Dr. Roxanne Dryden-Edwards is an adult, child, and adolescent psychiatrist. She is a former Chair of the Committee on Developmental Disabilities for the American Psychiatric Association, Assistant Professor of Psychiatry at Johns Hopkins Hospital in Baltimore, Maryland, and Medical Director of the National Center for Children and Families in Bethesda, Maryland.
Dr. Lee was born in Shanghai, China, and received his college and medical training in the United States. He is fluent in English and three Chinese dialects. He graduated with chemistry departmental honors from Harvey Mudd College. He was appointed president of AOA society at UCLA School of Medicine. He underwent internal medicine residency and gastroenterology fellowship training at Cedars Sinai Medical Center.
Dr. Shiel received a Bachelor of Science degree with honors from the University of Notre Dame. There he was involved in research in radiation biology and received the Huisking Scholarship. After graduating from St. Louis University School of Medicine, he completed his Internal Medicine residency and Rheumatology fellowship at the University of California, Irvine. He is board-certified in Internal Medicine and Rheumatology.
Regardless of the medication that may be used to treat depression, practitioners have become more aware that different ethnic groups may have different responses and have different risks for side effects than others.
Antidepressant medications
Selective serotonin reuptake inhibitors (SSRIs) are medications that increase
the amount of the neurochemical serotonin in the brain. (Remember that brain
serotonin levels are often low in depression.) As their name implies, the SSRIs work
by selectively inhibiting (blocking) serotonin reuptake in the brain. This block
occurs at the synapse, the place where brain cells (neurons) are connected to
each other. Serotonin is one of the chemicals in the brain that carries messages
across these connections (synapses) from one neuron to another.
The SSRIs work by keeping serotonin present in high concentrations in the
synapses. These drugs do this by preventing the reuptake of serotonin back into
the sending nerve cell. The reuptake of serotonin is responsible for turning off
the production of new serotonin. Therefore, the serotonin message keeps on
coming through. It is thought that this, in turn, helps arouse (activate) cells that have been deactivated by depression, thereby relieving the depressed person's symptoms.
SSRIs have fewer side effects than the tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs), which are discussed below. SSRIs do not interact with the chemical tyramine in foods, as do the MAOIs, and therefore do not require the dietary restrictions of the MAOIs. Also, SSRIs do not cause orthostatic hypotension (sudden drop in blood pressure when sitting up or standing) and heart-rhythm disturbances, like the TCAs do. Therefore, SSRIs are often the first-line treatment for depression. Examples of SSRIs include fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), citalopram (Celexa), fluvoxamine (Luvox), and escitalopram
(Lexapro).
SSRIs are generally well tolerated, and side effects are usually mild. The
most common side effects are nausea, diarrhea, agitation, insomnia, and
headache. However, these side effects generally go away within the first month
of SSRI use. Some patients experience sexual side effects, such as decreased
sexual desire (decreased libido), delayed orgasm, or an inability to have an
orgasm. Some patients experience tremors with SSRIs. The so-called serotonergic
(meaning caused by serotonin) syndrome is a serious neurologic condition
associated with the use of SSRIs. It is characterized by high fevers, seizures,
and heart-rhythm disturbances. This condition is very rare and has been reported
only in very ill psychiatric patients taking multiple psychiatric medications.
All patients are unique biochemically. Therefore, the occurrence of side
effects or the lack of a satisfactory result with one SSRI does not mean that
another medication in this group will not be beneficial. However, if someone in
the patient's family has had a positive response to a particular drug, that
drug may be the preferable one to try first.
Dual-action antidepressants: The biochemical reality is that all classes of
medications that treat depression (MAOIs, SSRIs, TCAs, and atypical
antidepressants) have some effect on both norepinephrine and serotonin, as well
as on other neurotransmitters. However, the various medications affect the
different neurotransmitters in varying degrees.
