When the Antidepressants Run Out
Prozac is the most prescribed antidepressant. It is also prescribed
for obsessive-compulsive disorder (OCD) and co-morbid anxiety. By
inhibiting serotonin re-uptake, more serotonin is available at the
synapse, which is anti-depressant. There are many SSRIs prescribed
for depression: Prozac, Zoloft, Paxil, Celexa, Lexapro, etc. There
are antidepressant medications which target serotonin and other
neurotransmitters, such as norepinephrine (Effexor), but they lie
outside the scope of this article.
When raw ingredient
availability is interrupted these medications will become abruptly
unavailable. There are recent examples of this phenomenon in the
United States: in 2003 tetanus toxoid became very scarce for some
months due to a "pharmaco-political" issue, private clinics
and urgent care centers ran out of tetanus toxoid for a period of
some months, and it was available only in hospital emergency rooms.
In 2004 Ciprofloxacin became temporarily unavailable from any source
for largely unknown reasons. It is used for many common infections
and it was nowhere to be found.
will evolve to produce critical shortages in vital medications as
is happening now in Greece: "Pharmaceutical companies are no
longer interested in selling to Greece where hospitals and pharmacies
are in debt," said Kostas Lourantos, head of the pharmacies'
association in the Attica region that includes the capital Athens.
Rampant inflation is making lifesaving drugs unaffordable even if
available. This is especially true for cancer drugs, antibiotics,
antidepressants, and insulin (emphasis
of SSRI's creates both prompt and delayed withdrawal symptoms.
This is well recognized and variously called "SSRI withdrawal
syndrome," "SSRI cessation syndrome," "Discontinuation
syndrome," etc. Neurologically, phenomena called "paraesthesias"
occur, feeling like "electric shocks" in the head. Other
symptoms include: sweating,
agitation, anxiety, akathesia,
attacks, irritability, hostility, aggressiveness, worsening
of mood, dysphoria
(unhappiness), crying spells, mood instability, hyperactivity, depersonalization,
decreased concentration, slowed thinking, confusion, and memory/concentration
standards of medical practice advise a slow, gradual, well controlled
withdrawal of SSRI's in cases where discontinuation is advisable.
In the event of drug shortages and hyperinflation, discontinuations
will be abrupt, and acute withdrawal syndromes will be frequent.
As with other
survival strategies, those who take SSRI anti-depressants must
plan for their unavailability. In general, naturally occurring substances
and adjunct therapies are not enough by themselves to treat depression
completely, although there is much disagreement on this issue. Naturally
occurring substances often do not produce the pronounced pharmacological
effects like manufactured medications do. For this reason, when
SSRI's are available, one must not discontinue the
SSRI's in favor of taking "natural" substances whose anti-depressant
effects may not be as pronounced. One could endanger one's health,
have recurrent depression which resists treatment, become suicidal,
etc. ("Available" is a relative term: congress just
passed a bill to prohibit and destroy any medications bought online
from foreign pharmacies, thereby eliminating access to affordable
pharmaceuticals for those on a budget).
this informational article, we discuss the situation where the American
economy, society and infrastructure are collapsing and SSRI's are
no longer available. In that case, it will be necessary to substitute
available substances and strategies to replace the SSRI's and continue
to treat depression. If the U.S. ends up like Greece, one may have
to seek and use natural substances, plants, foods to treat depression.
is involved in mood, appetite, sleep and impulse control. Serotonin
taken orally cannot easily cross the blood brain barrier. However,
serotonin levels can be increased by ingesting a precursor amino
acid: tryptophan. L-tryptophan is an essential amino acid necessary
for the production of serotonin. Some people find that boosting
their L-tryptophan levels helps alleviate the symptoms of depression
or insomnia. The figure below shows l-tryptophan converting into
5-HTP, which then readily converts into serotonin. Once serotonin
is made, the pineal gland is able to convert it at night into melatonin,
the sleep-inducing hormone.
> 5-Hydroxytryptophan 5-HTP
> N-Acetyl-serotonin > Melatonin
or 5-hydroxy-trytophan are good natural options since they convert
into serotonin after going into the brain. If supplemental tryptophan
and 5-HTP are available, they can be stockpiled. But, supplements
too are manufactured and may become unavailable.
dietary supplements were available for use in the 1980s. Consumers
were using tryptophan for sleep and as an antidepressant. It was
available without a prescription until 1989 when the FDA prohibited
its over-the-counter sale because a manufacturer in Japan shipped
a contaminated batch to the U.S. causing a serious illness called
eosinophilia myalgia syndrome (EMS) in about 1,000 individuals.
