughters after her death. Despite a normal medical assessment, Ann remained convinced that she was dying of metastatic cancer as had her mother years before. She “felt” the cancer cells destroying her liver and kidneys and pointed to her twenty-pound weight loss in six months as proof of terminal illness. Ann’s appetite was poor, yet she remained constantly, unproductively active throughout the day. At night she lay awake crying about leaving her daughters without a mother, while during the day she worried constantly about becoming an emotional and financial burden on her family in the late stages of her “terminal” illness. Ann decided she must kill herself to protect her family and took a lethal overdose of an antidepressant medication that had been prescribed by her family physician.

Psychosis in depression is not rare. Between 10 and 25 percent of patients hospitalized for serious depression, especially elderly patients, develop psychotic symptoms. Symptoms of psychosis may include delusions (irrational beliefs that cannot be resolved with rational explanations) and hallucinations (seeing, hearing, feeling, tasting, or smelling things or people that are not present).
People with psychoses may develop paranoia, believing that they are being manipulated by known or unknown people or forces, that there is a conspiracy against them, or that they are in danger. No amount of rational explanation changes the delusional belief. Others may be convinced that they have committed an unpardonable sin against loved ones or against their God and deserve severe punishment, even death. Some sufferers become so firmly convinced of their own worthlessness that they begin to view themselves as a burden to their families and choose to kill themselves. Occasionally, severe depression may result in hallucinations in which the depressed person hears or sees things or people that are not present; other types of hallucinations, such as smelling or feeling things that are not present, are less common in severe depression than in some other brain disorders.

The changes occurring with depression understandably result in alterations in behavior. Most individuals with moderate-to-severe depression will experience decreased activity levels and appear withdrawn and less talkative, although some severely depressed individuals show agitation and restless behavior, such as pacing the floor, wringing their hands, and gripping and massaging their foreheads. Given a choice, most begin to avoid people and activities, yet others will be most uncomfortable when alone or not distracted. In general, the severely depressed become less productive, although they may successfully mask the decline in performance if they have been highly productive in the past. In the workplace, depression may result in morale problems, absenteeism, decreased productivity, increased accidents, frequent complaints of fatigue, references to unexplained aches and pains, and alcohol and drug abuse. Severely depressed individuals have been known to work their regular schedule during the day, interact with their coworkers in a routine way, and then go home and kill themselves.

Depression is more than a mental illness. It is a total body illness. People suffering from moderate-to-severe depression experience changes in their body functions. Their energy levels fall, and they fatigue more easily. Insomnia is common and takes many forms; depressed individuals may have difficulty going to sleep or experience early morning awakenings. A subgroup of depressed patients feel an excessive need for sleep. Depressives consistently complain that their sleep is not restful and that they feel just as tired in the morning when they awake as they did when they went to bed the evening before. Some may be troubled by dreams that carry the depressive tone into sleeping hours, causing abrupt awakenings due to distress.

Appetite changes are common. Most depressives experience decreased or total loss of appetite, with associated weight loss resulting in lower energy levels. The same individuals who oversleep when depressed also tend to overeat. They gain weight from a combination of increased caloric intake and decreased activity level, which compounds their problems through increased frustration and lowered self-esteem. Whether the appetite increases or decreases, the end result is a vicious cycle of physical symptoms aggravating the depression.

Physical complaints are common and may or may not have a physical basis. Many seriously depressed people, in fact, first go to their physicians with physical complaints. The depressed mood may not be recognized initially by these patients, especially if they are men. Men, in general, are less apt to look inward when they “feel bad, ” attempting instead to locate the problem in their environment.

Physical symptoms associated with depression can occur in any part of the body and can include pain (headache, backache), gastrointestinal problems (nausea, stomach pain, diarrhea, constipation), neurologic complaints (dizziness, numbness, memory problems), sexual disorders (lack of desire, failure of orgasm), and general complaints of feeling unwell and heavy, as if one’s feet are stuck in mud. The physical complaints of depressed patients cannot be overlooked, because many studies indicate an increased risk of real physical illness in people who have severe forms of depression.

