Syd Baumel, our guest and author of Dealing With Depression Naturally, joined us to discuss natural remedies for treating depression, stress, and PMS, from vitamins and herbs (such as St. John's Wort, Gingko, and more) to maintaining a healthy diet, and exercise.

To find out more about natural treatments for depression, read the transcript below.

David Roberts is the HealthyPlace.com moderator.

The people in blue are audience members.

David: Good Evening. I'm David Roberts. I'm the moderator for tonight's conference. I want to welcome everyone to HealthyPlace.com.

(note: see What is Depression?)

Our topic tonight is "Dealing With Depression Naturally." Our guest is Syd Baumel, author of a book by the same name. Mr. Baumel wrote Dealing With Depression Naturally after researching and using alternative therapies to treat his own depression. It covers many alternatives to treating depression, most of which employ readily obtainable vitamins and herbs, or feature cognitive therapy or exercise programs.

Mr. Baumel maintains that there are natural antidepressant therapies which can restore emotional health, from vitamins and dietary adjustments to visualization exercises and sleep therapy. Good evening, Syd, and welcome to HealthyPlace.com. To start with maybe you can tell us a bit about yourself and your history of depression?

Syd Baumel: Well, the depression bug first bit me in my teens about 30 years ago. It hit me like a ton of bricks. It took until my mid-twenties for me to find some lasting solutions - first drugs, then natural treatments, which I continue to use as needed to this day.

David: What lead you to start exploring natural remedies for depression?

Syd Baumel: I'm just one of those people who is drawn to natural approaches to solving problems. Ironically, the effectiveness of drugs helped me try harder to find natural chemical help.

David: What do you mean by that?

Syd Baumel: In my case, an amino acid called phenylalanine, which is a precursor to a few mood regulating neurochemicals, made the most dramatic and lasting difference.

David: If the pharmaceutical medications were effective, why would you turn to natural treatments?

Syd Baumel: They had very obvious and varyingly unpleasant side effects. Also, there was and always is the concern that a "xenobiotic" (foreign to the body) chemical could do harm if used chronically.

David: There is one thing I'd like you to clarify for everyone here. When you talk about "natural treatments," what exactly are you referring to?

Syd Baumel: It's a very wide spectrum that excludes artificial/human-made drugs and includes such things as diet, exercise, meditation, psychotherapy, herbs, and preventative/therapeutic lifestyle changes, such as identifying and avoiding depressing toxic chemicals.

I better clarify that I'm not against "unnatural; antidepressants" in addition to the natural approaches.

David: Yes, in fact, I believe you mention that some of the natural treatments can be used in addition to taking pharmaceutical antidepressants.

Syd Baumel: And only a few of them - notably the natural chemical ones, including herbs - need to be taken with much caution when combining with drugs.

David: Before we get into the herbs and other substances, I'd like you to talk about how diet and exercise can impact a person's level of depression.

Syd Baumel: Exercise is the easiest one to answer because there has been such a huge amount of research. Basically, it says that being physically active and being depressed are very largely mutually incompatible.

David: And so how much exercise is recommended?

Syd Baumel: Early research suggested that a typical aerobic conditioning regime - around 20 or 30 minutes of fairly intense aerobic exercise three times a week - would usually be very helpful. In the last decade or so, just as more moderate physical activity has been linked to better health in general, evidence that it too can be anti-depressive has begun to appear.

There also has been a parallel thread of research suggesting that non-aerobic exercise - especially of the weight-training type, but also perhaps things like yoga and tai chi - can work too.

David: And what about diet and depression?

Syd Baumel: There the research is mostly indirect. For example, study after study has found that depressed people tend to be deficient - mildly or severely - in nutrients known to be key to good mental health. Some research has gone further, suggesting that some of these vitamins and minerals can be therapeutic for depression.

David: Can you give us a short list of nutrients that would be helpful to reducing depression?

Syd Baumel: The important thing is to cover all bases by taking a well-rounded, moderate/high dosage multivitamin and mineral supplement. Then one can focus on higher doses of nutrients with a high profile as antidepressants, at least for some people. The B vitamin folic acid is probably at the top of the list right now, based on current evidence. Other contenders include vitamins B1, B6, and B12, vitamin C, and the mineral selenium.

It's hard to generalize, because a combination of testing people for specific deficiencies and using nutrients as if they were drugs - in high or mega doses - is the "art" and science that's involved here.

David: Mr. Baumel is coming to us from Winnipeg, Manitoba, Canada. He dealt with depression for a long time and actually started researching, then using, natural remedies to treat his own depression.

Gor more information visit Mr. Baumel's website.

We have a lot of audience questions. I want to get to a few, then get into a discussion of some of the herbs that might be helpful in treating depression. Here's the first question:

donotknow: What foods should we avoid?

Syd Baumel: There are two general answers to that question. The first one has to do with what kinds of food everyone would be best off avoiding, the second has to do with individual sensitivities, intolerances, or allergies that can cause some people - some research and much anecdotal evidence suggest - to be more susceptible to depression.

Regarding the first consideration: In general, as far as the evidence has been able to show us so far, the same kind of diets that help prevent cancer, heart disease, etc. also are good for the brain and the mind and one's mood. This means avoiding things like a diet over-endowed with processed grains, sugar, and an evolutionarily unnatural balance of fatty acids.

On the latter point, what I mean is: avoid too much saturated and hydrogenated fat, and also attempt to concentrate on fats and oils that are unrefined and that have a higher balance of omega-3 fatty acids to omega-6 fatty acids than modern diets typically have.

Omega 3s abound in the fat of wild animals - especially cold-water fish - and in vegetable crops from temperate or northern climates, especially dark leafy greens, beans, and (above all) flax and hemp.

David: Here's an interesting comment from one audience member, which has to do more with the stigma of having depression or mental illness:

WildWindTeesha: There is a stigma attached to taking prescribed anti-depressants. In my case, I have found it almost shameful to admit that I am taking anti-depressants, but if I were to tell my family and friends I am on NATURAL remedies, well, that means that their relative or friend (me) is not so MAD after all.

Syd Baumel: That's interesting. In some circles, I think being on Prozac et al is almost considered normal. It is nice, though, to see that using natural treatments has become kind of "cool," where years ago it was rather... dorky .

David: Before we get into the herbs, do you see herbal remedies as being as effective as pharmaceutical antidepressants? And secondly, I'm wondering if natural treatments work as well for clinical depression (brain chemical depression) as non-clinical depression?

Syd Baumel: The evidence - research and anecdote both - suggest that natural antidepressants (NAs) can be as effective or more effective than drugs for some people and that some NAs are generally about as effective as any drug for mild, moderate, or even severe major depression. I'm thinking of St John's Wort (SJW), for example.

David: So what herbs have you found to be the most effective in treating depression and in what dosages?

Syd Baumel: St Johns Wort (SJW) is, so far, the star here. The most commonly used and recommended dosage is 300 mg of a standardized extract (0.3% hypericin) three times a day. But if you actually look at the studies and what people say, you find that people can apparently respond to as little as 300 mg and as much as 2700 mg a day.

I believe, if memory serves, it was 2700 mg that was used in a recent study which found SJW about equal to imipramine (the gold standard tricyclic) for severe major depression, but with far fewer side effects. The current NIMH-sponsored trial is supposedly allowing research psychiatrists to administer up to 2700 mg also.

Other herbs that show varying degrees of effectiveness or promise include Ginkgo biloba (at least as an adjunct to drugs) and several herbs for "women's problems" (traditionally) that appear to work for PMS and/or perimenopausal depression, e.g. Vitex agnus-castus and black cohosh.

David: Here's an audience question on St. John's Wort:

MsPisces:I've read that St John's Wort only helps mild depression... Is this true? Will it help with clinical depression?

Syd Baumel: The "rap" on SJW that it only helps for mild depression is based on the fact that most clinical trials have used only patients with mild to moderate depression (major or dysthymic are undefined). But at least one or two have successfully used it for severe major depressive disorder. By "successfully" I mean that the response rate was significantly better than a placebo and/or not significantly different from an adequate dosage of an effective antidepressant drug.

It's really hard to say just how effective SJW might truly be for severe depression. The large NIMH study should help answer that question. For now, it's very much a trial and error, your mileage may vary thing. But then that's true of any antidepressant drug when it comes down to the individual.

donotknow:What about the side effects of St. Johns Wort?

Syd Baumel: The more SJW has been used, the more people have reported side effects. The studies, overall, suggest SJW has a net side effect rate that's little different than a placebo, but some studies suggest worse. And there's always the concern that - as probably happens with drugs in some studies - the researchers are biased against reporting the full extent of SJW's adverse effects.

All in all, I think St Johns Wort has a much lower side effect profile than the average drug (probably any drug) and that most people don't notice any side effects, but there is good reason to use SJW and other supplements knowledgeably and cautiously. Most books and websites that write about SJW et al. in any depth are very forthcoming about known side effects, drug interactions, precautions, etc.

Gattaca:Would you recommend combining St. John's Wort with gingko? I have read the increased blood flow is beneficial in itself from the gingko and also helps deliver the SJW more effectively. I have seen combined tablets at 300mg SJW with 60mg gingko, 3 times a day. What range of doses would you recommend for the gingko?

Syd Baumel: Not being a clinician, I hesitate to recommend, but the dosage you cite is right in the pocket as far as average therapeutic dosages for the two herbs are concerned. Also, because at least one placebo-controlled study has found that Ginkgo can augment antidepressant drugs it stands to reason that it might do the same for herbs like SJW which appear to work via identical or very similar mechanisms. In general, combos are both potentially riskier and potentially more likely to help.

David: Here are a few audience comments on what's been said, so far, tonight, then we'll continue with the questions:

ronnie@tnni.net: I have been bipolar all my life. I found out 13 years ago I was manic depressive and have been on medicines for 13 years. I also do fitness 4 times a week. It has helped me in so many ways. I'm not 100 percent but I can deal with a lot more in my life.

WildWindTeesha: Who feels like doing aerobics when they are depressed!?

finngirl: Cardiovascular exercise 3 times a week increases endorphins and natural chemicals.

bladedemon: I'm willing to try anything right now. Nothing works as far as a meds.

finngirl: Natural is closer to not having any depression - if you can take an over the counter herb you're not all that depressed. It is just what the people perceive of their own reality.

Syd Baumel: I love the comment about not feeling like doing aerobics when you're depressed. How true, but it's true of many things that go together with depression in either a vicious cycle or a healing cycle. That is: depression disturbs your sleep, makes you lazy, makes you withdraw from people and from activities, makes you less assertive, makes you get sloppy about eating well, makes you question your spiritual values and beliefs, and on and on and on. Yet, if you can - with a little help from your friends, a "professional," or your own bootstraps - go against the grain on these depressive tugs, there is so much evidence that you can reverse the tide.

Of course, the milder the depression, the easier it is to perform this reversal, but even in hospitalized depressives with severe depression, exercise on the side (for example) has been found to significantly improve their response to standard therapies.

David: Here's an audience member's comment which addresses just that point, Syd:

ddoubelD: I decided recently that I am going to do everything I can think of to take care of my physical, mental, and emotional health, and just that decision has made me feel better cause I am taking charge.

Syd Baumel: Talk about hitting a nail right on the head. Feeling out of control - helpless, hopeless - is one of the defining hallmarks of depression. But again, if you can do anything that makes you feel even just a little bit in control again, you will almost certainly feel that much better.

David: Here's the next audience question:

finngirl: How do the natural approaches affect levels of serotonin?

