Emsam; An Anti depressant which is applied as a patch

Emsam was released a few years ago as transdermal patch for the treatment of depression. Emsam is Selegeline. Selegeline is a monoamine oxidase inhibitor (MAOI) used in the treatment of Parkinson’s disease and has been around for more than a decade. It was observed that many parkinsonian patients who were treated with selegeline had improved mood and spirits. Further work revealed that selegeline did improve mood in patients with depression.

Monoamine oxidase inhibitors have been used to treat depression for more than half a century and are some of the oldest drugs in the pharmacopeia. While the drugs are effective, the major problem with MAOI is that people have severe dietary restrictions otherwise complications can occur. However, with Emsam, the drug is delivered via the skin and the same type of dietary restrictions are not needed (esp at the low dose).

Emsam is slow absorbed through the skin and enters the brain where it works in depressed patients. The biggest advantage of Emsam is that because it does not go via the stomach and avoids the liver, it has a very low risk of inducing problems which were previously seen with older MAOI. The risk of high blood pressure with this formulation is less than 1 percent.

Emsam is usually applied as patch on the skin. When the 6 mg patch is applied every 24 hours there are no dietary restrictions. The drug is slowly absorbed through the skin continuously for 24 hours and this keeps level of Emsam fairly constant thought out the day.

IF I have bipolar, can I take antidepressant drugs?

As a rule anti depressants are almost never used to treat bipolar disorder. It is only the rare physician who treats bipolar with an antidepressant. The reason for the hesitancy in treating a bipolar patient who is depressed with a conventional anti depressant is that the drug may rapidly induce a state of mania with potential adverse outcomes, such as extreme paranoia, suicide or psychosis.

Further, not all anti depressants work in the same way and there is always a chance of harming the patient. For the above reasons most psychiatrists have been very hesitant in using the conventional anti depressant in individual with a bipolar disorder. The routine practice has been to use an anti depressant in combination with a mood stabilizer to prevent the sudden onset of mania. Some physicians only use a mood stabilizer alone or combine it with a anti psychotic (neuroleptic) drugs which is approved for use in bipolar depression.

At the moment there is no way of knowing which bipolar individual will react adversely to the anti depressant drugs. Most of the factors which determine the type of reaction are individually based. Individuals who continue to abuse drugs, or have had prior treatment failures with anti depressant, or those who have a rapid cycling form of bipolar disorder or those with a genetic alteration a certain gene (serotonin transporter gene) have a high risk of developing adverse reactions.

So far there are no rigid rules or guidelines as to when an anti depressants can be used in patients with bipolar disorder. In those individuals with bipolar disorder who continue to have prolonged episodes of depression, it is important to discuss this issue with your mental health counselor. One needs to develop a treatment plan to meet individual needs. If an anti depressant is started, one needs very close follow up to ensure that there are no untoward problems during the with mania phase.

Transcranial magnetic stimulation for depression

In the last decade, there have been some advances in treatment of a variety of neurological disorders like Parkinson’s disease with deep brain stimulation. Essentially the technique involves inserting very thin electrodes into appropriate parts of the brain and stimulating nerves to mimic the real physiological situation. Now researchers want to apply similar techniques (but without electrodes) to treat depression and a variety of other mental health disorders. Transcranial magnetic stimulation involves the use of an electromagnetic coil around the brain. The electromagnetic field generated results in a number of effects- one of which is an antidepressant effect.

Transcranial magnetic stimulation is not clinically available at the moment and is still in the experimental stages. The treatment has not even been approved by the FDA. Currently some large centers are conducting clinical trials.

At the moment, clinical trials are including patients who have severe drug resistant depression. Individuals who have metal clips, pacemakers or other metal implants in the brain are excluded from the trials. Also excluded are pregnant females because effects of the magnetic field on the fetus have not been thoroughly studied. One other group which has also been excluded from the clinical trials, are individuals who are at high-risk for seizures.

Unlike Electroconvulsive therapy, Transcranial magnetic stimulation does not require use of anesthesia or any type of shock therapy. One does not even require any type of anesthesia. From the limited clinical trials, the observed side effects have been minimal. The majority of individuals only complain of a slight tingling feeling at the site or a mild headache. The only disadvantage of therapy is that one lies on a bed and the head is placed inside a tunneled device (like a CT Scan). The machine is loud but the patient is given a pair of ear muffs. Individuals who do not like enclosed spaces may not be keen to undergo this type of therapy.

One simply lies on the flat bed for a few hours until the treatment is completed. At the end of the treatment, one can go home. The protocol involves five treatment sessions per week for 4-6 weeks. While this may sound like a lot of time commitment, it is better than taking drugs for the rest of life. In addition, the drugs for depression also have many side effects and often the drugs do not work.

At the moment enrollment is free in clinical trials. To participate in a trial, you need to speak to your health care worker and get a referral. The trials do have inclusion and exclusion criteria but it is definitely worth a try. It is not often that one gets a chance to receive free treatment, which has minimal side effects. However, like all treatments for depression, Transcranial magnetic stimulation is not a cure for depression.

Does Caffeine worsen depression?

There are some individuals who drink coffee (caffeine) and are worried that it may worsen or even cause depression. Today, there is very little evidence to link caffeine and depression. Despite the fact that Caffeine is a brain stimulant; it does worsen depression in a fair number of individuals. Why this brain stimulant induces depression is a mystery. There are suggestions that caffeine may alter blood sugar levels and this may be one cause for the mood alterations. Other experts claim that perhaps caffeine induces a severe state of alertness and anxiety and thus the individual is no longer able to sleep or function properly and hence gets depressed

The number of individuals whose depression is worsened by caffeine is not known. In any case, if your depression gets worse after consuming caffeine, one should limit the intake of caffeine containing beverages. The caffeine beverages should be gradually deceased because abrupt discontinuation of caffeine can also lead to mild withdrawal symptoms such as headaches, lethargy, irritability, and anxiety. There are a few anecdotal reports indicating that lessening caffeine intake can lessen the severity of depression.