Costs of Depression

// November 20th, 2010 // No Comments » // Depression

Approximately one in five adults in the United States will suffer from depression at some time. Depression affects more than 17 million Americans each year. Mood disorders, including mania and various forms of depression, account for as many as 70 percent of psychiatric hospitalizations.

Sufferers of depression include some of the most creative and productive members of society, which means that the direct and indirect costs of this common illness are very high. The latest National Institutes of Health (U.S.) study on the cost of depression, reported for 1990, estimated the cost of depressive illness in the United States at between $33 billion and $44 billion annually (fig. 1.1), including direct treatment costs ($12.4 billion), absenteeism ($11.7 billion), lost productivity ($12.1 billion), and mortality costs ($7.5 billion). The number of lost work days due to depression may be as high as 200 million days per year.

On a more personal level, patients treated in psychiatric hospitals for serious depression may find themselves billed $1,000 to $1,500 a day or more for a hospitalization that may exceed five to seven days and occasionally last several weeks. Those charges may not even include the costs of physician visits, consultants, or special studies such as antidepressant medication blood levels or brain scans.

Most people, even solid middle-class individuals with good health insurance, will find themselves psychiatrically indigent if they require hospitalization for the treatment of depression. Health insurance policies, even good ones, commonly discriminate against psychiatric illness. Many policies have a poorer reimbursement rate for mental disorders, impose a lifetime maximum reimbursement limit (sometimes as little as $50,000), and require larger copayments for psychiatric treatment. The length-of-stay allowances for inpatient care of seriously depressed patients may also place the patient at significant risk. For example, a psychiatrist recently hospitalized a severely depressed woman on an emergency basis following her suicide attempt by overdose of prescribed medications. The insurance company ruled that the patient had to be discharged the day she no longer reported suicidal intent. The fragility of severely depressed patients in early recovery, including their increased risk for suicide, was apparently not a cost-efficient consideration.

Another problem is the stigma associated with mental illness, which can make treatment for depression and other brain disorders that are labeled as mental illnesses costly in personal ways. Traditionally, people with mental illnesses such as depression have been required to report their disorders on applications for a driver’s license, for employment, for security clearance, and for other routine purposes, while people with other medical conditions generally have not. Although the recent federal Americans with Disabilities Act attempted to correct that form of discrimination, the problem remains. When a physician recently changed her medical liability insurance policy, the application asked whether the applicant had ever been treated for mental illness. Nowhere on the policy was there another question about any other medical illness or treatment. Fearing discrimination in hiring, promotion, and other occupational and educational opportunities, many people who recognize their own depression will not seek treatment because of concerns that they may have to report it later.

What Is Depression?

// November 20th, 2010 // No Comments » // Depression

what is depression

The innocuous-sounding word “depression” refers to a potentially disabling illness that affects many but is understood by few. Sufferers often do not realize the nature of their terrible malaise until they are so devastated that they can no longer help themselves, or they may recognize what they have been through only after they are on their way out of the shadows. The reason is simple. Depression is a sneak thief, slipping into a life gradually and robbing it of meaning, one loss at a time. The losses are imperceptible at first, but eventually weigh so heavily that the person’s life becomes empty. Once begun, the course of depression varies with the individual and with the form of the illness. Untreated, it can last weeks, months, or even years.

In the general population, as many as one in five individuals may eventually suffer a significant depressive illness, although most will not seek treatment. During any year, one in ten people experience the sluggishness of mind, body, and spirit we know as depression. The risk is about the same in prepubertal boys and girls, but the ratio alters in adulthood, with females twice as likely as males to become depressed. This two-to-one ratio exists regardless of racial, ethnic, or economic background and has been reported in several countries.

Although depression can occur in very young children, even in those under five years of age, it is more likely to occur for the first time during teenage years or in early adulthood. Depression can also occur for the first time in midlife or later.