Syd Baumel: Many if not most natural approaches have been shown to have a positive effect on brain levels of serotonin. This is true not only of chemical approaches like tryptiophan and 5-hydroxytryptophan (5-HTP), which the brain make serotonin FROM, but also of other chemical approaches that facilitate either serotonin's synthesis or that, like most antidepressant drugs, increase its potency in the brain (e.g. SJW, Ginkgo). The interesting thing is that several lifestyle or non-chemical antidepressants (e.g. exercise, acupuncture) have also been shown to increase brain serotonin.

There are a few books that deal with natural serotonin boosters, including my own (Serotonin) and a good one by psychiatrist Michael Norden, entitled Beyond Prozac.

David: Here's the link to the HealthyPlace.com Depression Community. You can click on this link and sign up for the mail list at the top of the page so you can keep up with events like this.

Here's the next question:

Kellijohn: Can you give maximum dosage on the PMS herbs? How quickly can persons see results?

Syd Baumel: I've just rather frantically checked my book, but to no avail as far as Vitex is concerned. Black cohosh, which may also alleviate PMS, is usually taken at a dose of 40 to 200 mg per day. Vitamin B6 - an old standby - usually seems to work in the 50-200 mg range, if memory serves. I'm honestly, offhand, not sure of how long it tends to take to see a response, but these things tend to take weeks rather than days.

David: Several of our audience members want to know what natural treatments you take and what effect have they had on your depression and well-being?

Syd Baumel: I've had the most bang for buck from L-phenylalanine - a low dose of (usually) 400 or 500 mg every morning on a "protein-free stomach" for optimal absorption by the brain. I've also - much more recently - noticed a kind of "stress guard" effect from a modest dosage of St Johns Wort. This is on top of a nutritious, low junk-food vegetarian (vegan, since last summer) diet and a few other odds and ends. The effect has been that - for the last twenty or so years - when I get down, it's a) not nearly as frequent as before, b) typically very mild, and c) also very short-lived. If I had to quantify it, I'd estimate that my degree of suffering and impairment from depression has been about 15% of what it was prior to my breakthrough with phenylalanine.

David: What do you mean by "stress guard" effect?

Syd Baumel: About the stress guard effect: What I mean is that I noticed, after I first began using a properly standardized St Johns Wort product, that I wasn't getting as perturbed, bothered, disturbed etc. as I expected I would be by the great amount of stress in my life at the time.

David: Thank you, Syd, for being our guest tonight and for sharing this information with us. And to those in the audience, thank you for coming and participating. I hope you found it helpful. Also, if you found our site beneficial, I hope you'll pass our URL around to your friends, mail list buddies, and others. http://www.healthyplace.com

David: Thank you again Syd for being our guest tonight.

Syd Baumel: It was my pleasure and privilege to be your guest. Thanks to everyone who came to listen and participate.

David: Good night everyone and I hope you have a pleasant weekend.

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Disclaimer: We are not recommending or endorsing any of the suggestions of our guest. In fact, we strongly encourage you to talk over any therapies, remedies or suggestions with your doctor BEFORE you implement them or make any changes in your treatment.

1. Coping With Feelings and Thoughts of Suicide
   Guest: Dr. Alan Lewis

2. Depression Medications, Bipolar Medications
   Guest: Dr. Carol Watkins

3. Depression Treatments
   Guest: Dr. Louis Cady

4. Electroconvulsive Therapy Experiences
   Guests: Sasha and Julaine

5. Fighting Depression Safely and Effectively
   Guest: Dr. Michael B. Schachter, MD,

6. Food and Your Moods
   Guest: Dr. Kathleen DesMaisons

7. Living Without Depression and Manic Depression: A Guide To Maintaining Mood Stability
   Guest: Mary Ellen Copeland

8. Loss and Grief - Grieving the Different Losses in Your Life
   Guest: Russell Friedman

9. Mood Disorders in Children
   Guest: Trudy Carlson.

10. Natural Treatments for Depression
    Guest: Syd Baumel

11. Self-Help Stuff That Works
    Guest: Adam Khan

12. Treating Self-Injury
    Guest: Michelle Seliner

13. Undoing Depression
    Guest: Dr. Richard O'Connor

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Russell Friedman, author of the Grief Recovery Handbook and Executive Director of the Grief Recovery Institute, joined us to discuss dealing with many different kinds of loss and grief, including losing a loved one through death or divorce, or the sadness one experiences from the loss of a pet or the loss of a stillborn baby. Mr. Friedman also talked about the pain associated with a loss, how to deal effectively with a loss and the sad or painful feelings that accompany a loss.

Audience questions centered on the grieving process, whether to grieve alone, talking about your loss and grief with others, experiencing an emotional crisis from multiple losses and the concept of trying to move forward.

David Roberts is the HealthyPlace.com moderator.

The people in blue are audience members.

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David: Good Evening. I'm David Roberts. I'm the moderator for tonight's conference. I want to welcome everyone to HealthyPlace.com. Our topic tonight is "Grieving the Different Losses in Your Life." Our guest is Russell Friedman, author of the Grief Recovery Handbook and Executive Director of the Grief Recovery Institute.

Good evening, Mr. Friedman and welcome to HealthyPlace.com. We appreciate you being our guest tonight. Before we get into the meat of the conference, can you please tell us a bit more about yourself and your expertise in this area?

Russell Friedman: Yes, thanks for asking me onto the show. I had spent much of my life in the restaurant business. I arrived at the Grief Recovery Institute devastated by a second divorce and a bankruptcy. It was at the Institute that I learned to deal with my own pain and then to help others.

David: When you talk about "loss and grief," you're not only addressing the topic of "death and dying," are you? (see: What Is Grief?)

Russell Friedman: No, not at all. We identify at least 40 different life experiences which can produce the range of emotions called grief. Death is just one of the 40.

David: And can you tell us 3 or 4 others, just so we can get a sense of what loss and grief encompass?

Russell Friedman: Yes, divorce is a fairly obvious one, and so are major financial changes, where we would even use the word "loss," as in the loss of a fortune. Less obvious is MOVING, which changes everything we are familiar with.

David: What have you discovered in people that makes it difficult for some to deal with the grieving process?

Russell Friedman: The biggest culprit is the misinformation we have all learned since we were 3 or 4 years old. For example, we were all taught that time heals all wounds, yet time only passes, it does not complete what is unfinished between you and someone else, living or dead.

David: What is it then that makes for "effective grieving"-- a way for people to actually heal or better deal with their loss?

Russell Friedman: Good question. The first order of business is to learn what has not been effective so we can replace it with better ideas. In addition to the fact that time does not heal, there are at least 5 other myths which contribute to our inability to deal effectively with loss. For another example, we were all taught to "not feel bad" when something sad or painful happens. That idea puts us into conflict with our own nature, which is to be happy when something positive happens and to be sad when something painful happens.

David: So, are you saying that it's perfectly alright to feel the pain associated with a loss and not to bottle up your emotions or dismiss the pain?

Russell Friedman: Not only alright, but very healthy. The human body is a "processing plant" for emotions, not a container to carry them around.

David: Do you think some people are afraid to grieve over a loss? Afraid to deal with the pain associated with a loss?

Russell Friedman: Yes, absolutely, and it's totally based on false information - ideas that indicate that we are somehow defective if we have sad or painful feelings.

David: Here's an audience question on this subject:

sugarbeet: I lost my dad in October and it is really hitting me hard. How do you stop yourself from bottling up your emotions?

Russell Friedman: Hi Sugarbeet. Sorry to hear about your dad's death. Probably the first thing you need to do is establish at least one friend or relative that it is safe for you to talk with, where you won't feel judged or criticized for being human.

David: I think some people may be afraid to talk with others for fear of being judged or pushed away.

Russell Friedman: Yes, based on the fact that we were all taught to "Grieve Alone" for example, the expression that says, "laugh and the whole world laughs with you, cry and you cry alone." Therefore, you will be judged if you cry.

sugarbeet: I had to see him suffer, and I keep getting flashbacks... Thanks. It seems like most other people don't want to talk about this subject.

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David: The preoccupation of the griever wanting to talk about the person and the relationship to that person can sometimes push people away. In the other person's mind, they're saying, "enough already," and after awhile they might start to avoid you. Is there a point where you should stop talking about your loss and grief with others?

Russell Friedman: Sadly, since people are socialized to believe that they should "give you space," which creates isolation, and since we are falsely taught that our sad feelings would be a burden on others, we feel trapped and go silent, which is not good for us. That's why the first thing I told Sugarbeet was to find someone safe.

Wannie: When do you stop being so mad?

Russell Friedman: There is sometimes great confusion about the emotions we experience following a loss. People are incorrectly encouraged to believe that there is a "stage" of anger that relates to death of a loved one. We don't believe that is always true. Most people are heartbroken and sad, but society allows anger more than sadness.

David: Should you give yourself a timeline for "getting over" your grief?

Russell Friedman: That presumes that "time" would heal you, which it can't. Our humor for that is to ask the question - if you went out to your car and it had a flat tire, would you pull up a chair and wait for air to get back in your tire? Clearly not. As it takes actions to fix the tire, it takes actions to heal your heart.

Wannie: What kind of actions heal your heart?

Russell Friedman: The first of several actions is to discover what ideas (time heals, "be strong," and others) you have learned to deal with loss. Next is to review your relationship with the person who died to discover all of the things you wish had ended different, better, or more, and all of the unrealized hopes, dreams, and expectations you had about the future.

djbben: Does it have to be actions or can distraction help as well?

Russell Friedman: Ah, great question. Distractions come under the heading of one of the 6 myths that we identify which hurt, rather than help, grieving people. That myth is "Keep Busy," as if staying busy and making Time Pass would complete what was unfinished between you and the person who died. It won't because it can't. Keeping busy merely delays the real work you must do.

Hannah Cohen: Mr. Friedman, this past New Year's eve I lost my long time friend to suicide. I feel guilty and numb with periods of crying in-between. Feelings were not allowed when I was growing up and even now. Could I have done something to prevent this tragic loss? It makes me want to go back to my addictions again. The pain is horrible. I slipped. I went back to drinking so I could continue not to feel. Thank you. She was to receive her Ph.d. in anthropology in May.

Russell Friedman: Ouch! Hannah. One aspect first - guilt implies intent to harm. May I assume that you never did anything with intent to harm your friend? I bet that I'm right - in which case the word guilt is a dangerous word. It is probably more accurate to say that your heart is broken in a million pieces and that you have a hard time thinking about the future without your friend. I'll address the issues of addictions in a few minutes.

David: Hannah, I also want to suggest that if you have slipped back into drinking to deal with your emotions, maybe it's time to get some professional help, ie., see a therapist to talk about what's going on.

Is there a point, Russell, when one should realize that dealing with this pain is just too much and they should seek professional help?

Russell Friedman: In a crisis, we all tend to go back to old behavior. Our addictions certainly qualify as "old behavior." It is very difficult to do something new and helpful when an emotional crisis happens.

It is never too soon to get help. Many people wait, especially on issues about grief and loss, because we've all been taught that time will heal, and that we're not being "strong" if we're having those kinds of feelings which are caused by loss.

David: I think that's very important to keep in mind.

izme: I have had four deaths in my family within the last eight months and will be losing another family member soon. I am having problems dealing with one loss before another has to be dealt with. Any suggestions that might help?

Russell Friedman: Izme: the problem with multiple losses is that if you don't have the tools, skills, or ideas to deal with the first loss, then you don't have them for the second, the third, or fourth - and to top it off, it makes you terrified to think about dealing with another one, because of the accumulation of feelings caused by the prior losses. You must go back and work on each loss - the techniques in The Grief Recovery Handbook are designed for doing that.

David: Mr. Friedman's website is here: http://www.grief-recovery.com

How do you deal with the cliches like: "you've got to move forward" and "time heals all wounds," etc. that your friends and others throw at you?

Russell Friedman: Our website features a series of 20 articles which can be downloaded for free. One of the current ones being featured is entitled Legacy of Love or Monument to Misery. It talks about how a loving relationship would not leave us crippled in pain after a death.

