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Peptic ulcer (stomach or duodenal) is a break in the inner lining of the esophagus, stomach, or duodenum. A peptic ulcer of the stomach is called a gastric ulcer; of the duodenum, a duodenal ulcer; and of the esophagus, an esophageal ulcer. Peptic ulcers occur when the lining these organs is eroded by the acidic digestive (peptic) juices that the cells of the lining secrete of the stomach secrete. A peptic ulcer differs from an erosion because it extends deeper into the lining and incites more of an inflammatory reaction from the tissues that are involved, occasionally with scaring. Peptic ulcer also is referred to as peptic ulcer disease.

Types of Peptic Ulcer 

There are three types of peptic ulcers:

• Gastric ulcers: ulcers that develop inside the stomach
• Esophageal ulcers: ulcers that develop inside the esophagus
• Duodenal ulcers: ulcers that develop in the upper section of the small intestines, called the duodenum

By Names

By location

• Duodenum (called duodenal ulcer)
• Esophagus (called esophageal ulcer)
• Stomach (called gastric ulcer)
• Meckel’s diverticulum (called Meckel’s diverticulum ulcer; is very tender with palpation)

Modified Johnson

• Type I: Ulcer along the body of the stomach, most often along the lesser curve at incisura angularis along the locus minoris resistantiae. Not associated with acid hypersecretion.
• Type II: Ulcer in the body in combination with duodenal ulcers. Associated with acid oversecretion.
• Type III: In the pyloric channel within 3 cm of pylorus. Associated with acid oversecretion.
• Type IV: Proximal gastroesophageal ulcer
• Type V: Can occur throughout the stomach. Associated with the chronic use of NSAIDs (such as ibuprofen).

Causes of Peptic Ulcer 

Common causes include

• A bacterium – Helicobacter pylori bacteria commonly live in the mucous layer that covers and protects tissues that line the stomach and small intestine. Often, the H. pylori bacterium causes no problems, but it can cause inflammation of the stomach’s inner layer, producing an ulcer.
• Regular use of certain pain relievers – Taking aspirin, as well as certain over-the-counter and prescription pain medications called nonsteroidal anti-inflammatory drugs (NSAIDs) can irritate or inflame the lining of your stomach and small intestine. These medications include ibuprofen  and naproxen sodium, but not acetaminophen .
• Peptic ulcers are more common in older adults who take these pain medications frequently or in people who take these medications for osteoarthritis.
• The food is partially digested in the stomach and then moves on to the duodenum to continue the process.
• Peptic ulcers occur when the acid and enzyme overcome the defense mechanisms of the gastrointestinal tract and erode the mucosal wall.
  • Aspirin, nonsteroidal anti-inflammatory drugs (such as ibuprofen and naproxen), and newer anti-inflammatory medications such as celecoxib
  • Alcohol
  • Stress: physical (severe injuries or burns, major surgery)
  • Caffeine
  • Cigarettesmoking

Some types of medical therapy can contribute to ulcer formation. The following factors can weaken the protective mucosal barrier of the stomach increasing the chances of getting an ulcer and slow the healing of existing ulcers.

Radiation therapy – used for diseases such as cancer – Not everyone who gets an ulcer is infected with H pylori. Aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) can cause ulcers if taken regularly.

In the past it was thought that ulcers were caused by lifestyle factors such as eating habits, cigarette smoking, and stress.