Some of the newer antidepressant drugs, however, appear to have particularly robust effects on both the norepinephrine and serotonin systems. These
medications seem to be very promising, especially for the more severe and chronic cases of depression. (Psychiatrists, rather than family practitioners, see such cases most frequently.) Venlafaxine
(Effexor), duloxetine (Cymbalta) and desvenlafaxine (Pristiq) are three of these dual-action compounds. Effexor is a serotonin reuptake inhibitor that, at lower doses, shares many of the safety and low side-effect characteristics of the SSRIs. At higher doses, this drug appears to block the reuptake of norepinephrine. Thus, venlafaxine can be considered an SNRI, a serotonin and norepinephrine reuptake inhibitor. Cymbalta and Pristiq tend to act as equally powerful serotonin reuptake inhibitors and norepinephrine reuptake inhibitors regardless of the dose. They are, therefore, also considered SNRIs.
Mirtazapine (Remeron), another antidepressant, is a tetracyclic
compound (four-ring chemical structure). It works at somewhat different
biochemical sites and in different ways than the other drugs. It affects
serotonin, but at a postsynaptic site (after the connection between nerve
cells). It also increases histamine levels, which can cause drowsiness. For this
reason, mirtazapine is given at bedtime and is often prescribed for people who
have trouble falling asleep. Like the SNRIs, it also works by increasing
levels in the norepinephrine system. Other than causing sedation, this
medication has side effects that are similar to those of the SSRIs but to a
lesser degree in many cases.
Atypical antidepressants are so named because they work in a variety of ways.
Thus, atypical antidepressants are not TCAs, SSRIs, or SNRIs, but they are effective in treating depression for many people nonetheless. More specifically, they increase the level of certain neurochemicals in the brain synapses (where nerves communicate with each other). Examples of atypical antidepressants include nefazodone (Serzone), trazodone (Desyrel), and bupropion (Wellbutrin). The United States Food and Drug Administration (FDA) has also approved bupropion for use in weaning from addiction to cigarettes. This drug is also being studied for treating attention deficit disorder (ADD) or attention deficit hyperactivity disorder (ADHD). These problems affect many children and adults and restrict their ability to manage their impulses and activity level, focus, or concentrate on one thing at a time.
Lithium (Eskalith, Lithobid), valproate (Depakene, Depakote), carbamazepine (Epitol, Tegretol), and lamotrigine (Lamictal) are mood stabilizers and anticonvulsants. They have been used to treat bipolar depression. Certain antipsychotic medications, such as ziprasidone (Geodon), risperidone (Risperdal), quetiapine
(Seroquel), aripiprazole (Abilify), asenapine (Saphris),
and paliperidone (Invega), may treat psychotic depression. They have also been found to be effective mood stabilizers and are therefore sometimes been used to treat bipolar depression, usually in combination with other antidepressants.
Monoamine oxidase inhibitors (MAOIs) are the earliest developed
antidepressants. Examples of MAOIs include phenelzine (Nardil) and
tranylcypromine (Parnate). MAOIs elevate the levels of neurochemicals in the
brain synapses by inhibiting monoamine oxidase. Monoamine oxidase is the main
enzyme that breaks down neurochemicals, such as norepinephrine. When monoamine
oxidase is inhibited, the norepinephrine is not broken down and, therefore, the
amount of norepinephrine in the brain is increased.
MAOIs also impair the ability to break down tyramine, a substance found in
aged cheese, wines, most nuts, chocolate, and some other foods. Tyramine, like
norepinephrine, can elevate blood pressure. Therefore, the consumption of
tyramine-containing foods by a patient taking an MAOI drug can cause elevated
blood levels of tyramine and dangerously high blood pressure. In addition, MAOIs
can interact with over-the-counter cold and cough medications to cause
dangerously high blood pressure. The reason for this is that these cold and
cough medications often contain drugs that likewise can increase blood pressure.
Because of these potentially serious drug and food interactions, MAOIs are
usually only prescribed after other treatment options have failed.
Tricyclic antidepressants (TCAs) were developed in the 1950s and '60s to
treat depression. They are called tricyclic antidepressants because their
chemical structures consist of three chemical rings. TCAs work mainly by
increasing the level of norepinephrine in the brain synapses, although they also
may affect serotonin levels. Doctors often use TCAs to treat moderate to severe
depression. Examples of tricyclic antidepressants are amitriptyline (Elavil),
protriptyline (Vivactil), desipramine (Norpramin), nortriptyline (Aventyl,
Pamelor), imipramine (Tofranil), trimipramine (Surmontil), and perphenazine (Triavil).