Regarding dealing with incorrect and unhelpful comments: One piece of language that I have used for myself and encouraged for others is to simply say: "Thank you, I really appreciate your concern." The point is not to have to try to educate someone while your heart is broken, or to distract yourself by getting angry with someone who says the wrong things.

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MicroLion: How do you address the loss of a pet? Other people often do not understand the intensity of grief that can result from this.

Russell Friedman: Wow! I spend at least 20% of my waking hours dealing with grieving pet owners. It is shameful that many people in our society do not understand that the closest the thing to unconditional love that we humans ever perceive is from our pets. Go to a website called www.abbeyglen.com and click on the grief recovery button. There you will find some articles I wrote for pet owners.

HPC-Brian: How do you deal with death when you think that you're over it and it comes back to haunt you

Russell Friedman: Since we have been socialized to deal with grief in our heads (or with our intellect) rather than emotionally with our hearts, there is a very high probability that we will try to just move past and through the loss, without taking actions that will actually complete the pain. What is left is like a series of land mines, which can explode anytime there is a stimulus or reminder of the person who died - even decades later. That is why the sub-title of our book is The Action Program For Moving Beyond Death, Divorce, and Other Losses. Without actions, what most people do is just shift the pain out of sight.

katy_: Is it healthier to keep yourself busy and your mind off the issue or to dedicate time thinking about it?

Russell Friedman: Katy - No, staying busy is a recipe for disaster. On the other hand, just "thinking" about a loss is not helpful either. What is called for are a series of small and correct choices which lead to the completion of unfinished emotional business and in turn to an acceptance of the reality of the loss and the retention of fond memories.

David: Here's a short summary of what Katy has been dealing with:

katy_: When I was about 12, I went through some huge life changes. A very close family member died, my dad suffered depression and had become a stranger to me - I found this extremely difficult to deal with. I was unsure of how to deal with the emotions. I bottled them up, feeling that I'd be ok, but I became very unhappy. I had to deal with a lot of complex emotions at a young age. This had its effect. I definitely felt a huge sense of grief. I grieved over the loss of my childhood and my life.

Russell Friedman: Absolutely, Katy, any other outcome would almost be illogical. While we cannot give people their childhood's back (I couldn't retrieve mine either), we can help people become complete with the past, so that they don't have to relive it and repeat it over and over and over - do I make my point?

David: We seem to have a lot of people in the audience, Russell, who have suffered very large multiple losses. Here's another comment:

angelbabywithwings: I have had many, many losses, and I know I have never learned how to deal with them. Traumatic childhood, several deaths in my family in the last four years, and a lifetime of being depressed. I had a stroke 10 years ago which has left me with short term memory loss in which I can't learn anything new. Two years ago, I was hit by a car and suffered a fracture in my right ankle. I had surgery, etc -- all the stuff that goes with it. The second surgery was a year later to take out the pins.

David: This sort of brings me to the question, do you think that with multiple losses, we leave ourselves open to self blame? Sort of like: "I guess I deserved this pain."

Russell Friedman: David, if we have no better choices, we'll latch onto anything that seems to makes sense. But, if you attach to self-blame, I'd bet that self blame is a "habit." And if you'll recall, earlier I said that in a crisis we go back to old behavior - old behavior is a habit. When you acquire better skills you can replace the old, ineffective ones.

pmr: I don't seem to have any problem dealing with final losses, such as death, but I'd like to know: What is the most helpful way to deal with losses that are left open-ended, like with victims of abuse who are no longer able to maintain contact with even their children, because of the results of the abuse in the family. I have difficulty accepting totally losing all my children to this.

Russell Friedman: pmr - I'm glad you brought this up. It points out just how essential it is that we learn better ways of dealing with loss. I, myself, have lost contact with a child who I was very close with because of a falling out with her mother. My heart is broken, but I must deal with it so that my life is not limited any further. As to the abuse issues, the tragedy is exponential: when anyone has been abused sexually, physically, emotionally, etc. It is horrible enough that the abuse happened, but the tragedy compounds when the victim's memory recreates the pain over-and-over and creates an almost impossibility for loving and safe relationships. Grief Recovery is very helpful in limiting the ongoing impact of things that happened a long time ago.

David: Here's an audience comment:

kaligt: I feel pretty much like you do Russell, but I do not want to go on. I want to be with her.

David: "Acceptance" is one of the hardest parts of the grieving process.

Russell Friedman: David, acceptance, from a grief recovery point of view, is different than other uses of that word. For us, acceptance is the result of the actions of completing what is emotionally unfinished.

kaligt - I hear you - loud and clear. It is not uncommon for broken hearted people to feel that way. One of the tragedies is that people get scared and tell you that you shouldn't feel that way. I'd rather allow that your feelings are normal, but any action on those feelings would not be. Therefore, it becomes important for you to learn better ways to deal with the feelings you have. You wouldn't want to live in that kind of pain for a long time.

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kaligt: I am not thinking about suicide, but I am ill, and whatever happens, happens. That is how I look at it now -much differently than I did before my daughter died. I know I have to accept it. I am still in shock but have now found the courage to be able to accept death as I didn't have that before.

MicroLion: Why does the pain of grief and depression seem to keep coming in "waves?"

Russell Friedman: Microlion, in our book we use the phrase "roller coaster of emotions" to describe, in a general way, how grievers feel. In part, it is because our bodies have a kind of thermostat, so when we are emotionally overwhelmed it kind of shuts us down. On another front, the factor of how many reminders or stimuli to remember the person or relationship vary.

rwilky: Mr. Friedman, do the feelings/stages that are described by Kubler-Ross in "On Death and Dying" apply to the stages that we might go through with the loss of our loved one, our marriage if it fails, or a pet that dies? I hope that's not a silly question.

Russell Friedman: rwilky, in our book we gently remove ourselves from Elisabeth Kubler-Ross's work, which was not about grief. The stages she defined were about what you might go through if you were told you had a terminal illness. Therefore, although I have talked to more than 50,000 people who are dealing with loss, I have never met one who was in denial that a loss had occurred.

The first thing they say to me is, "my mom died" or "my husband left me."

Del25: In the early stage of heavy grief, is it normal to want to be alone and not have to interact with other people right away?

Russell Friedman: del25, if you have been here for the whole chat, you might recall that a few times I alluded to "in a crisis we go back to old behavior." That might be one issue. A second might be that the level of safety one feels about showing others the raw emotions you are feeling might cause you to avoid contact. And thirdly, you get to be YOU, and whatever you do is okay and normal, because it is you reacting to your own loss. Nobody gets to judge you for that.

jmitchell: Is there any advice you can offer mother's that are grieving over the loss of a stillborn baby?

This mother that lost her daughter has been running constantly and does not know how to slow down. This is fitting into your discussion about doing the real grief work.

Russell Friedman: jmitchell, all loss is about relationships. Society often harms grieving moms and dads by implying that since they didn't get to know the baby, there wasn't really much of a loss, but that is not true. From the moment a woman becomes pregnant she begins a relationship with the baby inside of her. When that relationship is altered by the death of the baby, it is devastating. The moms (and dads) must grieve and complete those relationships just as they would others of longer duration.

ict4evr2: I understand everyone here is here for the same reason. For the first time in my life, I have lost someone special in a violent way. I am learning this is a lengthy process. Does anyone ever really get past a death that was so violent and unexpected?

Russell Friedman: ict4evr2, without wishing to seem simplistic or insensitive, let me suggest that length of time is not the essential issue, rather it is the actions taken within time that can lead to a diminution of the horrific pain caused by loss. Also, please recognize that the "violence" is only one aspect of the loss. A question we always ask, though it might sound crude, is: "Would you miss them any less had they died some other way?" There is only one correct answer to that question. It is the fact that they died, not how, which is the key element of grief.

David: Here's the link to the HealthyPlace.com Depression Community. Also, don't forget to stop by Mr. Friedman's website: http://www.grief-recovery.com

And this is the link to the Grief Recovery Handbook: The Action Program for Moving Beyond Death Divorce, and Other Losses.

pantera: I have had many losses throughout my life, mostly in childhood. I tend to close myself off to future relationships for fear of further loss which would cause too much pain. Any suggestions?

Russell Friedman: Pantera, again, it would almost be illogical for you to do anything else, at this point. If your heart is full of the pain from prior losses, it is almost a definition of being "emotionally unavailabe" or "not being able to make a commitment." The essential task is to go back and complete what was unfinished in prior relationships, otherwise your only choice is to protect your heart from future hurt. That is not really a choice.

David: Thank you, Mr. Friedman, for being our guest tonight and for sharing this information with us. And to those in the audience, thank you for coming and participating. I hope you found it helpful. Also, if you found our site beneficial, I hope you'll pass our URL around to your friends, mail list buddies, and others. http://www.healthyplace.com

David: Thank you, again, Russell.

Russell Friedman: I appreciate you inviting me and I hope I was helpful to those of you who came tonight. Thanks.

David: Good night, everyone.

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Disclaimer: We are not recommending or endorsing any of the suggestions of our guest. In fact, we strongly encourage you to talk over any therapies, remedies or suggestions with your doctor BEFORE you implement them or make any changes in your treatment.

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Sasha, our first guest, suffered from treatment-resistant depression and had a positive ECT experience.

Julaine, our second guest, has a different story to tell. Although her depression has greatly improved, her ECT experience really shocked her.

David Roberts is the HealthyPlace.com moderator.

The people in blue are audience members.

David: Good Evening. I'm David Roberts, the moderator for tonight's conference. I want to welcome everyone to HealthyPlace.com. Our topic tonight is "ECT, Electroconvulsive Therapy Experiences." We have two guests who have undergone ECT (Electroconvulsive Therapy), with differing experiences and results.

Sasha suffered from treatment-resistant depression and had a positive ECT experience and will be coming on first. Our second guest, Julaine, who will be joining us in about forty minutes, coped with excruciating anxiety and depression, underwent ECT and had a different ECT outcome.

If you're not familiar with ECT, also known as shock therapy or electroshock therapy, or want more information on it, find here the latest information on Electroconvulsive Therapy (ECT) for Depression. Both ladies have extraordinary stories to share. They are truly inspiring.

Good evening, Sasha and welcome to HealthyPlace.com. We appreciate you being our guest tonight. Please tell us a little about yourself and your experience with having depression (see: What is Depression?).

Sasha: Hi! I'm so happy to be able to share my experience. Last year, I got married and it was the happiest time of my life.

Suddenly, I began experiencing severe depression and anxiety. I began a new job and we also bought a house. I was very stressed out at work. I'm a teacher and I was crying all the time. I went to the doctor and he told me that I was depressed. He prescribed Paxil for me and everything just got worse. I ended up so severely depressed that I had to leave my job and check into a hospital.

Nothing worked, and I started talking about killing myself almost all the time. I could not function. I thought that my life was over, and I thought about all the different ways that I could die. I was in the hospital for over a month, until finally, a doctor suggested ECT (Electroconvulsive Therapy). This was our last hope, since we tried all the medicines and nothing worked.

After my first ECT treatment, I could already feel the difference. It was a miracle. I never thought that I would feel good again. I had six treatments and now I am back to work and leading a normal life. I feel so good and I am so thankful for the ECT. It saved my life.

David: So everyone knows, Sasha is thirty years old. She underwent Electroconvulsive Therapy, shock therapy, about six months ago.

Sasha, when the doctor discussed ECT with you, what did he tell you about it? How did he describe it?

Sasha: He told me that it was a safe procedure and that in Europe it is often the first line of treatment. He said that he has seen many success stories with it and that I should not worry.

David: Were you worried at all? (See: ECT Therapy for Depression: Is ECT Safe?)

