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.
What is the general approach to treating depression?
In general, the severe depressive illnesses, particularly those that are
recurrent, will require antidepressant medications (or ECT in severe cases) along with psychotherapy for the best outcome. If a person suffers
one major depressive episode, he or she has a 50% chance of a second episode. If
the individual suffers two major depressive episodes, the chance of a third
episode is 75%-80%. If the person suffers three episodes, the likelihood of a
fourth episode is 90%-95%. Therefore, after a first depressive episode, it
might make sense for the patient to gradually come off medication. However,
after a second and certainly after a third episode, most clinicians will have a
patient remain on a maintenance dosage of the medication for an extended period
of years, if not permanently.
Patience is required because the treatment of depression
takes time. Sometimes, the doctor will need to try a variety of antidepressants before finding the medication or combination of medications that is most effective for
the patient. Sometimes, the dosage must be increased to be effective.
In choosing an antidepressant, the doctor will take into account the patient's age, his/her other medical conditions, and medication side effects. Doctors often use one of the SSRIs initially because of their lower severity of side effects compared to the other classes of antidepressants. Side effects of SSRI medications can be further minimized by starting them at low doses and gradually increasing the doses to achieve full therapeutic effects. For those patients who do not respond after taking a SSRI at full doses for six to eight weeks, doctors generally switch to a different SSRI or another class of antidepressants. For patients whose depression failed to respond to full doses of one or two SSRIs or whom could not tolerate those medications, doctors will then try medications from another class of antidepressants. Some doctors believe that antidepressants with dual action (action on both serotonin and norepinephrine), such as duloxetine (Cymbalta), (Cymbalta), mirtazapine (Remeron), venlafaxine (Effexor), and desvenlafaxine (Pristiq), may be effective in treating patients with severe depression that
is treatment resistant. Other options include bupropion (Wellbutrin, Wellbutrin SR, Wellbutrin XL, Zyban), which has action on dopamine (another neurotransmitter). Sometimes doctors may use a combination of antidepressants from different classes. Also, new types of antidepressants are constantly being developed, and one of these may be the best for a particular patient.
If the depressed person is taking more than one medication for depression or medications for any other medical problem, each of the patient's doctors should be made aware of the other prescriptions. Many of these medications are cleared from the body (metabolized) in the liver. This means that the multiple treatments can interact competitively with the liver's biochemical clearing systems. Therefore, the actual blood levels of the medications may be higher or lower than would be expected from the dosage. This information is especially important if the patient is taking anticoagulants (blood thinners), anticonvulsants (seizure medications), or heart medications, such as digitalis (Crystodigin). Although multiple medications do not necessarily pose a problem, all of the patient's doctors
may need to be in close contact to adjust dosages accordingly.
Patients often are tempted to stop their medication too soon, especially when they begin feeling better. It is important to keep taking medication
therapy until the doctor says to stop, even if the patient feels better beforehand. Doctors often will continue the antidepressant medications for at least six to
12 months because the risk of depression quickly returning when treatment is stopped decreases after that period of time in those people experiencing their first depressive episode. Some medications must be stopped gradually to give the body time to adjust (see discontinuation of antidepressants below). For individuals with bipolar disorder or chronic major depression, medication may have to become a part of everyday life for
an extended period of years in order to avoid disabling symptoms.
Antidepressant medications are not habit-forming, so there need not be concern about that. However, as is the case with any type of medication prescribed for more than a few days, antidepressants must be carefully monitored to ensure that the patient is getting the correct dosage. The doctor will want to check the dosage and its effectiveness regularly.
If the patient is taking MAOIs, certain aged, fermented, or pickled foods must be avoided, like many wines, processed meats, and cheeses. The patient should obtain a complete list of prohibited foods from the doctor and keep it available at all times. The other types of antidepressants require no food restrictions. Remember that some over-the-counter cold and cough medicines can also cause problems when taken with MAOIs.
People should never mix medications of any kind (prescribed, over the counter, or borrowed) without consulting their doctor. The dentist or any other medical specialist who prescribes a drug should be informed that the patient is taking antidepressants. Some drugs that are harmless when taken alone can cause severe and dangerous side effects when taken with other drugs. This may also be the case for individuals taking supplements or herbal remedies. Some drugs, such as alcohol (including wine, beer, and hard liquor), tranquilizers, narcotics or marijuana, reduce the effectiveness of antidepressants and should be avoided. These and other drugs can also be dangerous when the person's body is either intoxicated with or withdrawing from their effects due to increasing the risk of seizure in combination with antidepressants medications.
Antianxiety drugs such as diazepam (Valium), alprazolam (Xanax), and
lorazepam (Ativan) are not antidepressants,
but they are occasionally prescribed alone or with antidepressants for a brief
period of anxiety. However, they should not be taken alone for depressive
disorder. Furthermore, the antianxiety drugs should be phased out as soon as the
antidepressant and antianxiety effects of the antidepressant medications begin
to work, which is usually in four to six weeks.
Finally, the doctor should be consulted concerning any questions about a medication or problem that the patient believes is medication-related.
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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