•    Serious physical disease is a common cause of depression. In the acute phase of a serious disease at least a quarter of patients become depressed, according to one US study of 150 people in hospital for physical ailments. Several studies have found a high correlation between suicide and physical illness. Rheumatoid arthritis, peptic ulcer, and high blood pressure, were found to have the greatest ‘suicide’ potential in one study.

Chronic illness and disability can, undoubtedly, make people depressed. For some such people depression becomes a way of life.

Talking of chronic disease, several surveys have found that people who are depressed stand a much greater chance of dying prematurely of cancer than do others of the same age.

•    ’Glandular’ problems can sometimes cause depression. Thyroid disease is a fairly common cause.

Food allergies and intolerances are an increasingly recognized cause of depression. Foods especially likely to be at fault are cows’ milk, eggs, nuts, and wheat and its products. Elimination diets can be useful in detecting the culprit but results can take several weeks (as opposed to days with other food-allergy manifestations) so one has to be very careful in the early stages to be sure that the diet is not so poor that this adds to the clinical problem. Taking plenty of water, minerals and vitamin supplements will definitely help.

•     Babies and children are a major source of depression. One of the most depressed groups of people in the West is the group of young children’s mothers. Post-natal depression is extremely common, with eight out of ten women complaining of at least some ‘baby blues’. Women who deliver at home have much lower levels of depression post-natally, as do those whose babies are exclusively breast-fed.

•     Success. We have been conditioned into thinking of depression as caused by failure and negative life events but a small minority of people become depressed when they achieve goals and are successful. Some see their success as undeserved or a hollow sham and yet others fear it will be taken away from them. Some fear what success will bring and back away from it just as they are about to achieve it. Many people unconsciously (and sometimes even consciously) fear the effect that their success has on others and fear the rivalry it produces. Rather than provoke such rivalry (which may remind them of childhood rivalry) they fight shy of success even when it stares them in the face.

•     Mental or physical fatigue is a little-discussed cause of depression but most of us can easily slide into true depression if either or both strike. This could be at the heart of much of the depression seen in young women with small children.

The menstrual cycle causes depression regularly in a proportion of women. About half of all women have at least some premenstrual symptoms, and depression can be a real problem for a few. Admission to mental hospitals, suicide attempts, child battering, and depressive episodes are all more common pre-menstrually than at any other time of the month in the female population generally. Clearly there is a hormonal effect but recent thinking suggests that dietary imbalances too play a vital role.

•    Retirement, divorce, separation and loneliness are powerful sources of depression in our culture today. Divorce and separation are especially likely to make people depressed, particularly if children are involved. Admission to mental hospital and all kinds of physical illness (including cancers) are much more common in the divorced and separated than in the married. Marital problems themselves are potent and common causes of depression. One large study compared various different forms of therapy for depression and found that of all those tested (including drugs) marital therapy was the most successful.

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A criticism sometimes made with regard to animal trials of substances intended for use on human beings is that the information gained may not be applicable. This means that the results of tests done carefully and objectively on rat models may not relate directly to those that would have been evident from the same trial on human patients, which is not surprising when we think about it. For instance, animal models live under very different circumstances to humans; they may also indicate quite different immunity response to infections. Sue, features can influence their responses to stimuli in such a wa4 that a direct comparison with human response is not accurate.

Take another line of reasoning. Animals used in trial work are usually bred specifically for this purpose and are healthy in all respects except the condition induced for the intention of the trials. The human patient, afflicted with the same condition as the trial rat, may also be infected with several other health problems which may substantially influence circumstances. The human patient may be confined to bed during the period of therapy whereas the animal model would probably be returned to its cage to carry on life in the norm way.

There is a difference of opinion amongst the profession; people involved in this field of work about the value animal trial results. Without doubt the results are valuable, but interpretation of animal trial information must take into account the limiting factors.

With reference to the second category of animal trials, those used on substances intended as veterinary products, we are probably approaching a more attainable ideal. At least here we are testing substances on animals for subsequent use with animals.

One of the main problems in this area is the attempt to scale up the results of work done on rats and mice to be applicable to, say, horses or cows. It is not always true that something which works well on a laboratory scale also does so on a full scale. Another factor which can be influential is the difference in activity of different groups. For instance, the effect of a particular drug could be quite different in an active working animal, such as a horse, to a relatively sedentary animal maintained in a laboratory cage.

*27/48/5*

For some women, chemotherapy or radiotherapy is used as a primary treatment rather than as an adjuvant following surgery. In the case of rapidly growing breast cancer, by the time a diagnosis is made the tumour may be too large to be removed surgically, or cancer cells may already have spread to other parts of the body. Although the surgeon may take a biopsy of the tumour for examination, the first line of treatment in these cases may be chemotherapy or radiotherapy.

Primary chemotherapy

The drugs used are the same as those mentioned above for adjuvant chemotherapy, but they may be given more often or in higher doses.

You may have to stay in hospital during your treatment, or it may be given in the outpatients’ clinic. The doctor will monitor your chemotherapy carefully and will examine you regularly to make sure that the tumour is shrinking.

Once the tumour has been reduced to a more manageable size, it may then be removed surgically or be treated by radiotherapy. This form of chemotherapy is used most commonly for young women with large, fast-growing breast cancers for whom subsequent surgery is less mutilating once the tumour has shrunk.

Primary radiotherapy

Similarly, radiotherapy may be used as a primary treatment for a tumour that is too large to be removed surgically. The course of primary radiotherapy treatment is longer than that for adjuvant radiotherapy following surgery, and it may be administered by X-ray beam as well as internally through radioactive wires inserted into the breast under anesthetic. Internal radiation treatment is given over a period of 3 to 4 days, during which time you will have to remain in hospital.