Sasha: No, because at that point I wanted to die anyway, so it didn't matter what I did.

David: Please describe for us what it was like getting ECT?

Sasha: It's just like going in for surgery. You get anesthesia and you go to sleep. You wake up and it's done. I didn't feel a thing. I remember that they put something on my head but that is all.

David: So when you woke up, what were you feeling?

Sasha: Sleepy and a little sore on my head.

David: Sasha, you mentioned that you underwent six ECT treatments. Did you steadily feel improvement in your mental condition as each treatment went by?

Sasha: It's routine to do at least six treatments. It is actually a small amount compared to others. After the first treatment, I felt better right away, and I felt perfect after the third.

David: We have some audience questions, so let's get to those and then we'll continue:

jonzbonz: Sasha, did you experience memory loss and confusion?

Sasha: Only during the time of the treatments. I think it was mainly due to the anesthesia.

Steve11: Did you get bilateral or unilateral ECT?

Sasha: Unilateral.

tntc: Are you receiving any maintenance treatments?

Sasha: Yes, I'm on Remeron until January.

David: Are you worried that your depression will return?

Sasha: Yes, but I try not to think about it. I just feel so happy now that I can't imagine that I will ever feel that way again. I just live my life and pray that it will not return.

David: The six ECT treatments you received, over what period of time was that?

Sasha: That would be two weeks.

Tammy_72: Did you experience any aphasia, or seizures afterward?

Sasha: No.

David: You mentioned that you are back at work, what are you doing now?

Sasha: I am a teacher. I went back to the same school!

David: Congratulations! Here are some audience comments:

anniegirl: I had it too, but it just made me lose a lot of memory. It didn't help me.

npcarroll:Hi, this isn't a question, rather a comment. I also suffer from treatment-resistant depression. Over the last four years, I have tried almost every medication known to man. When the drug trial became unbearable, I received ECT, thirty in all. They worked the best and I'd like to try maintenance ECT but don't know much about it.

David: Earlier, you said that you had tried many medications, antidepressants that weren't helpful. Did your doctor mention why they didn't help?

Sasha: No, she just said that some people just couldn't be helped with medications.

David: How did your family react to the suggestion that you needed ECT?

Sasha: They were so devastated that I was constantly talking about suicide that they wanted to try anything. My husband was very supportive.

David: I'm glad to hear that it worked for you, Sasha. We appreciate you being our guest tonight. Is there anything else you would like to add?

Sasha: I just want to say that if you are are suffering from depression, and you've tried everything else, please give ECT a chance. It could save your life.

David: Thanks again, Sasha. I hope you have a good evening. Here are a few more audience comments and then Julaine will be joining us.

tntc: I've also just last week finished a six treatment course of bilateral ECT with great success. However, my doctor is going to give me one ECT every other week as maintenance and has taken me off of medications completely, which weren't working that great anyway.

npcarroll: I must, in all fairness, state that I have severe problems with concentration, memory, etc. Although I can't say if it is from the depression, the medication, or the ECT.

David: Good evening, Julaine and welcome to HealthyPlace.com. Thank you for joining us tonight.

Julaine: Thank you.

David: Can you please tell us a little bit about yourself and your experience with depression before we get into your ECT experience?

Julaine: I have had major depression with severe anxiety for twenty years, but with no trauma in my background. Just very severe treatment-resistant depression.

David: What was it like for you living with that?

Julaine: I could not eat, would pace twenty-four hours a day, and was suicidal.

David: Had you tried various therapies before the Electroconvulsive Therapy and what were the outcomes?

Julaine: Yes, I was first diagnosed in the 1980's. There were very few new antidepressants at the time. I was on Elavil and Doxepin, etc. Nothing seemed to help.

David: Julaine is very involved in the mental health community in Florida, where she now lives. Julaine, how old are you?

Julaine: I hate to say, but I am in my second childhood now :) Forty-six.

David: Still young, I see :)

Julaine: Very much so now :)

David: I have heard many different stories about how the doctors explain ECT to the patient. What did your doctor tell you about it?

Julaine: I was very sick at the time so I cannot tell you all the exact details. However, I remember that they told me enough and I observed other people in the hospital with me getting better, so I consented quickly.

David: At that point in your illness with depression and anxiety, did it even matter what the doctor was saying to you? Were you at the point that you didn't care?

Julaine: I was dying, so to speak, but I could still understand facts. The fact was, this was my only chance to live.

David: How many ECT treatments did you receive and over what period of time?

Julaine: At that time period, about twenty, over two trials, separated by about four months.

David: What were the side effects of ECT that you experienced? And please be very detailed.

Julaine: During that set of ECTs, I did not experience any sign of memory loss. I did have mild headaches afterward and drowsiness.

David: I think you also mentioned to us that you had delusions. Is that true?

Julaine: Yes, delusions and memory loss were experienced in later trials of ECT treatments. About twelve years later in Florida.

David: So just to clarify, you had the first set of ECT treatments consisting of twenty treatments, in two trials over four months. Then twelve years later you had another set of treatments. How many and over what period of time?

Julaine: That is a fairly good estimate of numbers and time. The last twenty, or so, were done in 1992 and 1995.

David: Why is it that you needed the second series of treatments? And were you afraid that after receiving shock treatments before that, another round of treatments might result in some permanent damage?

Julaine: I had developed hypothyroidism about the time of 1992 and my medication ceased to work. I was tried on all the newer antidepressants at that time, but they did not work.

David: I'm getting some questions about what ECT, Electroconvulsive Therapy is used for. Sometimes called shock therapy or electroshock therapy, it's used to treat treatment-resistant depression, i.e., depression that hasn't responded to other lines of treatment, like therapy and antidepressants. It can also be used to treat mania and so you may hear that some people with bipolar disorder have received ECT.

Were you concerned about any permanent brain damage if you underwent another series of ECT?

Julaine: No, because I had no ill effects from the previous times in the 1980's.

David: How serious was the memory loss that you experienced?

Julaine: I combined reality with unreality. Similar to a psychotic patient. I could not remember recent events as well.

David: You also mentioned delusions. Can you describe those for us?

Julaine: I saw a lamp post outside the window and I thought it was a human being.

David: And how long did that last?

Julaine: The delusions were very short in time, perhaps, a week or so. The unreality/reality lasted a few weeks more, and the memory loss of recent time took longer.

David: Do you still suffer from depression and anxiety?

Julaine: I am recovered and am a grad student in Licensed Counseling today, but I am not cured :) I am looking forward to that day when we find a cure :).

David: I read your story, and interestingly, you don't attribute your improvement of the severe depression to ECT.

Julaine: ECTs, rarely, are responsible for someone's recovery, but they buy time.

David: Here's an audience question, Julaine:

tntc: Did you have bilateral ECT or unilateral ECT?

Julaine: I experienced both. The unilateral ECT was not as effective with me since I was so severe.

backfire1: Was the Thyroid disease responsible for some of your previous symptoms and was it treated first?

Julaine: It could have. Undiagnosed thyroid disease can cause depression or prevent your medications from working properly.

aurora23: Lately, I have been having delusions and losing track of time. It is bothering me, what is going on? Sometimes I can't tell the difference from what's fake and reality, can you give me some advice?

Julaine: Delusions are very complex. They can originate from schizophrenia type illnesses, or take that form because of possible trauma.

David: Here are some Electroconvulsive Therapy experiences, shared by our audience members:

RAH: I had six ECTs in April of 1, two bilateral. My relief from depression was less than one week. The memory loss is still very much a problem. I have lost two months totally and pieces of my life are gone. I still suffer from severe depression and, of course, I am badgered to get a recharge which I refuse. I can get off meds, I can't repair brain damage.

Tammy_72: I had five ECT treatments and they left me physically very ill, and made me much more depressed than I was before. I experienced aphasia and seizures after my treatments ended.

suzieq46: I had ECT and would advise against it, except as a last resort. Such memory is lost, that a doctor or lawyer could no longer practice.

npcarroll: I consider my experiences with ECT successful, even though I am still suffering from depression. I seem to be resistant to medications. I would like to try ECT maintenance and see what happens without drugs.

jonzbonz: I had ECT. Four treatments that were disastrous for me I lost memory for quite some time, I was confused for a long while, and my depression returned within a month.

jamtess: I had ECT treatments over a three week period and it didn't help the depression. Plus I had to deal with the bad headaches, confusion, memory loss and I returned home more of a mess than when I entered the hospital.

ladyshiloh: I had thirty plus ECT treatments many years ago and now suffer from frontal lobe epilepsy that has been directly related to the ECT I had.

suzieq46: Ladyshiloh, I believe that I did not have anything that disastrous happen, but I lost at least a third of my memory from life. We know so little about the brain, and to shock it, I believe, is a dangerous risk. Yet the doctors who perform it are really gung ho and make you feel guilty if you don't have it done.

(Read also HealthyPlace section of ECT Stories: Personal Stories of ECT)

David: Julaine, would you recommend shock therapy to others who might be suffering from treatment-resistant depression, based on your experience with it?

Julaine: Yes, I would recommend considering ECT, however;

1. First the patient and family must be told the full facts.
2. It would be very helpful to ask exactly who might benefit from ECTs, or who might not, as effectively.
3. Those who suffer from disorders such as trauma or PTSD should especially ask specific questions.

David: Here are some more ECT experiences from the audience and some comments:

jonzbonz: Two years after I had unilateral ECT, I had a sub-arachnoid hemorrhage of my brain on that side. I suspect strongly that the ECT is responsible for the stroke I had.

npcarroll: I still suffer from quite a few side effects also. I have discovered over the years on how to work around them. Anything to allow me to feel, at least partially function, and last but not least, stop me from slipping back into that deep dark hole I was in, works for me.

RAH: I feel that I was ill-informed about Electroconvulsive Therapy. Texas is the only state with a full consent form. The days prior to ECT are lost, so I have no idea what was presented to me and no one is talking. Informed consent is my crusade. If it works, I can't totally condemn it.

katey1: I too, have been on every medication out there, and nothing is working. For the past two years, I have gone through two trials of nine treatments. In the past eight months, I have had serious memory loss, and am still suicidal. In fact, I attempted again two weeks after the last treatment. I am still suicidal and nothing is helping. I am still on about five different medications, and I think about suicide daily. I am diagnosed with major depression and PTSD, Post-Traumatic Stress Disorder. I really have given up all hope. I can't get rid of the pain.

suzieq46: Julaine, how much memory loss did you have?

Julaine: During the treatments with bilateral ECT, I had very severe mixed reality with unreality and could not remember much. However, the biggest portion was loss of recent memories and some of them have never returned, but although it took a few months, the important ones have.

David: How are you functioning now, Julaine?

Julaine: Wow, very well. I am a graduate student in counseling and a very enthusiastic mental health advocate. It helped bring about needed reforms in Florida's MH :).

David: One last question Julaine, are you concerned about your future mental health and the return of depression?

Julaine: To deny I am worried about the return of depression would be false, but on the other hand, I must press forward with hope and optimism :)

David: Thank you, Julaine, for being our guest tonight and for sharing your ECT experiences with us. And to those in the audience, thank you for coming and participating. I hope you found it helpful. We have very large Depression and Bipolar communities here at HealthyPlace.com. Also, if you found our site beneficial, I hope you'll pass our URL around to others http://www.healthyplace.com.

Thank you again, Julaine.

Julaine: Thanks very much and to all: NEVER GIVE UP you are not your diagnosis :)

Disclaimer: We are not recommending or endorsing any of the suggestions of our guest. In fact, we strongly encourage you to talk over any therapies, remedies or suggestions with your doctor BEFORE you implement them or make any changes in your treatment.

online conference transcript

Dr. Louis Cady: on the latest advances in depression treatments, antidepressant medication, ECT (electroconvulsive therapy) and psychotherapy treatments for depression.