Depression tends to run in families. Children of depressed parents have a twofold-to-threefold greater risk of developing depression than children of non depressive parents. Studies of families with histories of depression in many of their members support the theory that predisposition to depression can be inherited. Since the family tendency could be explained by similar environments rather than by genes, twins who have been adopted outside their biological families and reared apart have been studied with regard to risk for depression. Most of those studies show that if one identical twin (identical twins share the same genes) suffers from depression, the second twin will have a 70 percent chance of also becoming depressed, while the risk for siblings who are not identical twins is only about 25 percent. If heredity were the only factor, the shared rate of depression in identical twins would be 100 percent. Since this is not the case, genetics cannot be the only factor involved. At this point, no single gene has been identified as the culprit in causing depression, and it is more likely that several genes are involved.

According to the fertile ground theory, heredity and environment collude to cause depression. Environmental factors that may be important in causing depression include loss of a parent early in life, separation or divorce of parents, rearing patterns, abuse, low socioeconomic class, and recent life stresses.

SHOULD CHILDREN BE GIVEN PROZAC

// November 4th, 2010 // No Comments » // Antidepressants, Depression

It Can Stunt Growth, Damage Young Brains and Even Trigger Suicide. Yet Now This Most Controversial Antidepressant Is about to Be Prescribed to Youngsters of Just Eight . . .

prozac and children

JAMES was ten when he was first put on the antidepressant Prozac. His mother was an invalid, and after his father left home, the pressure of caring for his mother had become overwhelming.

Sometimes James would sit and stare into the middle-distance, not responding to anything; other times he’d lock himself in his room. He cried a lot.

Increasingly, he refused to go out because he was being bullied at school.

‘He started showing signs of depression,’ says Jude Sellen, a children and adolescent mental health consultant at the charity Young Minds, who was involved with his case.

‘His situation was very difficult and he badly needed psychological help.’

But there was an 18-month wait for therapy, so what he got instead was long-term treatment with an antidepressant.

Two years later he is still on Prozac – even though it causes him stomach problems, including diarrhoea and painful cramps, and makes him feel ‘funny’.

He also suffers from painful headaches.

He wants to stop taking the medication, but when he does, he becomes violent – a potential-side-effect of withdrawal from drugs such as Prozac – and his mother insists that he goes back on the pills.

James is now being seen by a psychologist and his medication is being reduced. But as Sellen points out, his case shows ‘how important it is to monitor patients on the drug carefully – and only use it short-term’.

The tragedy is that stories such as James’s could become increasingly common. Last week, in a controversial move, the European Medicines Agency announced that depressed children as young as eight could be given Prozac.

This is one of a class of drugs known as selective serotonin reuptake inhibitor, or SSRIs – and in America, children as young as three are already being prescribed them.

These drugs have already been linked with a raised risk of suicide and patients becoming dependent on them. But some experts are now concerned about giving these drugs to younger children because almost nothing is known about how these drugs might affect their growing brains.

‘This is ignorance in the broadest sense of the term,’ said Dr Glen R.

Elliott, a child psychiatrist at the University of California at San Francisco. ‘We don’t know if this is a good idea or not.’ The drugs might also stunt growth.

One trial, reported two years ago, found that children given Prozac between the ages of eight and 17 were, on average, 1cm shorter and 1.1kg lighter than those on a placebo.

In fact, we don’t really know exactly how SSRIs work to treat depression in adults or children – we believe they increase the amount of the ‘ feelgood’ chemical serotonin in the brain, but evidence for this theory is surprisingly thin on the ground.

The latest research suggests that they work by encouraging the growth of new brain cells. But whether this is good for a young brain that is already growing fast is also unknown.

What is known is that childhood depression is a growing problem in the UK.

About 1 per cent of children aged five to 11 and 3 per cent of adolescents aged 11 to 18 are thought to suffer from depression in any one year – with 80,000 five to 16-yearolds suffering from serious depression.

Some experts believe that the increase is partly to do with children’s high expectations – they expect life to be rosier than it is.

Others suggest that children are being exposed to increasingly stressful and emotional experiences, such as sex.