Around 1995, tryptophan gradually became available by prescription
through compounding pharmacies, and since the year 2000 it slowly
and cautiously resurfaced on the over-the-counter market through
a few vitamin companies.
side effects, caution, safety, toxicity
A common tryptophan
side effect from high dose use is drowsiness. Therefore, it should
be taken in the evening and not while driving or operating heavy
machinery. Dry mouth is a less common side effect. Other less common
l-tryptophan side effects include nausea, dizziness, and loss of
appetite. A beneficial l-tryptophan side effect is drowsiness since
that is the desired effect of many users who take this supplement
for sleep. Confusion or disorientation is rare. L-tryptophan occurs
naturally in food and there is no danger of EMS from eating foods
which contain tryptophan. Poultry and some vegetables
supply tryptophan (remember turkey sandwich bedtime snack helps
you sleep?). So, the approach should include adequate intake of
tryptophan containing foods:
turkey, red meat, fish, shellfish, poultry, pork chops.
Milk, egg whites and cheese are all good source of tryptophan
- Soy products,
nuts and seeds are high in tryptophan. Fruits and vegetables containing
tryptophan are bananas, spinach and beans.
seeds are a natural source of L-tryptophan, with a tryptophan
content of 0.576 grams per 100 grams of dried pumpkin seeds. Roasted
pumpkin seeds, with or without added salt, have a slightly lower
(5-HTP) is an amino acid that is the immediate precursor of serotonin.
It is produced in the body and is used to make the neurotransmitter
serotonin. Although taking 5-HTP in supplement form may boost the
body's serotonin levels, some experts feel there is not enough evidence
to determine the safety of 5-HTP. There is general agreement that
5-HTP should not be combined with other pharmacologic anti-depressants.
Since 95% of
depressed individuals also have one or more anxiety symptoms, anxiety
will be mentioned often as accompanying depression. One RCT (retrospective
controlled trial, the "sine qua non" for many
doctors) examined 5-HTP for anxiety disorders. A total of 45 patients
with agoraphobia, panic attacks, generalized anxiety disorder, panic
disorder, or obsessive compulsive disorder, were randomized
to clomipramine (a tricyclic antidepressant), 5-HTP or placebo for
8 weeks. Patients treated with 5-HTP showed a reduction in anxiety
which was similar to that of clomipramine. Five out of 15 treated
with 5-HTP improved more than 50%, compared with only one out of
15 on placebo.
A study by
Kahn, et.al. showed an initial and transient worsening
of anxiety symptoms in those treated with 5-HTP before improvement.
Overdosing on 5-HTP can cause: fever, nausea, dizziness, confusion,
hallucinations, and restlessness; severe cases can result in fever
and death. These symptoms can progress very quickly and can prove
to be fatal within 24 hours of the first symptom.
Those on other
serotonin-targeting chemicals such as SSRI's, tryptophan, SAM-e,
or St. John's wort should not take 5-HTP supplements.
5-HTP should not be taken with anti-depression or anti-anxiety medication
because this can cause serotonin levels to increase to a dangerous
level, causing "Serotonin Syndrome." Supplements of 5-HTP
can also raise blood pressure and increase heart rate, so it is
not recommended for those with high blood pressure unless approved
by their physician. Pregnant and nursing women should
also avoid 5-HTP, as well as anyone with cardiovascular disease
or who is at risk for cardiovascular disease. The
increased blood pressure brought on by 5-HTP may also increase tumor
growth rate: those with carcinoid tumors should avoid 5-HTP.