Tetracyclic antidepressants are similar in action to tricyclics, but their
structure has four chemical rings. Examples of tetracyclics include maprotiline
(Ludiomil) and mirtazapine (Remeron), a drug that was discussed above under dual-action antidepressants.
TCAs are safe and generally well tolerated when properly prescribed and administered. However, if taken in overdose, TCAs can cause life-threatening heart-rhythm disturbances. Some TCAs can also have anticholinergic side effects, which are due to the blocking of the activity of the nerves that are responsible for control of the heart rate, gut motion, visual focus, and saliva production. Thus, some TCAs can produce dry mouth, blurred vision, constipation, and dizziness upon standing. The dizziness results from low blood pressure that occurs upon standing (orthostatic hypotension). Anticholinergic side effects can also aggravate narrow-angle glaucoma, urinary obstruction due to benign prostate hypertrophy, and cause delirium in the elderly. TCAs should also be avoided in patients with seizure disorders or a history of strokes.
Stimulants such as methylphenidate (Ritalin) or dextroamphetamine (Dexedrine) are used primarily for the treatment of depression that is resistant to other medications. The stimulants are most commonly used along with other antidepressants or other medications, such as mood stabilizers, antipsychotics, or even thyroid hormone. They are sometimes used alone but rarely. The reason they are usually used sparingly and with other medications for depression is that unlike the other medications, they may induce an emotional rush and a high in both depressed and nondepressed people. Therefore, the stimulants are potentially addictive drugs.
Electroconvulsive therapy (ECT)
In the ECT procedure, an electric current is passed through the brain to produce controlled convulsions (seizures). ECT is useful for certain patients, particularly for those who cannot take or have not responded to a number of antidepressants, have severe depression, and/or are at a high risk for suicide. ECT often is effective in cases where trials of a number of antidepressant medications do not provide sufficient relief of symptoms. This procedure probably works, as previously mentioned, by a massive neurochemical release in the brain due to the controlled seizure.
Often highly effective, ECT relieves depression within one to two weeks after beginning treatments in many people. After ECT, some patients will continue to have maintenance ECT, while others will return to antidepressant medications or have a combination of both treatments.
Over the years, the technique of ECT has been much improved. The treatment is given in the hospital under anesthesia so that people receiving ECT do not
hurt themselves or feel pain. Most patients undergo six to 10 treatments. An electrical current is passed through the brain to cause a controlled seizure, which typically lasts for 20 to 90 seconds. The patient is awake in five to 10 minutes. The most common side effect is short-term memory loss, which resolves quickly. ECT can usually be safely done as an outpatient procedure.
Psychotherapies
Many forms of psychotherapy are effectively used to help depressed
individuals, including some short-term (10 to 20 weeks) therapies. Talking
therapies (psychotherapies) help patients gain insight into their problems and resolve them
through verbal give-and-take with the therapist. Behavioral therapists help
patients learn how to obtain more satisfaction and rewards through their own
actions. These therapists also help patients to unlearn the behavioral patterns
that may contribute to their depression.
Interpersonal and cognitive/behavioral therapies are two of the short-term
psychotherapies that research has shown to be helpful for some forms of
depression. Interpersonal therapists focus on the patient's disturbed personal
relationships that both cause and exacerbate the depression.
Cognitive/behavioral therapists help patients change the negative styles of
thinking and behaving that are often associated with depression.
Psychodynamic therapies are sometimes used to treat depression. They focus on
resolving the patient's internal psychological conflicts that are typically
thought to be rooted in childhood. Long-term psychodynamic therapies are
particularly important if there seems to be a lifelong history and pattern of
inadequate ways of coping (maladaptive coping mechanisms) in negative or
self-injurious behavior.
Anxiety is a feeling of apprehension and fear characterized by physical symptoms. Anxiety disorders are serious medical illnesses that affect approximately 19 million American adults.