David: HealthyPlace.com moderator.

The people in blue are audience members.

David: Good Evening. I'm David Roberts. I'm the moderator for tonight's conference. I want to welcome everyone to HealthyPlace.com. Our topic tonight is "Depression Treatments". Our guest is psychiatrist, Louis Cady, M.D.

Dr. Louis Cady is a board-certified psychiatrist based in Evansville, Indiana. In addition to his private practice, Dr. Cady, has written two books, gives lectures, and is one of the few male psychotherapists who conducts a weekly support group for women on women's issues. 

The reason Dr. Cady is here tonight is because one of his areas of expertise is Depression, especially treatment-resistant depression.

Good Evening Dr. Cady and welcome to HealthyPlace.com. We appreciate you being here tonight. Many people who visit our site have been living with depression for years and can't seem to "get over it". How difficult is depression to treat?

Dr. Cady: Good evening David and guests. It is a pleasure to be here.

Depression is both an easy and a difficult condition to treat. Let me explain in the next several sentences.

Depression, as we understand it, is a biological disturbance in the brain and not a defect in moral character, moral laxity, etc. Treatments for depression which are currently available these days, are generally safe and effective. This wasn't always the case.

If depression is treated skillfully and carefully by an expert, it's usually not that difficult to bring it to heel. If it's been a problem for a long period of time, or if it's severe, it can be more of a problem, require quite a lot of time to get the medicine right, and, of course, we can't forget the aspect of psychotherapy or talk therapy to help people deal with the psychological realities of it as well.

I know, a long answer to what looks like a simple question, but hopefully this will frame our discussion for this evening.

David: Why is it that some people can recover from their depression in a shorter period of time than others?

Dr. Cady: Several explanations. Some people's depression isn't as bad as other's, and some people respond better and more briskly to antidepressant medications. And some people have a moment of startling, clear insight in their psychotherapy which affords them a glimpse into a different, better way of making decisions and conceptualizing the existential (and other!) aspects of their existence. Particularly in relationships which are not good, business situations which are not going well, and when they have a warped and distorted view of the world. Also, the newer antidepressants simply work faster than the old-timey way of treating depression with tricyclic antidepressants.

David: A few minutes ago, you mentioned about being treated by an expert who is skillful. Can you clarify what that means and how an individual would find that type of person to treat them?

Dr. Cady: Certainly. I see two primary psychopharmacological ("pill prescribing") misadventures in physicians from whom I get patients who are not doing well:

• underdosing
• overdosing

In underdosing, the medication is never pushed up high enough to get the job done. In overdosing, the medication is typically started so high, or "too hot" - to use the Goldilocks analogy - that the unfortunate patient gets so many side-effects from the first dose... or first few doses... that they are already off to a bad start.

Finally, antidepressant medications should be selected carefully for the type of depression which one is treating. Every medication on the US market right now could be thought of in a particular "niche" for a particular type of depression, or, conversely, in particular "niches" where their prescribing could be harmful. Therefore, "choosing wisely" in terms of selecting the right agent, and then prescribing with a suitable level of sophistication and technical finesse - in other words, not turning your patient into a zombie or putting them up on the ceiling with anxiety from the first dose of medication they pop into their mouths... these are the criterion I would look at for "skillful".

David: Are there tests that can be given to determine what is wrong, brain chemical wise" and which medication should be used?

Dr. Cady: Excellent question. At one time, is was thought that the "Dexamethasone suppression test" could tease apart "real", "biological" or "melancholic" depression for the more reactive, "psychological" types. Not true. There is currently no available blood test in clinical practice which can determine which antidepressant to select. On the other hand, the astute clinician can, if listening to the patient clearly and empathically, come up with some reasonable hypotheses about what neurotransmitters might be out of whack. One classic example would be a woman suffering from premenstrual dysphoric disorder, with carbohydrate cravings, "low mood" on a monthly basis, and classic signs and symptoms of depression. That is a serotonin deficiency unless proven otherwise. Accordingly, a medication which boosts serotonin (SSRIs) should be selected. That would not include such things as Wellbutrin - a great medication, to be sure, but not one specifically indicated for this condition. That is an example of how I would BEGIN to conceptualize which medication to select.

David: I used the term "treatment-resistant depression." Is there truly such a thing as depression that can't be treated or that is highly resistant to treatment?

Dr. Cady: Yes. In severe cases of intractable depression, where all antidepressants fail, and ECT (electro-shock therapy) fails, psychosurgery to break the obsessively ruminative feedback loop in the unfortunate sufferer's brain has and can be used. This is a RARE procedure, is not done in a cavalier fashion and there are all sorts of hoops that a treatment team must jump through. In my four years of training at Mayo, where we saw some of the worst cases of depression, I saw only ONE case of a patient with intractable depression that came to this state and ultimately had the surgery and benefited from it. I want to emphasize that that is a rare situation, however. Typically, treatment resistant depression is simply a case where the right medications, or the right combination of medications has not yet been tried. One of my mentors of psychopharmacology - Dr. Steven Stahl, has come up with some very creative combinations. His book, Essential Psychopharmacology, 1998 (new edition coming out this summer) is a goldmine of information on what he calls "heroic pharmacotherapy."

David: We have plenty of audience questions, Dr. Cady. Let's get started:

amaranth: Does cognitive therapy really work?

Dr. Cady: Yes, cognitive therapy really works. It was designed by Aaron T. Beck, and popularized by David Burns in his great book, FEELING GOOD: The New Mood Therapy.

It should be noted that psychotherapy certainly works in the type of depression, which, although it is biologically derived, may be psychologically caused and exacerbated. Thus, cognitive therapy, as well as interpersonal therapy, behavioral therapy, and even the more classic psychoanalytic or psychodynamic psychotherapies can all work. However, it typically takes more time.

And just one more thing. Biological treatment of depression with medications does not mean that psychological issues should be ignored. They should be dealt with appropriately in psychotherapy. On the other hand, if the depression is primarily biological - meaning there's a terrible history of it in the family, you started out as a happy camper, and you have no reason to be depressed - but are anyway - then cognitive therapy will probably not make you better and you will need biologically oriented treatment.

David: Is the "best" treatment for depression a mixture of medications and therapy? or can medications alone do the trick in a lot of cases?

Dr. Cady: Good question, David. Antidepressant medication and psychotherapy is probably the best combination of the type of depression treatment where there is a clear evidence that it is moderate to severe, has biological (neurotransmitters out of whack) problems, and the person actually has reasons to be depressed and is doing maladaptive things cognitively.

This is the kind of "middle of the road," garden variety depression, and "medication plus psychotherapy" is definitely the way to go. But, the other two extremes are the exclusively psychologically mediated difficulties where psychotherapy should be used, and the exclusively biological (see above) where endless hours of therapy will only frustrate the patient and not really accomplish anything...because they didn't need that to start with. Does that make sense?

David: Yes, and here's another question from the audience:

Ablueyed: My depression feels very urgent and life-threatening. The thing is I don't talk a lot, I'm afraid of both being with people and being alone. Are these common symptoms of depression and how do I overcome them?

Dr. Cady: You have touched on some key elements of depression - you have a sense of urgency and of a threat to your life (see Darkness Visible - by William Styron, where he noted the same thing), but have difficulty talking about it. Basically everything you mentioned is a symptom of depression. The classic symptoms of depression are : sleep difficulties, feelings of sadness and despair/depression, loss of interest, feelings of guilt and worthlessness, poor energy, poor concentration, appetite changes, feelings of being sped up or slowed down and thoughts of suicide. Five out of nine of those is a gold standard diagnosis for depression. BTW - you need to have them for two weeks, and the symptoms of depression can't be caused by any other biological or psychiatric problem. In terms of how to overcome them. Here are some suggestions:

1. You're here. That's a start. Learning about the illness is one of the first steps to overcoming it. I congratulate you for being here.
2. Learn what treatments are available. If you have a difficult time talking with people, this might be a good way to ease into an understanding about it.
3. Finally, make an attempt - please, for your own sake - to find someone you can trust and talk to. Just talk a little bit about what's going on. You don't have to regurgitate your entire life history or go into every gruesome detail. Find out if you can trust this person; then you can begin building a good, solid, psychotherapeutic relationship.

I hope that this begins to answer your question. Good luck to you. It was a pleasure answering your question.

David: On the subject of talking to a therapist, here's a question:

imahoot: Is it typically because of fear why someone has difficulty talking to a therapist?

Dr. Cady: The quick answer, imahoot, is "possibly." On the other hand, maybe the therapist is just not the kind that gives you warm fuzzies. I've heard tales of some therapists (and doctors, and lawyers, and CPA's, etc., etc.) that I wouldn't send my dog to. Additionally, depressed people aren't usually the kind that can muster a "hale fellow well met" style of engaging with people. Other folks might have an "anxiety disorder" - which is a little bit outside the simple "fear" description.

WBOK: If you've been using the same antidepressant medication for 3 years or more and have had reoccurring depression, should your medication be changed?

Dr. Cady: Quick answer: YES, or raised, or something combined with it. Medications should be pushed to the limit before they are declared a failure. Here are some doses of medications that I would go up to (absent side-effects) before I would consider the medication trial a failure:

Prozac, 80 mg per day. - 200 mg per day. Paxil - 50 - 60 mg per day. Wellbutrin - 450 mg per day. Effexor - 375 mg per day. Celexa - 60 - 80 mg per day. Serzone - 600 mg per day. If you haven't gone all the way to the max on a medication, you can't say that the possibilities have been exhausted.

poet: Dr. Cady, my medications are no longer working. I have suicidal thoughts and constant feelings of worthlessness. Should I consider inpatient treatment for depression?

Dr. Cady: Dear poet: you actually have two choices: not only the inpatient versus outpatient option. But, logically, whether or not you can reasonably expect your medications to work at the dosages they have been prescribing. For example, if you are taking 10 mg of Prozac, or 25 mg of Zoloft per day, or some low dose, aren't any better, and are suffering, and your physician is not raising the dose, then the choice really isn't so much inpatient or outpatient, but are you going to keep plowing the same soil with the same rusty instrument - if you get my drift. Inpatient treatment for depression won't make bad medication dosages work any better. If, on the other hand your depression is severe, you have significant psychological or trauma issues to deal with, and you need the nurturing sanctuary of a protective and caring environment where you can mentally and psychologically "catch your breath" and give your medications a chance to work, then the option of inpatient treatment is certainly a reasonable one and should be considered. I hope that this answered your question logically and completely. Good luck to you.

David: Dr. Cady, if a person can't find reasonable improvement in their level of depression after 6 months, would you say it's time to find another doctor?

Dr. Cady: It depends on what's been happening in the last six months. If one dose of medication has been selected and the physician has been twiddling his/her thumbs for the last six months after it's been prescribed, I would say, yes, it's time to change. If, on the other hand, the condition is extreme and severe, creative and intellectually aggressive and coherent pharmacological strategies are being considered and implemented, the physician has expressed to you a logical PLAN and you believe in him/her, then I would stick with the program.

jakey9999: I am taking Lithium and Zyprexa. Although I get a little relief while taking them, I have no energy. I have tried every over-the-counter remedy, can you suggest anything to increase my energy levels?

Dr. Cady: Good question, jakey9999. Lithium and Zyprexa are not, per se, antidepressants. Both have a known problem with causing sedation and "loss of energy" - with the Zyprexa being a worse offender than the Lithium. Lithium has been historically used to augment antidepressant therapy but, with the advent of the new "gangbuster" antidepressant drugs (Effexor, Wellbutrin, Remeron, Serzone and the like... which can be combined with other drugs), its use as an augmenter has fallen into disuse, except in the most extreme cases. If you have bipolar disorder (and you might, given that you are on lithium), another antidepressant should be considered. Wellbutrin seems to have gotten the nod for this niche in the treatment of depression in bipolar disorder.

maddy: How about the role of ECT or electro-shock therapy? And how safe is that?