5-HTP shows promise for anxiety disorders which often accompany
depression. Many physicians feel insufficient research has been
done to recommend 5-HTP (Expert Rev Pharmacoeconomics Outcomes Res.
its chemical/biochemical relationship to L-Tryptophan, 5-HTP has
been under scrutiny by consumers, industry, academia and government
for its safety. However, extensive analyses of several sources of
5-HTP have shown no toxic contaminants similar to those associated
with L-Tryptophan. References: "Safety of 5-hydroxy-L-tryptophan,"
Toxicol Lett. 2004; Expert Rev Pharmaco- economics
Outcomes Res. 2009;9(5):445-459).
is involved in the metabolism of tryptophan to serotonin. Vitamin
B-12 and other B vitamins play a role in producing brain chemicals
that affect mood and other brain functions. Low levels of B-12 and
other B vitamins such as vitamin B-6 and folate may be linked to
depression and can result from eating a poor diet or not being able
to absorb the vitamins consumed. Older adults, vegetarians and people
with digestive disorders such as celiac disease or Crohn's disease
may have trouble getting enough B-12. Sometimes a vitamin B-12 deficiency
occurs for unknown reasons.
The best way
to make sure one is getting enough B-12 and other vitamins is to
eat a healthy diet including sources of essential nutrients. Vitamin
B-12 is found in animal products such as fish, meat, poultry, eggs
and milk. Fortified breakfast cereals also are a good source of
B-12 and other B vitamins.
| Taking a
daily supplement that includes vitamin B-12 may help the body get
the nutrients it needs, especially if one is older than 50 and/or
a vegetarian. However, B-12 and other vitamin supplements can interact
with some medications, especially in high doses and one should consult
with a doctor before taking a vitamin supplement.
role of B vitamins in depression not clear. In the case of a vitamin
deficiency, taking a supplement may help. But no supplement
can replace proven depression treatments such as antidepressants
and psychological counseling (see below for more on B vitamins).
Skarupski KA. "Longitudinal association of vitamin B-6, folate,
and vitamin B-12 with depressive symptoms among older adults over
time," American Journal of Clinical Nutrition. 2010;92:330.
Mayo Clinic, Daniel K. Hall-Flavin, M.D.
the leaves of the Ginkgo biloba tree are used therapeutically.
EGb 761® is a Ginkgo biloba extract registered in a
number of countries for the treatment of dementia disorders. According
to mayoclinic.com, studies show possible benefits of using ginkgo
for depression in elderly patients. Investigation is ongoing.
of action in improving depression and anxiety is not precisely known.
Ginkgo may inhibit serotonin reuptake at serotonin receptor sites.
According to the University of Maryland Medical Center, clinical
studies suggest that ginkgo provides improvement in the areas of
cognition, daily living, social behaviors and feelings of depression
in the elderly. Persons with depression may need to take ginkgo
consistently for 12 weeks before seeing benefits; others have reported
positive effects as soon as two to three weeks after starting ginko.
The Mayo Clinic
information on ginko suggests dosages between 80 and 240 mg taken
daily by mouth in two to three divided doses. A dosage of 3 to 6
mL of 40 mg per mL extract may be taken in three divided doses,
or the herb is available as a tea. These dosages are for adults
over the age of 18 years; there have been no clinical studies of
ginkgo use in children. The recommended dosage is 80 mg twice a
day, once in the morning and again after lunch.
The University of Maryland Medical Center cautions when adding
ginkgo to a current depression regimen and should be done under the
care of a physician. Ginkgo should be taken with caution when combined
with selective serotonin reuptake inhibitors (SSRI) or other MAO inhibitors
(anti-depressants), because of possible negative side effects. In
addition, ginko has anti-coagulant properties and should not be combined
with warfarin (Coumadin) to avoid bleeding. Bleeding is also a consideration
in the very elderly.
Expert Rev Pharmacoeconomics Outcomes Res. 2009;9(5):445-459;
Mayo Clinic "Ginko Evidence;" National Institutes of Mental
Kava is a
plant native to the South Pacific. The root is used for medicine.
Kava affects the brain and other parts of the central nervous system.
The kava-lactones in kava are believed to be responsible for its
substantial safety concerns about kava. Many cases of liver damage
and even some deaths have been traced to kava use. As a result,
kava has been banned from the market in Switzerland, Germany, and
Canada, and several other countries are considering similar action.
The National Institutes of Health firmly recommends against
using Kava at this time, citing the histories of deaths, and serious
interactions with other medications and herbs.
is a plant native to the Americas used as a folk remedy for anxiety
and insomnia, and can be used to treat anxiety symptoms that may
occur with an agitated depression, or generalized anxiety disorder
with depression. The therapeutic mechanism is not understood, but
may be related to activation of benzodiazepine receptors.