Palliative therapy

When breast cancer is very advanced, and cannot be cured, chemotherapy and radiotherapy can be used to slow its growth or help relieve its symptoms. Hormones other than tamoxifen may also be used to slow the growth of the tumour without causing too many side-effects.

Palliative treatment of this sort may successfully prevent the cancer from growing for many months or years, even though it cannot be completely eradicated.

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How effective is Danazol

Danazol is commonly believed by gynecologists to be the most effective hormonal treatment for endometriosis but there is increasing evidence that it is no more effective than some of the other drugs.

Up to 80% of women experience total or partial relief from their symptoms and about 40% to 80% of women who wish to become pregnant conceive following treatment. Some 20% to 30% of women will have a recurrence of endometriosis within the first twelve months and a further 5% to 10% will experience a recurrence each year thereafter.

Danazol, pregnancy and breastfeeding

Danazol should not be used during pregnancy as it can cause masculinisation of the external genitals of a female foetus. If you become pregnant or suspect that you may be pregnant while taking Danazol you should stop taking it and contact your gynecologist immediately.

As is not known if Danazol is excreted in the breast milk nor whether it has any harmful effects on the infant, you should not take Danazol if you are breastfeeding.

Interaction with other drugs, alcohol or foods

There are no known interactions of Danazol with any foods or alcohol. It can interact with some drugs and you should make sure that your gynecologist is aware of any other drugs that you may be taking.

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Of all the classes of antidepressants, the tricyclic antidepressants, or TCAs, have been studied most. (“Tricyclic” refers to the drug’s three-ring chemical structure.) The TCAs shown to work best are desipramine, imipramine, and amitriptyline. All of these products have some troublesome side effects – sedation, dry mouth, lowered blood pressure. Because it has the lowest incidence of side effects, desipramine is usually my first choice for treatment if I am using a tricyclic antidepressant. If a patient has trouble sleeping, I will consider prescribing a product that is more sedating, such as imipramine or amitriptyline.

Of course, because of her purging, a bulimic patient may have trouble keeping anything in her stomach. Medicine won’t do any good if it doesn’t get absorbed. I therefore ask my patients to take their medication just before bedtime, so the drug has time to work.

Sensible practice means giving the lowest dose of medication that still has a chance of producing benefit. Doing so minimizes the risk of side effects. If the patient doesn’t seem to be responding, I gradually increase the dosage. We usually see results within a week or two, but, as in treatment for depression, an adequate trial of these medications often needs a good six weeks.

During the course of therapy it’s necessary to monitor the levels of the medication in the patient’s body. We do so by analyzing blood samples. This step is important because different people metabolize medications at different rates. Two people on the same dosage regimen may show very different plasma levels, and may thus have completely different responses to the medicine. We try to achieve the same plasma levels in bulimics as we do in depressed patients who use the medication.

Getting the right concentration of the drug can mean the difference between therapeutic success and failure. One study showed that a group of patients with a plasma level of desipramine that was below the therapeutic range noticed no improvement in their bulimia. But when the concentration was raised, four out of six patients stopped bingeing.

Some patients incorrectly think that “if a little medication works, then taking more should work even better.” Nortriptyline (another tricyclic), for example, has what we call a “therapeutic window.” This means there are both minimum and maximum levels of concentration that will provide benefits. Above or below those levels, the drug loses its effectiveness.

I also discuss the possible side effects with my patients before I write the prescription. Doing so helps prepare them for any problem they may have with the medication. This in turn improves compliance. If the patient is suicidal or psychotic, or if she abuses drugs or alcohol, antidepressants must be used with extreme caution.

As I’ve said, medications are just part of an overall treatment plan. Prescribing antidepressants without setting up a solid psychotherapeutic relationship with the patient may hurt her chances of getting better.

*61/35/5*

When Carol Haas was 17 years old, she began forcing herself to vomit after meals in a desperate and dangerous attempt to slim down. At 5 foot 8 and 160 pounds, the high-school athlete was hardly obese. But her self-image had taken such a beating as a result of a lifetime of painful personal problems that she became fixated on her weight.

So began a 20-year struggle with eating disorders that dragged Carol through episodes of anorexia, bingeing and purging, excessive dieting, and compulsive exercising. “I felt awful about myself and what I was doing,” says the 57-year-old Downingtown, Pennsylvania, resident. “But I couldn’t stop myself. I was out of control. I was determined to not be fat, regardless of the price I paid.” I

It took the demise of a troubled first marriage, and the understanding and concern of the man who would become her second husband, to finally free Carol from the eating disorders that had plagued her for so long. With encouragement from her new partner, jshe sought counseling to help her deal with the issues that had skewed her self-image and her attitude toward food and eating.

Through her counseling sessions, Carol came to understand the reasons for her eating disorder. She learned that she had to take control of her eating habits rather than let them control her. She gradually adapted to eating three healthy meals a day and exercising regularly—not compulsively.

“During my recovery, one of the most important things I did was allow myself foods that I had always considered off-limits,” Carol says. “That empowered me because I realized I could choose what to eat and what not to eat.

“There’s dignity in choice,” she adds. “It explodes self-imposed boundaries. It puts you in charge. It gives you freedom and power over food. For someone with an eating disorder, that’s a life-altering and often lifesaving revelation.”

It certainly had a profound impact on Carol. As she made peace with food, her self-image improved. She began to heal, physically and emotionally. And, to her pleasant surprise, she lost 20 pounds over the course of 2 years.

A few years later, in the mid-1980s, Carol enrolled in college to earn certification as an eating disorders counselor. “I was so grateful for my own recovery that I wanted to help others,” she explains.

“My life changed dramatically when I finally stopped my power struggle with food,” Carol says. “I was able to focus on being healthy instead of on what I was or wasn’t eating. That has made all the difference.”

*115\89\8*