Whatever the cause, the difficulty for parents is knowing if their child is depressed or just feeling a bit down.

And giving medication to children who are not seriously depressed is a cause for concern.

The new guidelines from the European Medicines Agency recommend that the first line of treatment for moderate to severe depression should be psychological therapy.

Only after four to six sessions can fluoxetine – the name of the chemical in Prozac – be prescribed, and even then it should be combined with therapy.

HOWEVER, there is a drastic shortage of therapists as the case of James shows. He has been on Prozac for two years without having any counselling.

Provision of psychological services across Britain is notoriously patchy.

A recent report estimated that 10,000 more therapists were needed to provide effective treatment for depression in all age groups. As a result, the problem of medication without counselling is increasing.

David Cottrell, Professor of Child and Adolescent Psychiatry at the University of Leeds, says: ‘Far more prescriptions are written for children than there ought to be, and many GPs are not so good at monitoring the effects.’ But there is a more deep-rooted problem.

In 2003, the Medicines and Health Products Regulatory Authority advised that most SSRIs were not suitable for children, and that only fluoxetine should be given to them.

However, research by the Mail has found that doctors are still prescribing the other SSRIs.

In other words, while we worry about children being given Prozac, many of them might be receiving other antidepressants that the health authorities have said are not suitable for children.

In a written response to a Parliamentary question by Liberal Democrat MP Paul Burstow, the Department of Health revealed that four SSRIs which the drug regulator has said should not be used are still being widely prescribed.

One of these is Venlafaxine (Effexor), which, not only is unlikely to produce any ‘clinically important improvement’ but, astonishingly, has a rate of ‘suicide-related events’ 14 times greater than a placebo, according to a major review published in The Lancet in 2004.

THIS study looked at all the evidence for the safety and effectiveness of the five SSRIs most commonly used to treat children. And its conclusion about one of them, Citalopram (Cipramil, Celexa), was equally worrying: ‘It is unlikely to produce a clinically important reduction in depressive symptoms’ and doubles the risk of suicide.

One of the authors of this study was Professor Cottrell, who at the time explained that the review was unusually reliable because it combined published with unpublished trials. The conclusion of The Lancet review was that only Prozac was suitable, while the others – including Paroxetine (Seroxat) and Sertraline (Zoloft) should be avoided.

The intention of the trial was to provide information to guide doctors.

But, clearly, GPs did not heed the alarm bells – for as the Parliamentary figures reveal, only around 30 per cent of antidepressant prescriptions written for children under 18 in 2004 were for Prozac.

Another 35 per cent were for one or other of the four ‘banned’ drugs (the cost to the NHS for Prozac was [pounds sterling]407,107, and for the other SSRIs, [pounds sterling]1.6 million). The remainder of the prescriptions were for other forms of antidepressants.

‘Doctors do seem to be flouting the guidelines,’ says Professor Cottrell.

‘Doctors are allowed to prescribe drugs that don’t have a licence for that use, and while there will be a small number of cases where these drugs could be relevant – such as anxiety or obsessive compulsive behaviour a large percentage of these prescriptions should not have been written.’ Dr Jim Kennedy, prescribing spokesman for the Royal College of General Practitioners, questions whether doctors are prescribing medication without therapy.

‘But these figures do raise the question: are there any hotspots where more are being prescribed than should be?’ he says.

‘I think we should be looking in detail at how doctors are prescribing, and if we find a problem, we should re-educate GPs in those areas.’ The Department of Health, while noting the guidelines state that antidepressants should ‘be used rarely in the five to 11 age group’, says that ‘it is for clinicians to decide which of these drugs, if any, to prescribe to their patients.

‘It is important to note that some drugs which may be classified as antidepressants are used for other disorders such as nocturnal enuresis [bedwetting], anxiety, obsessive compulsive disorder and phobic states.’ Most clinicians agree that when faced with the pain of a child who is severely depressed, the benefits associated with antidepressants outweigh the risks.

‘Most experts recognise that psychological support is very important and should be tried first, but there are cases where a drug can help,’ says Professor Cottrell.