Dr. Cady: Maddy, there's a good discussion of electroconvulsive therapy on this web site, I noticed tonight. It's pretty strongly anti-ECT, but I believe both sides should be aired.

My own feeling about ECT (have done it hundreds of times with patients, many more at Mayo in my residency than in my current practice) is that it absolutely works for real, legitimate, heavy duty, biological depression. It also doesn't scramble your brains (although you might have some retroactive memory loss during your hospital stay) - but you won't forget who you are, what you are about, etc. It's pretty safe. It's currently done under total anesthesia and full body muscle paralysis, so the One Flew Over the Cuckoo's Nest scenario simply doesn't apply anymore. It works, it's effective, and it's safe. That being said, it should only be used if a strong, coherent, logical trial of medications has failed or the patient is right there on the brink of suicide and heroic measures are absolutely called for.

Turbo: If one stops responding to an SSRI, does that mean other SSRI's should not be tried?

Dr. Cady: Not necessarily, Turbo. The dosage might need to be raised. Secondarily, an augmenting agent (such as Wellbutrin - which boosts both dopamine and norepinephrine) could be added to "harmonize" with the serotonin-boosting properties of the SSRI.

WhoAmI: Is it possible that antidepressant medications can make depressed people worse since medications are not tested on humans?

Dr. Cady: It is always possible that medicines can make depressed people worse. I tell my patients that the use of a medication can cause anything from seizures, to allergic reactions to death. People fall over dead every year in doctors' offices after a dose of penicillin in the you-know where.

On the other hand, your statement that antidepressants aren't tested on humans is, if I may be blunt, erroneous, and would come as a great surprise to the FDA. In fact, after they are determined to be both safe, and effective. Medicines are tested in humans in clinical trials before they are released to the market and before they are tested on humans, they're tested on animals to make sure that they

1. work;
2. are non-toxic;
3. would be reasonable and extremely safe to try in people.

But the wrong medicine, for anything, can make you worse. Hope that answers your questions.

shan10: Please try to shed some light why some people gain weight with medications such as Zoloft and Celexa?

Dr. Cady: Shan10, the issue of weight gain is a vexing one for certain antidepressants. The biggest offenders used to be the tricyclics; the most serious offender now is Remeron. The atypical antipsychotics are the champion "weight-gainers", however. Some antidepressants are thought to be weight neutral. Actually, Celexa is one of them, as is Serzone and Wellbutrin. But, like I mentioned above, anybody can have any kind of reaction to any medication and what stimulates somebody to eat more and gain weight may not do it to the next person. The safest thing to do is to ask your doc to switch you to another antidepressant if you're gaining too much weight.

Kaprikel: In the same light as Shan10's question. I am dieting, and taking Wellbutrin and Neurontin, and I cannot seem to lose weight. Can these medications contribute to that?

Dr. Cady: Great question, Kaprikel. Neurontin can tend to put on weight. Wellbutrin typically does not. The best "diet" by the way, that I've found and that's physiologically and biologically sound and rational really isn't a diet, but a commitment to healthy eating.

David: Here are a few audience comments on what's being said tonight. Then we'll get to more questions.

amaranth: In my case, I've been depressed since I was 6 and I've been working to get better since I was 13. No antidepressant medications have worked on me yet. I'm on Remeron and its not doing a thing for me.

lisarp: It's very discouraging and I go deeper with each episode. I have been for a second opinion consult and still am struggling. I become angry when I hear that no one has to be depressed in this day and age.

mazey: I just got out of the psych unit on Monday with a relapse of depression. What they thought would work, didn't, and now the doctors want to make another med change. Last time, I ended up in a medication induced psychosis. I'm afraid of medications.

David: Here's a good question from a young person, Dr. Cady:

Bzuleika: Is there any way to seek professional help without letting my parents know?

Dr. Cady: Bzuleika, it depends. If you're under 18, legally, a physician must have your parents' consent to treat you. Particularly if medicine is prescribed, it's considered "battery" if legal consent isn't obtained. I can't see that a physician would take you on as a patient in this context. On the other hand, you could begin treatment by exploring, with a school counselor, the nature of your feelings, and reasons why you might be feeling depressed. I hope that gives you a general framework to work in.

David: How can one tell if their depression is situational vs. chemical...or that what may have started as situational but has become a chemical imbalance?

Dr. Cady: First part of the question: if it starts "situationally" - and one's autobiographical memory is intact, one can frequently trace back to something like, "It all started when....." and then usually relate it to an event, a trauma, a reversal of fortune, etc. Then, if it worsens into clinical depression, or "major depression" as it's diagnosed, essentially the psychological problem has broadened into one which is now both psychological and biological. Basically, if it's a major depression, or "severe clinical depression" - it's biological - however it started. As noted some 45 minutes or so back in our conference, however, the strategy for dealing with it, should embrace both a psychotherapeutic one and a biologically based one.

David: Some people with depression turn to drinking alcohol to ease their pain, even while they are taking antidepressants. Can you address the effects of that please?

Dr. Cady: Alcohol can definitely anesthetize the pain and agony of depression temporarily. The problem is that it is a symptomatic, bandaid approach to things, such as the pain, and in some cases, the insomnia, brought on by depression. If used to treat insomnia, one can achieve tolerance (e.g., "get used to the stuff") requiring more and more, until one wakes up not only depressed but an alcoholic on top of it. Additionally, the use of alcohol WITH PROZAC OR PAXIL should be carefully considered. Both of these two medications ("the two P's") cause an inhibition in the liver enzyme system responsible for breaking down alcohol (as well as cough syrup and a host of other compounds). So you not only have to be aware of the dangers of alcohol but the dramatically greater dangers of mixing it with specific drugs.

EKeller103: Doctor, could you please discuss depression related to/ caused by Obsessive Compulsive Disorder (OCD)?

Dr. Cady: Good question, EKeller 103. The way I would conceptualize this would be probably two-fold:

First, OCD is classically thought to be a Serotonin deficit. Serotonin deficits are rampant in depression. Hence, what causes the OCD - lack of serotonin - is probably one of the difficulties in your depression.

Secondly, I have my patients learn the mantra "stress causes depression...stress causes depression..." so that they will realize that when they get (or got) depressed, it wasn't due to some moral laxity, etc, but related to (typically) overwhelming stress. People that have OCD and find themselves behaving in irrational, obsessive and compulsive ways are STRESSED. Obsessive Compulsive Disorder is considered "ego dystonic" - which means that you know that you are not acting right... you just can't help it. This is stressful. So, there could be both an underlying biological relationship between the two, as well as an underlying psychological, causally exacerbating link between the two.

Ablueyed: I've been reading this self-help book called "You Can Feel Better" and it describes our feelings as being caused by our thoughts, and that if you can think differently, this will change your mood. Do you believe in this?

Dr. Cady: To an extent, Ablueyed, this is true. One participant had mentioned cognitive therapy. Aron Beck, who founded cognitive therapy, noted that some of his patients who had undergone ECT (electroconvulsive therapy, electro-shock therapy) were simply not getting better. He determined that their problem was their thinking processes. Hence, he set about reversing their depressions by changing their thinking processes.

So the quick answer is, "I believe this" - that is, what you think about determines your reality. Earl Nightingale called this his "strangest secret" and sold a platinum 78 rpm vinyl recording (and later, a book) called "The Strangest Secret" based on this principle: "we become what we think about." On the other hand, to take a seriously depressed, imminently depressed patient and say, "see here, madame (or sir): your only problem is you've not selected the right things to think about" won't get the job done. There's a biological problem there. (See above). In that case, the combination of psychotherapy (to deal with "what they're thinking about"), as well as medication therapy, should be used. Hope this answers your question accurately and completely.

David: Here's the link to the HealthyPlace.com Depression Community. You can click on this link and sign up for the mail list at the top of the page so you can keep up with events like this. There's a lot of info there on depression and antidepressant medications.

AnnFP: So, in your experience, what happens as people try to rebuild their lives and climb out of a major clinical depression. How do they judge whether they are being successful at combatting their depression?

Dr. Cady: Most people, in my experience, and if they are truly getting better, have some idea that they are making process. This is tremendously exciting and motivating for them, because they can see a causal link between the medications and the psychotherapy they are using and the mental adjustments they are making correlated with their progress. This is "positive reinforcement." Also, the psychotherapeutic process facilitates pointing out to patients - if they are not yet aware - the subtle yet distinct changes that they are making in their lives as they get better.

Riki: What do you do if you have tried all the depression medications out there and still don't get any results from the depression lifting?

Dr. Cady: Riki, at this point, I have only one patient that I'm getting close to "trying all the medications out there" who hasn't significantly improved. The problem with "trying all the medications out there" is that, frequently:

1. they are not pushed up to the maximum dose;
2. they are changed too soon;
3. they are never tried in what Stahl calls "heroic combination pharmacotherapy."

If you consider, for example combining one of two SSRI's with Remeron, with Effexor, and with Wellbutrin, you have literally dozens of permutations of what could be tried. I'm not suggesting, willy nilly, simply putting people on a bunch of medications without thought of what you're doing. But, logically, trying someone on Prozac, then Paxil, then Luvox, then Celexa (five SSRI's in their order of market appearance) and saying, "we've tried five things and they haven't worked" is not a logical way to do things. That was probably at least three or four too many in the SSRI class before trying something a little more creative. This is simply an example of the thought process I encourage clinicians to consider.

topsy: I have seldom felt anger during my life, and my psychiatrist has said that depression is "anger turned inward". He has mentioned "constructive anger". What does he mean by constructive anger?

Dr. Cady: "Anger turned inward" was Freud's classical psychoanalytic concept of where depression came from. "Constructive anger" - which your therapist has mentioned, could refer to the fact that he/she perceives you as legitimately and appropriately angry at something or someone who traumatized you or did you an injustice. This would be appropriate anger, and could be "constructive" in the sense that it clues you into things in your life that you need to look at or change per se, however, free-floating, non-specific, uncontained, non-directed , and inwardly corrosive can be a terribly disempowering thing to deal with. You might want to check out "Dr Weisinger's Anger Work Out Book" and examine your anger through the lens that this particular author suggests. Good luck.

Alan2: Can I ask Dr. Cady to comment on the medications, Depakote and Risperdal, as they are used for Bipolar Disorder?

Dr. Cady: Great question, Alan2. Old style way to treat bipolar disorder: one mood stabilizer; if that didn't work, add a second mood stabilizer. New way to treat: one mood stabilizer and an "atypical antipsychotic." That is exactly the combination you mention with Depakote and Risperidal, respectively. It's a good combo. Here are some caveats. Depakote should be dosed up to the level where you either have side-effects or are better. The blood level numbers for this may range between 100 - 150 on the lab test. These are higher numbers than are typically seen in the use of Depakote for seizures. Also, periodic liver function tests should be obtained - every three months is a good idea - to make sure that your liver is still happy with the Depakote. In rare cases, it can cause your liver to become upset and you to become sick if it continues. Risperidal is one of those atypical antipsychotics about which we talked earlier which can contribute to weight gain. Watch out for that. But, if one is feeling great on this combination, it's a good one. Certainly it's logical and appropriate for bipolar disorder.

Kaprikel: I believe that my depression is probably situational, caused by unresolved grief. I find it very painful to discuss this in therapy, so I try to avoid it. How can I deal with this when its too painful to talk about?

