When the Antidepressants Run Out
Worldwide, 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. Current conditions 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 mine). Abrupt cessation 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, nausea, insomnia, tremor, confusion, nightmares, and vertigo agitation, anxiety, akathesia, panic attacks, irritability, hostility, aggressiveness, worsening of mood, dysphoria (unhappiness), crying spells, mood instability, hyperactivity, depersonalization, decreased concentration, slowed thinking, confusion, and memory/concentration difficulties. The current 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 TEOTWAWKI 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). However, in 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. Serotonin 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. L-Tryptophan – > 5-Hydroxytryptophan 5-HTP – > Serotonin – > N-Acetyl-serotonin – > Melatonin Either tryptophan 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. L-tryptophan 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. Tryptophan 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:
Description 5-hydroxy-tryptophan (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. Efficacy 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. Safety Issues: 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. Conclusion 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. 2009;9(5):445-459). Because of 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). B Vitamins Vitamin B6 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. The precise 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). Reference: 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. Ginkgo BilobaExtracts of 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. The mechanism 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. Precautions: 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.Reference: Expert Rev Pharmacoeconomics Outcomes Res. 2009;9(5):445-459; Mayo Clinic "Ginko Evidence;" National Institutes of Mental Health "Depression." Kava 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 sedative effects. There are 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. Passionflower (Passiflora incarnata) Passionflower 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. Passion Flower and anxiety Roots and 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. Safety Issues 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). Conclusion Anecdotal 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. Passion flower 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. St. John's Wort St John's 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. Numerous studies 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).* Scientific 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 full effects. Therapeutic Mechanism Evidence suggests 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. The daily 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. Safety issues Side effects 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. Overall, St 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. Omega-3 fatty acids Omega-3 fatty 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. Cold water 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. Controlled 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. SAM-e SAM-e, pronounced "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 maximum absorption. September 3, 2012 Copyright © 2012 Survival Blog
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