However, he adds: ‘Prozac has been the only drug recommended for children here since 2003.’ Meanwhile, if children like James are ever to have a real chance in life, much more attention must be paid to providing the kind of psychological support that everyone agrees is needed, and there should be a serious attempt to stop prescribing drugs that are known to be ineffective and dangerous.

The natural alternatives

PARENTS concerned about the use of SSRIs such as Prozac, the natural question is whether there is an effective alternative for children with mild depression.

There is some evidence that the herb St John’s Wort, available over the counter, can be effective in adults. One study suggested it might help children.

However, it can interfere with other drugs, including medications for asthma, epilepsy and migraine, and should not be taken without first consulting a doctor.

In a book published last year, the French neuroscientist Dr David Servan Schreiber claimed the quickest way to deal with depression was via the body.

In Healing Without Freud Or Prozac, he outlined a number of physical approaches for dealing with depression. Some are relatively familiar, such as nutrition and exercise, others more exotic such as ‘circadian therapy’ and ‘EMDR’ (but all, he claims, with evidence supporting their use).

They all capitalise on the mind and brain’s own healing mechanism for recovering from depression, anxiety and stress, he says.

Some experts believe that the key to tackling depression lies in diet.

Even though mainstream psychiatry is highly sceptical of the benefits of the nutritional approach to this, or to any other mental disorder, there are a few professionals who believe it can be valuable and a couple of centres that specialise in it.

According to Dr David Wheatley, a consultant private psychiatrist and previously director of the Maudsley Stress Clinic, it is ‘an infinitely preferable first line treatment option for those who feel mildly to moderately depressed’.

The nutritionist Patrick Holford suggests that parents should move their child onto a low-sugar diet and boost their intake of Omega 3s (found in oily fish and fish oil supplements).

Other options include a chromium supplement.

DEPRESSION DIET; Junk Food Link to High Risk of Mental Illness

// October 31st, 2010 // No Comments » // Depression, Obesity

SHUN fruit and veg in favour of fast food and you won’t just get fat – you’re more likely to end up feeling blue, too.

junk food

Research has found that gorging mainly on fried food, processed meats, sweets, chocolate and fatty dairy products increases the odds of you getting depression.

But eating a diet rich in fresh vegetables, fruit and fish can protect against the mental illness.

The study is the first to look at overall diet and depression.

Previous research in this field has tended to focus on individual nutrients. A research team at University College London quizzed nearly 4,000 Whitehall civil servants, with an average age of 55 about their eating habits and whether they suffered from depression. They found that those who ate the most whole foods were less likely to report symptoms of depression.

And the opposite was true of those who ate the most junk food. Experts believe the high levels of antioxidants in fruit and veg, and of the B vitamin folate in broccoli, spinach and cabbage, may help to lower the risk of depression.

And fish contains polyunsaturated fatty acids – a major part of neuron membranes in the brain.

But it is not clear why junk food increases the risk of depression.

Dr Andrew McCulloch of Mental Health Foundation said: “Studies like this are crucial because they hold the key to us better understanding mental illness.”

18st.. I have to be obese

EIGHTEEN stone is the average weight at which people recognise obesity is a crisis, research shows.

It is the tipping point at which many seek surgery to turn their lives around.

Weight op experts The Hospital Group explained the obese “suffer in careers, family life and health”.

Fewer than one in five weighing above 18st earns more than pounds 20,000, a study of 2,056 obese adults questioned by YouGov found.

Four in 10 of those hitting 18st suffer back pain and one in five have diabetes.

BUN TO AVOID Fatty burger

Depression: A New Sexually Transmitted Disease

// October 31st, 2010 // No Comments » // Depression

Nearly every discussion about sexual education focuses on preventing sexually transmitted diseases and pregnancy. However, recent research published in the American Journal of Preventive Medicine finds that, especially for girls, the discussion needs to include a third negative possibility: depression.