Panic attacks are sudden feelings of terror that strike without warning. These episodes can occur at any time, even during sleep. A person experiencing a panic attack may believe that he or she is having a heart attack or that death is imminent. The fear and terror that a person experiences during a panic attack are not in proportion to the true situation and may be unrelated to what is happening around them. Most people with panic attacks experience several of the following symptoms: racing heartbeat, faintness, dizzyness, numbness or tingling in the hands and fingers, chills, chest pains, difficulty breathing, and a feeling of loss or control. There are several treatments for panic attacks.
HIV (human immunodeficiency virus) is the cause of AIDS (acquired immunodeficiency syndrome). HIV is a type of virus called a retrovirus, which infects humans when it comes in contact with a break in the skin or tissues such as those that line the vagina, anal area, mouth, or eyes.
Lyme disease is a bacterial illness, which is spread by ticks when they bite the skin. Initially the disease affects the skin causing a reddish rash associated with flu-like symptoms. It takes weeks to months after the initial redness of the skin for its effects to spread throughout the body. Lyme disease can be treated with antibiotics. Lyme disease can be prevented by using tick avoidance techniques.
Fibromyalgia, formerly
known as fibrositis, causes chronic pain, stiffness, and
tenderness of muscles, tendons, and joints without detectable inflammation. Fibromyalgia patients have an unusually low pain threshold. Symptoms of fibromyalgia include fatigue, abnormal sleep, mental/emotional disturbances, abdominal pain, migraine and tension headaches, and irritable bladder. Treatment of fibromyalgia involves patient education, medication, exercise, and stress reduction.
Stress occurs when forces from the outside world impinge on the individual. Stress is a normal part of life. However, over-stress, can be harmful. There is now speculation, as well as some evidence, that points to the abnormal stress responses as being involved in causing various diseases or conditions.
Sarcoidosis, a disease resulting from chronic inflammation, causes small lumps (granulomas) to develop in a great range of body tissues and can appear in almost any body organ. However, sarcoidosis most often starts in the lungs or lymph nodes.
Anorexia is an eating disorder characterized by markedly reduced appetite or total aversion to food. Anorexia is a serious psychological disorder and is a condition that goes well beyond out-of-control dieting. With anorexia, the drive to become thinner is actually secondary to concerns about control and/or fears relating to one's body. There are psychological and behavioral symptoms as well as physical symptoms of anorexia including: depression, social withdrawal, fatigue, food obsession, heart and gastrointestinal complications, kidney function, flaky skin, brittle nails, and tooth loss (this list is not exhaustive).
Alcoholism is a disease that includes alcohol craving and continued drinking despite repeated alcohol-related problems, such as losing a job or getting into trouble with the law.
Post-traumatic stress disorder (PTSD), a psychiatric condition, can develop after any catastrophic life event. Symptoms include nightmares, flashbacks, sweating, rapid heart rate, detachment, amnesia, sleep problems, irritability, and exaggerated startle response. Treatment may involve psychotherapy, group support, and medication.
Schizophrenia is a disabling brain disorder that may cause hallucinations and delusions and affect a person's ability to communicate and pay attention. Symptoms of psychosis appear in men in their late teens and early 20s and in women in their mid-20s to early 30s. With treatment involving the use of antipsychotic medications and psychosocial treatment, schizophrenia patients can lead rewarding and meaningful lives.
Impotence, also known as erectile dysfunction, is a common
problem among men characterized by the consistent inability to sustain an
erection sufficient for sexual intercourse or the inability to achieve
ejaculation, or both. Impotence can have emotional causes but most often it is
due to a physical problem.
Suicide is the process of intentionally ending one's own life. Approximately 1 million people worldwide commit suicide each year, and 10 million to 20 million attempt suicide annually.
Bipolar disorder (or manic depression) is a mental illness characterized by depression, mania, and severe mood swings. Treatment may incorporate mood stabilizer medications, antidepressants, and psychotherapy.
Borderline personality disorder is a serious mental illness characterized by pervasive instability in moods, interpersonal relationships, self-image, and behavior. This instability often disrupts family and work life, long-term planning, and the individual's sense of self-identity. Originally thought to be at the "borderline" of psychosis, people with borderline personality disorder (BPD) suffer from a disorder of emotion regulation.