Dr. Cady: Your insightful characterization of the source of your depression is excellent and augurs well for your eventually working through it. One thing that you might do, if you currently find it difficult to talk about, is to read every book you can find on dealing with grief issues. There are grief support groups to which you could belong, or attend, which might also be helpful. Many of these groups do not demand that you speak, so you could sit there, take it all in, and realize that you are not the only one with this type of problem. However, I cannot emphasize enough the need for an EMPATHIC, emotionally attuned therapist to work with. If you can find this sort of person with whom to work, the difficulty in "opening up", I suspect, will fade. Please try to find someone like this to work with. It will help, I promise!

whiteray: What treatment would be best for an individual with childhood originated PTSD (Post-Traumatic Stress Disorder) as well as likely hereditary depression?

Dr. Cady: For the PTSD from childhood - excellent, skillful psychotherapy to work through the issues (kind of like the "constructive anger" question we reviewed above.) For the "hereditary depression" - we can translate that, I think - if I read your question correctly - as a biological depression. My proposal would be a "full court press," psychopharmacologically speaking. I'm talking good, solid, rational, drug therapy, pushed up to the limit, and used in appropriate combination with therapy, if required.

David: I'm wondering if you know of any new antidepressant medications or depression treatments on the horizon that we should be looking for, that would help those with depression?

Dr. Cady: Raboxitene is a norepinephrine specific reuptake inhibitor which is used in Europe and is currently awaiting FDA approval in this country. Also, there is a great deal of excitement about the Corticotropin releasing hormone (CRH) class of drugs which seem to have potent antidepressant effects. Finally, there is a great deal of interest in "Neuropetide Y" which seems to be a solid antidepressant in its action.

These and other developments can be researched by anybody including the lay public, at Pub Med - from the National Library of Medicine. Good luck.

David: I want to thank Dr. Cady for being our guest tonight and doing a wonderful job. We appreciate you sharing your knowledge, expertise and insights with us. I also want to thank everyone in the audience for coming tonight and participating.

Dr. Cady: Thank you for the opportunity to be here, David.

David: Thank you again Dr. Cady and good night everyone.

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Disclaimer: We are not recommending or endorsing any of the suggestions of our guest. In fact, we strongly encourage you to talk over any therapies, remedies or suggestions with your doctor BEFORE you implement them or make any changes in your treatment.

Recent use of electroconvulsive therapy (ECT) in adolescents and children reflects a greater tolerance for biological approaches to the problems of the young.

At a 1994 conference of the Child & Adolescent Depression Research Consortium, reporters from five academic centers added an experience with 62 adolescent patients to 94 cases already described (Schneekloth and others 1993; Moise and Petrides 1996). Adolescents with major depressive syndromes, manic delirium, catatonia and acute delusional psychoses were successfully treated, usually after other treatments had failed. ECT's efficacy and safety were impressive, and the participants concluded that it was reasonable to consider this therapy in adolescents in instances where condition of the adolescent meets criteria for ECT in the adult.

Less is known about the use of ECT in prepubescent children. The few reports that do exist, however, have been generally favorable (Black and colleagues; Carr and coworkers; Cizadlo and Wheaton; Clardy and Rumpf; Gurevitz and Helme; Guttmacher and Cretella; Powell and colleagues).

The most recent case report describes RM, 8-1/2, who presented with a one-month history of persistent low mood, tearfulness, self-deprecatory comments, social withdrawal and indecisiveness (Cizadlo and Wheaton). She spoke in a whisper and answered only with prompting. RM was psychomotor retarded and required assistance in eating and toiletting. She continued to deteriorate, with self-injurious behavior, refusing to eat and requiring nasogastric feeding. She was frequently mute, exhibited board-like rigidity, was bedridden, enuretic, with gegenhalten-type negativism. Treatment with Paroxetine (Paxil), Nortriptyline (Pamelor)-and, for a short while, Haloperidol (Haldol) and lorazepam (Ativan)-were each unsuccessful.

A trial of ECT led first to increased awareness of her surroundings and cooperation with daily living activities. The NG tube was withdrawn after the 11th treatment. She received eight additional treatments and was then maintained on Fluoxetine (Prozac). She was discharged to her home three weeks after the last ECT and was rapidly reintegrated into her public school setting.

Had her condition occurred in Great Britain, it might well have been labeled as pervasive refusal syndrome. Lask and colleagues described four children "...with a potentially life-threatening condition manifested by profound and pervasive refusal to eat, drink, walk, talk or care for themselves in any way over a period of several months." The authors see the syndrome to result from psychological trauma, to be treated with individual and family psychotherapy. In a case report Graham and Foreman describe this condition in 8-year-old Clare. Two months before admission she suffered a viral infection, and some weeks later gradually stopped eating and drinking, became withdrawn and mute, complained of muscle weakness, became incontinent and unable to walk. On admission to hospital, a diagnosis of pervasive refusal syndrome was made. The child was treated by psychotherapy and family therapy for more than a year, after which she was discharged back to her family.

Both RM and Clare meet present criteria for catatonia (Taylor; Bush and coworkers). The success of ECT in RM was lauded (Fink and Carlson), the failure to treat Clare for catatonia, either with benzodiazepines or ECT, was criticized (Fink and Klein).

The significance of the distinction between catatonia and pervasive refusal syndrome is in treatment options. If the pervasive refusal syndrome is viewed as idiosyncratic, the result of psychological trauma, to be treated by individual and family psychotherapy, then the complex and limited recovery described in Clare may result. On the other hand, if the syndrome is viewed as an example of catatonia, then the options of sedative drugs (amobarbital, , or lorazepam) are available, and when these fail, recourse to ECT has a good prognosis (Cizadlo and Wheaton).

Whether ECT is used in adults or adolescents, the risk is the same. The principal consideration is the amount of electrical energy needed to elicit an effective treatment. Seizure thresholds are lower in childhood than in adults and the elderly. The use of adult-level energies may elicit prolonged seizures (Guttmacher and Cretella), but such events may be minimized by using the lowest available energies; monitoring of EEG seizure duration and quality; and interrupting a prolonged seizure by effective doses of diazepam. There is no reason to assume, based on the known physiology and the published experience, any other untoward events in ECT in prepubertal children.

The main concern is that medications or ECT may interfere with the brain's growth and maturation and inhibit normal development. However, the pathology that led to the abnormal behaviors may also have extensive effects on learning and maturation. Wyatt assessed the impact of neuroleptic drugs on the natural course of schizophrenia. He concluded that early intervention increased the likelihood of an improved lifelong course, reflecting the awareness that the more chronic and debilitating forms of schizophrenia, those defined as simple, hebephrenic or nuclear, became rarer as effective treatments were introduced. Wyatt concluded that some patients are left with a damaging residual if a psychosis is allowed to proceed unmitigated. While psychosis is undoubtedly demoralizing and stigmatizing, it may also be biologically toxic. He also suggested that "prolonged or repeated psychoses might leave biochemical alterations, gross pathologic or microscopic scars, and changes in neuronal connections," citing data from pneumoencephalographic, computed tomography and magnetic resonance imaging studies. Wyatt compels our concern that the rapid resolution of an acute psychosis may be essential to prevent long-term deterioration.

What are the lifetime behavioral effects of an untreated childhood disorder? It seems imprudent to argue that all childhood disorders are of psychological origin, and that only psychological treatments may be safe and effective. Until demonstrations of untoward consequences are recorded, we should not deny the possible benefits of biological treatments to children on the prejudice that these treatments affect brain functions. They surely do, but the likely relief of the disorder is a sufficient basis for their administration. (State laws in California, Colorado, Tennessee and Texas proscribe the use of ECT in children and adolescents under ages 12 to 16.)

It may be timely to review the attitudes of pediatric psychiatrists to childhood disorders. A more liberal attitude toward the biological treatments of pediatric psychiatric disorders is encouraged by this recent experience; it is reasonable to use ECT in adolescents where the indications are the same as in adults. But ECT use in prepubertal children is still problematic. More case materials and prospective studies are to be encouraged.

References for above entitled article

1. Black DWG, Wilcox JA, Stewart M. The use of ECT in children: case report. J Clin Psychiatry 1985; 46:98-99.
2. Bush G, Fink M, Petrides G, Dowling F, Francis A . Catatonia: I: Rating scale and standardized examination. Acta psychiatr. scand. 1996; 93:129-36.
3. Carr V, Dorrington C, Schrader G, Wale J. The use of ECT for mania in childhood bipolar disorder. Br J Psychiatry 1983; 143: 411-5.
4. Cizadlo BC, Wheaton A. ECT Treatment of a young girl with catatonia: A case study. J Am Acad Child Adol Psychiatry 1995; 34:332-335.
5. Clardy ER, Rumpf EM. The effect of electric shock on children having schizophrenic manifestations. Psychiatr Q 1954; 28:616-623.
6. Fink M, Carlson GA. ECT and prepubertal children. J Am Acad Child Adolesc Psychiatry 1995; 34:1256-1257.
7. Fink M, Klein DF. An ethical dilemma in child psychiatry. Psychiatric Bull 1995; 19: 650-651.
8. Gurevitz S, Helme WH. Effects of electroconvulsive therapy on personality and intellectual functioning of the schizophrenic child. J nerv ment Dis. 1954; 120: 213-26.
9. Graham PJ, Foreman DM. An ethical dilemma in child and adolescent psychiatry. Psychiatric Bull 1995; 19:84-86.
10. Guttmacher LB, Cretella H. Electroconvulsive therapy in one child and three adolescents. J Clin Psychiatry 1988; 49:20-23.
11. Lask B, Britten C, Kroll L, Magagna J, Tranter M. Children with pervasive refusal. Arch Dis Childhood 1991; 66:866-869.
12. Moise FN, Petrides G. Case study: Electroconvulsive therapy in adolescents. J Am Acad Child Adolesc Psychiatry 1996; 35:312-318.
13. Powell JC, Silviera WR, Lindsay R. Pre-pubertal depressive stupor: a case report. Br J Psychiatry 1988; 153:689-92.
14. Schneekloth TD, Rummans TA, Logan KM. Electroconvulsive therapy in adolescents. Convulsive Ther. 1993; 9: 158-66.
15. Taylor MA. Catatonia: a review of a behavioral neurologic syndrome. Neuropsychiatry, Neuropsychology and Behavioral Neurology 1990; 3: 48-72.
16. Wender PH. The hyperactive child, adolescent and adult: Attention deficit disorder through the lifespan. New York, Oxford U Press, 1987.
17. Wyatt RJ. Neuroleptics and the natural course of schizophrenia. Schizophrenia Bulletin 17:325-51, 1991.

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Here's a list of psychiatric medications (antidepressants, antipsychotics, anti-anxiety medications) with splitting potential.

Drugs and Their Clinical Use

Clonazepam (Klonopin): panic disorder, epilepsy
Citalopram (Celexa): depression
Paroxetine (Paxil): depression, anxiety
Nefazodone (Serzone): depression
: impotence
: depression
Olanzapine (Zyprexa): schizophrenia, bipolar disorder

Warning: Do not make any changes in your medications or the way you take your medications without first talking it over with your doctor.

Source: Stanford University Medical Center; Veterans Administration Medical Center, Ashville, N.C.

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Researchers conclude that lithium therapy provides a huge benefit in preventing suicide amongst patients with bipolar depression.

Bipolar depression is strongly associated with suicide and premature death due to stress-related medical illness and complications of comorbid substance abuse. Because suicidal patients with bipolar depression are excluded from most clinical trials, remarkably little is known about the contributions of mood-altering treatments to reducing mortality rates in these persons. Despite clinical and ethical constraints on research into the therapeutics of suicide, encouraging new information is emerging to show that lithium (Lithium Carbonate) has a selective effect against suicidal behavior in patients with major affective disorders.