Most medical and mental health professionals would agree that there is a link between depression and sexual and drug using behavior in adolescents. However, it is commonly assumed that depressed teens use sex and drugs to “medicate” their depression. Thus, when faced with a depressed, sexually active teen, adults may overlook sexual or drug using behavior with the hope that the risky behavior will cease once the depression is gone.

Although the depression followed by sex and drugs link seems to make sense, a new study, which followed over 13,000 middle and high school students for two years in a row, found that depression did not predict risky sexual or drug using behavior.

Instead, the study found that depression often follows risky behavior. Lead author of the study, Dr. Denise Hallfors told me in an interview that her research team found evidence that heavy drug and alcohol use significantly increased the likelihood of depression among boys. For girls, the findings are stunning: Even low levels of alcohol, drug or sexual experimentation increased the probability of depression for girls.

Breaking down the results, Dr. Hallfors found that 25 percent of surveyed teens were complete abstainers, meaning they were virgins and used no substances, not even tobacco. Only 4 percent of these teens experienced depression.

Another group of teens could be considered dabblers in that they had experienced sexual intercourse and engaged in some kind of substance usage during the first 12 months of the study. For the boys, there was no increase in depression from this pattern of behavior (for boys, the significant risk was heavy drug use). However, for girls, the study revealed a more troubling pattern. Girls even experimenting with drugs were slightly more than two times as likely to be depressed (8-10 percent). Those experimenting with sex were three times more likely to be depressed than abstainers (12 percent versus 4 percent). For sexually promiscuous teen girls, the results are staggering: 44 percent of girls with multiple sexual partners during the study period experienced depression.

Did depression ever come first? Boys and girls were no more likely to begin or increase their sexual and drug use behavior when they were depressed than when they were not. In fact, depressed girls who were also abstinent were much less likely to engage in risky behaviors during the second year of the study. However, if they were already “dabbling” with substance use, depressed girls were more likely to go on to very risky sexual behaviors.

In other words, the sex and drug use are not only associated with depression but most often precede it. As a public policy matter, the drug use findings are not surprising and hardly controversial. For any teen, who advocates drug use of any kind?

On the other hand, for opponents of a strong abstinence message in schools, this study may be difficult to reconcile with their public policy activities. For instance, two groups opposed to abstinence education, Advocates for Youth and Sex Etc., are now sponsoring a contest for teens to promote condom usage. Teens can craft an e-postcard to send to their friends (and potential hook-up partners?) extolling the virtues of condom use. One such card has a picture of a heart and a condom with the caption: “Dream Team.” According to Dr. Hallfors’ research, for many teen girls, the caption should read: “Sad Nightmare.”

More research is needed to isolate the causes and cures for the link between experimentation and depression. However, there is no reason for policy makers to wait to encourage abstinence given these research findings. Citing the devastation and feelings of worthlessness that accompany depression, Dr. Hallfors warns, “Parents, educators and health practitioners now have even more reason to be concerned about teen risk behaviors and to take action about alcohol, drugs and sex.”

Instead of cheery postcards, teen girls need to know that their sexual behaviors may put them at risk for more than STDs and teen pregnancy. “Once a girl crosses that boundary, she puts herself at risk for a spiral of negative effects,” says Dr. Hallfors.

It seems to me that the evidence is consistent that teen sex is not a good idea, especially for girls. Why can’t everyone get behind that message?

Teens are nearly united in this sentiment. According to a poll conducted by the National Campaign to Prevent Teen Pregnancy, nine out of 10 adults and teens want society to send a clear message that abstinence is best for teens.

Whatever we think about the morality of sexual behavior, can’t we agree that teens should be given a clear and consistent message that it best to wait to engage in sex until they are ready to accept the financial, relationship and emotional consequences of making that choice? For nearly all teens, this would be adulthood.

My suggestion for a postcard? A picture of a gold nugget and a heart with the caption: “I’m worth the wait.”

Warren Throckmorton is associate professor of psychology and fellow for psychology and public policy in the Center for Vision and Values at Grove City College in Pennsylvania. He is past-president of the American Mental Health Counselors Association.