Flower and anxiety
leaves of the passion flower species, Maypop, were used by Native
Americans and later by the American colonists. The leaves were used
fresh or dried out to make a tea that was useful in treating epilepsy,
"hysteria" and insomnia. A tincture even proved to be
analgesic. The roots and leaves contain most of the active compounds:
flavonoids, maltol, cyanogenic glycosides, harman indole alkaloids,
etc. A double-blind randomized trial compared the efficacy of passion
flower extract with oxazepam ( a benzodiazepine in the same family
as Valium®) in the treatment of generalized anxiety disorder.
The study was performed on patients diagnosed with anxiety: 18 people
received passion flower extract 45 drops/day (plus placebo group
receiving sham drops), and 18 people received 30 mg/day (plus placebo
group receiving placebo tablets) for a 4-week trial. Passion flower
extract and oxazepam were effective in the treatment of generalized
anxiety disorder, which can often accompany depression. More problems
relating to impaired job performance were associated with oxazepam.
The results suggest that passion flower extract is an effective
herb for the management of generalized anxiety disorder, with low
incidence of impairment of job performance.
A case has been reported in which self-administration led to severe
nausea, vomiting, drowsiness, prolonged QTc (a dangerous cardiac
electrical effect seen on EKG) and episodes of nonsustained ventricular
tachycardia (which can progress to fatality).
and traditional historical use of passion flower suggest it is helpful
for treatment of anxiety, from whatever cause.
There is a lack of well controlled scientific studies for the medical
community to reach a consensus.
should not be relied on to treat panic disorder or other severe
anxiety disorders. Very often, several conditions will co-exist,
e.g. depression, anxiety and obsessive compulsive disorder. Along
with an anti-depressant there may be a need for an anti-anxiety
agent .However, note that the use of anti-anxiety medications and/or
herbal supplements/substances may worsen depression.
Exercise caution using passion flower use for anxiety in the setting
of concomitant depression. Reference: Expert Rev Pharmacoeconomics
Outcomes Res. 2009;9(5):445-459; Rehwald A, Meier B, Sticher
O. "Qualitative and quantitative reversed-phase high-performance
liquid chromatography of flavonoids in Passiflora incarnata L.",
Pharm Acta Helv . 1994;69:153-158.
wort is a flowering plant used as a traditional remedy for sadness,
worry, nervousness, and insomnia. The most common modern-day use
of St. John's wort is the treatment of depression. Today, the results
of over 20 clinical trials suggest that St. John's wort works better
than a placebo and is as effective as antidepressants for mild to
moderate depression, with fewer side effects.
report St. John's wort to be equally effective as tricyclic antidepressant
drugs in the short-term treatment of mild-to-moderate depression
(1-3 months). It is not clear if St. John's wort is as effective
as selective serotonin reuptake inhibitor (SSRI) antidepressants
such as sertraline (Zoloft®). In Germany, St. John's Wort is
indicated for clinical use in mild to moderate depression, nervous
disturbances, fear, somatoform disturbances, anxiety and insomnia.
Some 66 million annual doses of this plant are consumed in Germany
and three million prescriptions are given to patients. In Germany
use of hypericum extract is supported by many clinical
studies and doctors' prescriptions, and is extensively listed
in the German Commission
E Monographs (you can purchase the German Commission
E Monograph on Amazon).*
evidence supports the effectiveness of St. John's wort in mild-to-moderate
depression. It may also be helpful in treatment of Seasonal Affective
Disorder (S.A.D.) The efficacy of St John's wort in severe major
depression is unclear and it should not be used to treat severe
depression. St. John's wort may take 4 to 6 weeks to produce
serotonergic, dopaminergic and GABA-ergic activity, but the exact
mechanism is not known. St.
John's Wort is available from herbalists, health food stores,
drug stores and online in the form of capsules, tablets, liquid
extracts, or brewed as a tea. St. John's wort is easy to grow, and
although it is an annual, it readily reseeds itself coming back
year after year.
dose of St. John's Wort for capsules standardized at 0.3% hypericin,
is 300mg, 3 times per day. For non-commercial preparation, the flowering
and leafy parts of hypericum plant should be obtained from
dried above ground part of the plant just before or after the flowering
period. The lower part of stem has lower concentration and fewer
active ingredients. For tea one would place 2 teaspoons of herb
in 1 cup of boiling water, and take 3 times per day.
may include dizziness, dry mouth, indigestion, and fatigue. St.