Dissociative identity disorder (formerly known as multiple personality disorder or split personality disorder) is a mental illness in which a person has at least two distinct personalities. Symptoms and signs include lapses in memory, feeling unreal, blackouts in time, hearing voices in their head that are not their own, not recognizing themselves in the mirror, and finding items in one's possession but not recalling how they were acquired. Treatment usually involves psychotherapy, medications, and sometimes hypnosis.
Cushing's syndrome, sometimes referred to as hypercortisolism, is a hormonal disorder caused by prolonged exposure to high levels of the hormone cortisol. Symptoms may include obesity, thinning arms and legs, a rounded face, and increased fat around the neck. Some causes of Cushing's syndrome is from taking glucocorticoid hormones such as prednisone for inflammatory diseases. Treatment for Cushing's syndrome depends on the cause.
Huntington's disease is the result of degeneration of neurons in areas of the brain. Huntington's disease is an inherited disorder. Early symptoms include mood swings, apathy, depression, and anger uncharacteristic of the individual. Judgement, memory, and other cognitive functions may become impaired. Presymptomatic testing is available for individuals who have a family history of Huntington's disease. Treatment includes medication and therapy for symptoms.
Chronic fatigue syndrome is a debilitating and complex disorder characterized by profound fatigue that lasts 6 months or longer, is not improved by bed rest, and may be worsened by physical or mental activity.
Drug addiction is a chronic disease that causes drug-seeking behavior and drug use despite negative consequences to the user and those around him. Though the initial decision to use drugs is voluntary, changes in the brain caused by repeated drug abuse can affect a person's self-control and ability to make the right decisions and increase the urge to take drugs. Drug abuse and addiction are preventable.
Obsessive compulsive disorder (OCD) is an anxiety disorder that causes a person to suffer repeated obsessions and compulsions. Symptoms include irresistible impulses despite a person's realization that the thoughts are irrational, excessive hand washing, skin picking, lock checking, or repeatedly rearranging items. People with OCD are more likely to develop trichotillomania, muscle or vocal tics, or an eating disorder. Treatment for OCD includes psychotherapy, behavioral therapy, and medication.
Antisocial personality disorder (ASPD) has many symptoms, signs, and causes. Therapy is one treatment option for antisocial personality disorder. It is closely related to other personality disorders (PD), such as borderline personality disorder and narcissistic personality disorder.
Grief is the feeling one experiences after a loss (of a friendship, death of loved one, job). Complicated grief refers to grief that lasts for more than a year. Mourning describes the customs and rituals that help a bereaved individual make sense of their loss.
ADHD afflicts approximately 3 percent to 5 percent of school-age children and an estimated 60 percent of those maintain the disorder into adulthood. Symptoms of adult ADHD include chronic lateness, anxiety, low self esteem, employment problems, difficulty controlling anger, impulsiveness, poor organization skills, procrastination, chronic boredom among others.
Attention deficit hyperactivity disorder (ADHD) is a behavioral disorder characterized by the symptoms hyperactivity, impulsivity, and inattention. Treatment for ADHD may involve behavioral therapy and psychostimulant or antidepressant medication.
Insomnia is the perception or complaint of inadequate or poor-quality sleep because of difficulty falling asleep; waking up frequently during the night with difficulty returning to sleep; waking up too early in the morning; or unrefreshing sleep. Secondary insomnia is the most common type of insomnia. Treatment for insomnia include lifestyle changes, cognitive behavioral therapy, and medication.
Psychotic disorders are a group of serious illnesses that affect the mind. Different types of psychotic disorders include schizophrenia, schizoaffective disorder, schizophreniform disorder, brief psychotic disorder, shared psychotic disorder, delusional disorder, substance-induced psychotic disorder, paraphrenia, and psychotic disorders due to medical conditions.
Seasonal affective disorder is a type of depression that tends to occur as the days grow shorter in the fall and winter. Symptoms of seasonal affective disorder include tiredness, fatigue, depression, irritability, body aches, poor sleep and overeating.
Fatigue can be described in various ways. Sometimes fatigue is described as feeling a lack of energy and motivation (both mental and physical). The causes of fatigue are generally related to a variety of conditions or diseases for example, anemia, mono, medications, sleep problems, cancer, anxiety, heart disease, drug abuse, and more. Treatment of fatigue is generally directed toward the condition or disease that is causing the fatigue.
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