Previous studies of lithium and suicide. We reviewed studies comparing suicidal rates in affectively ill persons treated with lithium. In all studies providing annual suicidal rates with and without lithium treatment, risk was consistently lower with lithium, averaging a seven-fold reduction. Incomplete protection from suicide may reflect limited effectiveness, inappropriate dosing, variable compliance, or the type of illness treated in this broad assortment of patients with severe mood disorders.

The antisuicidal benefit of lithium may represent a distinct action on aggressive behavior, perhaps mediated by serotonergic effects. Alternatively, it may reflect mood-stabilizing effects, particularly against bipolar depression. Our new findings indicate that lithium produces powerful and sustained reductions in depressive phases of both bipolar type I and type II disorders when administered over years of treatment.

Clinicians should not assume that all mood-stabilizers protect equally against both depression and mania or against suicidal behavior. For example, suicidal behavior occurred in a small but significant number of bipolar or schizoaffective patients treated with carbamazepine, but not in those receiving lithium (the anticonvulsant treatment did not follow discontinuation from lithium, a major stressor leading to sharp increases in bipolar morbidity and suicidal behavior).

New study of lithium vs. suicide. These previous findings encouraged additional studies. We examined life-threatening or fatal suicidal acts in over 300 bipolar type I and type II patients before, during, and following long-term lithium treatment at a collaborating mood disorder research center founded by Leonardo Tondo, M.D., of McLean Hospital and the University of Cagliari in Sardinia.

The patients had been ill for over eight years, from onset of illness to the start of lithium maintenance. Lithium treatment lasted over six years, at serum levels averaging 0.6-0.7 mEq/L, reflecting lithium doses consistent with optimal tolerability and patient compliance. Some patients were also followed prospectively for nearly four years after discontinuing lithium, without other maintenance treatments. Treatment discontinuation was monitored and distinguished from interruptions associated with emerging illness. Most discontinuations were clinically indicated for adverse effects or pregnancy, or were based on patients' decisions to stop without consultation, usually after remaining stable for prolonged periods.

Early emergence of suicidal risk. In this population of over 300 patients, life-threatening suicidal acts occurred at a rate of 2.30/100 patient-years (a measure of frequency over cumulative years) before they began on lithium maintenance. Half of all suicide attempts occurred in less than five years from onset of illness, when most subjects had not yet begun regular lithium treatment. Delays in lithium treatment from onset of illness were shortest in men with bipolar type I and longest in type II women, possibly reflecting differences in the social impact of manic versus depressive illness. Most life-threatening suicidal acts occurred before sustained maintenance treatment, suggesting that lithium treatment was protective and encouraging intervention with lithium early in the course of the illness to limit suicidal risk.

Effects of lithium treatment. During maintenance treatment with lithium, the rate of suicides and attempts decreased by nearly seven-fold. These results were strongly supported by formal statistical analysis: by 15 years of follow-up, the computed cumulative annual risk rate was reduced more than eight-fold with lithium treatment. With lithium treatment, most suicidal acts occurred within the first three years, suggesting that greater benefits derive from persistent treatment or earlier risk in more suicide-prone persons.

Effects of lithium discontinuation. Among patients discontinuing lithium, suicidal acts increased 14-fold above rates found during treatment. In the first year off lithium, the rate rose an extraordinary 20-fold. There was a two-fold greater risk after abrupt or rapid (1-14 days) versus more gradual (15 - 30 days) discontinuation. Although this trend was not statistically significant because of the infrequency of suicidal acts, the documented benefit of slow lithium discontinuation on reducing risk of relapse supports the clinical practice of slow discontinuation.

Risk factors. Concurrent depression or, less commonly, mixed-dysphoric mood, was associated with most suicidal acts and all fatalities; suicidal behavior was rarely associated with mania and no suicides occurred with normal mood. Additional analyses, based on an expanded Sardinian sample, assessed clinical factors associated with suicidal events. Suicidal behavior was associated with depressed or dysphoric-mixed current mood, prior illness with severe or prolonged depression, comorbid substance abuse, previous suicidal acts, and younger age.

Conclusions. These findings demonstrate that lithium maintenance exerts a clinically important and sustained protective effect against suicidal behavior in manic-depressive disorders, a benefit that has not been shown with any other medical treatment. Lithium withdrawal, particularly abruptly, risks a rapid, transient emergence of suicidal behavior. Prolonged delay from onset of bipolar illness to appropriate maintenance lithium treatment exposes many young persons to mortal risks as well as cumulative morbidity, substance abuse, and disability. Finally, the close association of suicidality with depression and dysphoria in bipolar disorders calls for further study to determine safe and effective treatments for these high-risk illnesses.

Additional Reading:

Baldessarini RJ, Tondo L, Suppes T, Faedda GL, Tohen M: Pharmacological treatment of bipolar disorder throughout the life-cycle. In Shulman KI, Tohen M. Kutcher S (eds): Bipolar Disorder Through the Life-Cycle. Wiley & Sons, New York, NY, 1996, pp 299

Tondo L, Jamison KR, Baldessarini RJ. Effect of lithium on suicide risk in bipolar disorder patients. Ann NY Acad Sci 1997; 836:339‚351

Baldessarini RJ, Tondo L: Effects of discontinuing lithium treatment in bipolar manic-depressive disorders. Clin Drug Investig 1998; in press

Jacobs D (ed): Harvard Medical School Guide to Assessment and Intervention in Suicide. Simon & Shuster, New York, NY, 1998, in press

Tondo L, Baldessarini RJ, Floris G, Silvetti F, Hennen J, Tohen M, Rudas N: Lithium treatment reduces risk of suicidal behavior in bipolar disorder patients. J Clin Psychiatry 1998; in press

Tondo L, Baldessarini RJ, Hennen J, Floris G: Lithium maintenance treatment: Depression and mania in bipolar I and II disorders. Am J Psychiatry 1998; in press

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Source: McLean Hospital Psychiatric Update, A Practical Resource for the Busy Clinician, Volume 1, Issue 2, 2002

This article was contributed by Ross J. Baldessarini, M.D., Leonardo Tondo, M.D., and John Hennen, Ph.D., of the Bipolar & Psychotic Disorders Program of McLean Hospital, and the International Consortium for Bipolar Disorder Research. Dr. Baldessarini is also Professor of Psychiatry (Neuroscience) at Harvard Medical School and Director of the Laboratories for Psychiatric Research and the Psychopharmacology Program at McLean Hospital.

Lithium (Lithium Carbonate) Full Prescription Information

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(Cochrane Review)

ABSTRACT

A substantive amendment to this systematic review was last made on 19 March 2001. Cochrane reviews are regularly checked and updated if necessary.

Background: Mood disorders are common, disabling and tend to be recurrent. They carry a high risk of suicide. Maintenance treatment, aimed at the prevention of relapse, is therefore of vital importance. Lithium has been used for some years as the mainstay of maintenance treatment in bipolar affective disorder, and to a lesser extent in unipolar disorder. However, the efficacy and effectiveness of prophylactic lithium therapy has been disputed. Low suicide rates in lithium-treated patients have led to claims that lithium has a specific anti-suicidal effect. If so, this is of considerable importance as treatments for mental disorders in general have not been shown convincingly to be effective in suicide prevention.

Objectives: 1. To investigate the efficacy of lithium treatment in the prevention of relapse in recurrent mood disorders. 2. To examine the effect of lithium treatment on consumers' general health and social functioning, its acceptability to consumers, and the side-effects of treatment.3. To investigate the hypothesis that lithium has a specific effect in reducing the incidence of suicide and deliberate self-harm in persons with mood disorders.

Search strategy: The Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Register (CCDANCTR) and The Cochrane Controlled Clinical Trials Register (CCTR) were searched. Reference lists of relevant papers and major text books of mood disorder were examined. Authors, other experts in the field and pharmaceutical companies were contacted for knowledge of suitable trials, published or unpublished. Specialist journals concerning lithium were hand searched.

Selection criteria: Randomised controlled trials comparing lithium with placebo, where the stated intent of treatment was maintenance or prophylaxis. Participants were males and females of all ages with diagnoses of mood disorder. Discontinuation studies (in which all participants had been stable on lithium for some time before being randomised to either continued lithium treatment or placebo substitution) were excluded.

Data collection and analysis: Data were extracted from the original reports independently by two reviewers. The main outcomes studied were related to the objectives stated above. Data were analysed for all diagnoses of mood disorder and for bipolar and unipolar disorder separately. Data were analysed using Review Manager version 4.0.

Main results: Nine studies were included in the review, reporting on 825 participants randomly allocated to lithium or placebo. Lithium was found to be more effective than placebo in preventing relapse in mood disorder overall, and in bipolar disorder. The most consistent effect was found in bipolar disorder (random effects OR 0.29; 95% CI 0.09 to 0.93 ). In unipolar disorder, the direction of effect was in favour of lithium, but the result (when heterogeneity between studies was allowed for) did not reach statistical significance. Considerable heterogeneity was found between studies in all groups of patients. The direction of effect was the same in all studies; no study found a negative effect for lithium. Heterogeneity may have been due to differences in selection of participants, and to differing exposures to lithium in the pre-study phase resulting in variable influence of a discontinuation effect. There was little reported data on overall health and social functioning of participants under the different treatment conditions, or on the participants' own views of their treatment. Descriptive analysis showed that assessments of general health and social functioning generally favoured lithium. Small absolute numbers of deaths and suicides, and the absence of data on non-fatal suicidal behaviours, made it impossible to draw meaningful conclusions about the place of lithium therapy in suicide prevention.

Reviewers' conclusions: This systematic review indicates that lithium is an efficacious maintenance treatment for bipolar disorder. In unipolar disorder the evidence of efficacy is less robust. This review does not cover the relative efficacy of lithium compared with other maintenance treatments, which is at present unclear. There is no definitive evidence from this review as to whether or not lithium has an anti-suicidal effect. Systematic reviews and large scale randomised studies comparing lithium with other maintenance treatments (e.g. anti-convulsants, antidepressants) are necessary. Outcomes relating to death and suicidal behaviour should be included in all future maintenance studies of mood disorder.

Citation: Burgess S, Geddes J, Hawton K, Townsend E, Jamison K, Goodwin G.. Lithium for maintenance treatment of mood disorders (Cochrane Review). In: The Cochrane Library, Issue 4, 2004. Chichester, UK: John Wiley & Sons, Ltd.

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Depression on the job is often misinterpreted as a bad attitude or poor work ethic. Managers should be aware of an employee's mental health.

Just as managers should be aware of any physical ailment that may hinder an employee's work, so should they be aware of an employee's mental health. Mental illness often goes unrecognized because it's not so easy to spot and it's considered a private matter for most people.

Depression on the job is often misinterpreted as a bad attitude or poor work ethic. You won't change it with a reprimand or a pep talk. You may, however, be able to put your worker at ease by showing your awareness of the problem. First, you must be able to recognize it.

If an employee has recently suffered the death or departure of a family member or close friend, the grieving process and accompanying sadness is natural. It will take time and perhaps counseling for the individual to recover previous working habits and disposition. On the other hand, if no such loss or other traumatic event can be linked to an employee's apparent depression, the cause may be more complicated. It could be physiologically based (and a long-term condition), requiring medication or some other treatment plan.

Regardless of the cause, keep in mind that whatever problems you may be experiencing from someone's depression, their frustration with it is far more extreme. And the only control they have over it is to seek professional help.

The Warning Signs of Depression

One in 20 Americans currently suffer from depression severe enough to require medical treatment. If you suspect that an employee may be suffering from depression, consult the following list of symptoms. If these characteristics persist for a number of weeks, a thorough diagnosis may be necessary:

• decreased productivity; missed deadlines; sloppy work
• morale problems or a change in disposition
• social withdrawal
• lack of cooperation
• safety problems or accidents
• absenteeism or tardiness
• complaints of being tired all the time
• complaints of unexplained aches and pains
• alcohol and drug abuse

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