John's wort increases photosensitivity. Also, recent disturbing
information from the University of Alabama suggests that St. John's
wort is related to development of cataracts and macular
degeneration. Apparently, the hypericin in St John's wort
reacts with ultraviolet light producing free radicals which can
damage the lens and/or retina. These are serious and irreversible
side effects of using St. John's wort, and anyone beginning therapy
with this herb must weigh these risks of its use against the benefits
of its use. It is not known if polarized UV protection with sunglasses
can prevent these complications or not.One must take frequent
breaks from the use of this natural antidepressant and substitute
other dietary supplements that elevate mood. Reference:
"St John's Wort (Hypericum perforatum),",
Expert Rev Pharmacoeconomics Outcomes Res. 2009;9(5):445-459.
John's wort causes fewer side effects compared with the use of antidepressants.
However, it may have clinically dangerous interactions with
a range of prescribed medications, including anticancer agents,
anti-HIV agents, anti-inflammatory agents, antimicrobial agents,
cardiovascular drugs, CNS agents, hypoglycemic agents (oral diabetes
medication), immune suppressants , oral contraceptives,
proton pump inhibitors (for stomach acid), asthma medications and
statins (for lipids) . St. John's wort is not recommended
for pregnant or nursing women,
children, or people with bipolar disorder, liver
or kidney disease. St. John's Wort can cancel out the effects of
oral contraceptives, making one more likely to become pregnant.
People using this or any other medication/herbal remedies should
consult their healthcare providers prior to starting therapy. Reference:
Mayo Clinic St. John's wort (Hypericum perforatum L.) Natural
Standard Patient Monograph, 2012.
acids are a type of good fat needed for normal brain function. Our
bodies can't make omega-3s on their own, so we must obtain them
through our diet. Studies have linked depression with low dietary
intake of omega-3 fatty acids. In countries with higher fish consumption,
such as Japan and Taiwan, the depression rate is 10 times lower
than in North America. Postpartum depression is also less common.
Studies strongly suggest that omega-3's together with antidepressants
may be more effective than antidepressants alone.
fish such as salmon, sardines, and anchovies are the richest food
source of omega-3 fatty acids. But instead of eating more fish which
contain mercury, PCBs, and other chemicals, fish oil capsules are
a "cleaner" source of omega-3 fatty acids. Many companies
filter their fish oil so that these chemicals are removed.
Fish oil capsules
are sold in health food stores, drug stores, and online. When comparing
brands, the key active components for depression are EPA (eicosapentaenoic
acid) and DHA (docosahexaenoic
acid). Fish oil capsules may interact with blood-thinning drugs
such as warfarin and aspirin. Side effects may include indigestion
(To prevent the "fishy aftertaste" one may take the fish
oil just before meals). Fish oil should not be taken 2 weeks before
or after surgery to avoid bleeding.
studies have examined omega-3 fatty acids and placebo in depression.
One clinical study found that four months of treatment with 9.6
g of omega-3 fatty acids (6.2 g EPA/3.4 g DHA) showed a highly significant
effect in treating depression (p < 0.001). In another trial,
the addition of 2 g of pure EPA to standard antidepressant medication
enhanced the effectiveness of that medication vs. medication
and placebo. These particular patients had treatment-resistant
depression, and EPA had a beneficial effect on insomnia, depressed
mood, and feelings of guilt and worthlessness.
"sammy", is short for S-adenosyl-L-methionine, a chemical
found naturally in the human body and believed to increase levels
of neurotransmitters serotonin and dopamine. Several studies have
found SAM-e is more effective in treating depression than placebo.
A study found it was helpful even in depressed patients who did
not respond well to Prozac and other SSRIs. SAM-e works best for
depression associated with low energy and low motivation. High doses
can cause restlessness and anxiety. For depression associated with
anxiety, 5-HTP is a better option. There is a risk for overstimulation
with SAM-e use, hence dosage should be kept low and it is a good
idea to take a day or two off when one notices overstimulation.
Side effects can include nausea and constipation.
SAM-e is not advised for those who have manic depression (bipolar
disease). If a patient has been diagnosed with any
type of manic or anxiety disorder, use with extreme caution
only under a physician's monitoring. Severe manic
episodes can occur with the use of SAM-e.
In North America,
SAM-e is available as an over-the-counter supplement in health food
stores, drug stores, and online. It should be enteric-coated for
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