Caffeine is not as bad as what is made out in the lay media. It does have a few proven health benefits including ability to improve alertness, increasing concentration and allowing one to be more sociable. A number of French studies have shown that a daily cup of coffee can lead to a lesser degree of cognitive impairment with age. However despite its potential benefits, too much caffeine also has adverse effects. For the depressed individual, the trick is to consume the right balance of caffeine.

Fish oil supplements for depression

Over the last few years, there have been a few small studies indicating that perhaps fish oil supplements can help reduce the symptoms of depression. Anecdotal reports indicate that some individuals do better with fish oil supplements alone.

Fish oil is known to be a good source of omega 3 fatty acids. These fatty acids have been shown to play a role in the normal functioning and development of brain. A few isolated reports indicate that depressed individuals also have low levels of eicosapentaneoic acid, which is a long chain fatty acid.

However, the evidence for fish oil and depression is very scant and only sporadic reports are available. One study showed that taking 2 gr of fish oil had no effect but a 4 gr dose did show some improvement in symptoms. Current research is now taking place to determine what percentage of patients can improve and how long the effects of the fish oil last.

At this point, fish oil is not recommended as a substitute treatment for depression. For the time being anti depressants still remain the standard of therapy and before one starts to embark on a therapy of fish oil only, discuss this issue with your physician. However, since fish oil is known to be beneficial for heart disease, there is absolutely no harm in taking fish oil with the present day anti depressants.

Rather than taking fish oil pills to get omega 3 fatty acid, a better alternative is eat more fish. The pills are expensive and who knows what else they contain. Other foods, which also have high levels of omega 3 fatty acids, include flaxseed, canola oil, Soya beans, and walnuts. Unlike pills, natural foods are less likely to be contaminated with fake products or artificial ingredients (remember melamine?)

Vitamin B12 and depression

Physicians have known for a long time that individuals who have low levels of Vitamin B 12 develop many problems in their body, including depression. Vitamin B12 and related health supplements like folate are essential for function of neurochemicals in the brain. Many of minerals and vitamins act as co-factors and help in the synthesis of vital neurotransmitters in the brain.

However, the problem is that the brain is too complex. There are millions of nerves in the brain, each intricately linked and all working in harmony. Where B12 fits into this grand picture has remained a mystery. Besides B12, many other minerals have been linked to depression include, cooper, zinc, selenium and iron.

The most common cause of B12 deficiency is poor nutrition. One also has to remember that once depression sets in, the individual will further worsen the problem by not eating healthy. Individuals who develop depression often show little interest in food and tend to eat unhealthy foods thus worsening the cycle of depression.

While there has been a lot of hype about Vitamin B12 as a cure for depression, one should know that replenishing the diet with this vitamin does not always reverse the depression. However, that does not mean one should not eat healthy. All individuals who are depressed should eat a well balanced diet that contains all essential minerals, and vitamins including B 12. There is absolutely no point in buying vitamins from a health store. Vitamin B12 is found in ample amounts in many foods like breakfast cereals, meat, poultry, milk, and seafood.

For those who are on a vegetarian diet an over the age of 50, perhaps obtaining extra vitamins supplements may help.

All patients with depression should ensure that the health care professional has addressed any underlying medical disorder that can make your depression worse. Some of the common conditions that affect depression include under activity of the thyroid (hypothyroid) vitamins deficiencies and pernicious anemia. Once these conditions are treated, the depression may improve.

Why will my Anti Depressant medication not work anymore?

One common complaint among many depressed patients is that their medication no longer works. The majority of individuals notice that the depression just will not go away with the medication that helped them previously. So what gives?

Well, failure of anti depressants to work on long-term basis has been known for decades. The exact number of people affected by this so called “POOPING OUT” effect is not known, but is said to be quite high – at least 20%-40% of individuals.

This phenomenon where anti depressants fail to work has not been thoroughly studied but there are a few speculations as to why this may happen.

Most psychiatrists feel that depression is a chronic disease that does get worse with age. Why depression worsens with age is not understood but is felt to be due to depletion of certain neurochemicals in the brain. With age, the depressive episodes also are more frequent and more intense. Often the depression is affected by daily stresses in life and is harder to control

In a few individuals, the reason why anti depressants fail to work all of a sudden is presence of another medical disorder. The most common disorder that can worsen depression is hypothyroidism. If you are on an anti depressant and the medication fails to work, go and get your thyroid hormone levels checked out.

Often the failure of medications to work is because of interaction with other medications. Most individuals who are on anti depressants are on a hodge podge of many different medications, including sleeping pills, sedatives and anti anxiety pills. In many cases, the use of the other depressant drugs or even alcohol has been found to be the reason why anti depressants no longer work.

There are rare cases when the there has been a confusion in the diagnosis. Often some individuals are diagnosed with depression when they actual have manic depression, a disorder where depression is a well-known element.

Whenever an anti depressant fail to work, your health care professional will adjust the dose. Sometimes an additional drug may be added or a completely new class of anti depressant drug may be prescribed.

For those individual who have depression not responsive to their old prescription, it is essential to follow up with your psychiatrist. Depression is not curable but it is treatable with a number of drugs and psychotherapy.