• Elderly people with conditions such as arthritis are especially vulnerable.
• People who have had prior ulcers or intestinal bleeding are at a higher-than-normal risk.
• If a person takes these medications regularly, alternatives should be discussed with a health-care professional. This is especially true if the affected individual has an upset stomach or heartburn after taking these medications.People who take aspirin or other anti-inflammatory medications are at an increased risk even if they do not have H pylori infection.
  • The stool contaminates food or water (usually through poor personal hygiene).
  • The bacteria in the stool make their way into the digestive tracts of people who consume this food or water.
  • This is called fecal-oral transmission and is a common way for infections to spread.H pylori bacteria is spread through the stools (feces) of an infected person.
  • Many people who are exposed to the bacteria never develop ulcers.
  • People who are newly infected usually develop symptoms within a few weeks.
  • Researchers are trying to discover what is different about the people who develop ulcers.The bacteria are found in the stomach, where they are able to penetrate and damage the lining of the stomach and duodenum.It is more common in older adults, although it is thought that many people are infected in childhood and carry the bacteria throughout their lifetimes.
  • It is also more common in lower socioeconomic classes because these households tend to have more people living together, sharing bathrooms and kitchen facilities.
  • African Americans and Hispanic Americans are more likely to have the bacteria than Caucasians and Asian Americans.Infection with H pylori occurs in all ages, races, and socioeconomic classes.
• It is important to distinguish between ulcers caused by H pylori and those caused by medications because the treatment is completely different.Ulcers can be linked with other medical conditions.
• People who worry excessively are usually thought to have a condition called generalized anxiety disorder. This disorder has been linked with peptic ulcers.
• A rare condition called Zollinger-Ellison syndrome causes peptic ulcers as well as tumors in the pancreas and duodenum.

Other medications – Taking certain other medications along with NSAIDs, such as steroids, anticoagulants, low-dose aspirin, selective serotonin reuptake inhibitors , alendronate  and risedronate , can greatly increase the chance of developing ulcers.

• Drinking too much alcohol
• Radiation therapy
• Stomach cancer

Research done in the 1980s showed that some ulcers are caused by infection with a bacterium named Helicobacter pylori, usually called H pylori.

Symptoms of Peptic Ulcer 

• Abdominal pain, classically epigastric strongly correlated to mealtimes. In case of duodenal ulcers the pain appears about three hours after taking a meal;
• Bloating and abdominal fullness;
• Waterbrash (rush of saliva after an episode of regurgitation to dilute the acid in esophagus – although this is more associated with gastroesophageal reflux disease);
• Loss of appetite and weight loss;
• Hematemesis (vomiting of blood); this can occur due to bleeding directly from a gastric ulcer, or from damage to the esophagus from severe/continuing vomiting.
• Melena (tarry, foul-smelling feces due to presence of oxidized iron from hemoglobin);
• Rarely, an ulcer can lead to a gastric or duodenal perforation, which leads to acute peritonitis, extreme, stabbing pain and requires immediate surgery.
• Burning stomach pain
• Feeling of fullness, bloating or belching
• Fatty food intolerance
• Dull pain in the stomach
• Weight loss
• Not wanting to eat because of pain
• Nausea or vomiting
• Bloating
• feeling easily full
• Burping or acid reflux
• Heartburn (burning sensation in the chest)
• Pain that may improve when you eat, drink, or take antacids
• Anemia (symptoms can include tiredness, shortness of breath, or paler skin)
• Dark, tarry stools
• Vomit that’s bloody or looks like coffee grounds
• Vomiting or vomiting blood — which may appear red or black
• Dark blood in stools, or stools that are black or tarry
• Trouble breathing
• Feeling faint
• Unexplained weight loss
• Appetite changes

A history of heartburn, gastroesophageal reflux disease (GERD) and use of certain forms of medication can raise the suspicion for peptic ulcer. Medicines associated with peptic ulcer include NSAIDs (non-steroid anti-inflammatory drugs) that inhibit cyclooxygenase, and most glucocorticoids (e.g. dexamethasone and prednisolone).

Diagnosis of Peptic Ulcer 

The diagnosis of Helicobacter pylori can be made by:

• Urea breath test (noninvasive and does not require EGD);
• Direct culture from an EGD biopsy specimen; this is difficult to do, and can be expensive. Most labs are not set up to perform H. pylori cultures;
• Direct detection of urease activity in a biopsy specimen by rapid urease test;
• Measurement of antibody levels in the blood (does not require EGD). It is still somewhat controversial whether a positive antibody without EGD is enough to warrant eradication therapy;
• Stool antigen test;
• Histological examination and staining of an EGD biopsy.
• Upper gastrointestinal series – Sometimes called a barium swallow, this series of X-rays of your upper digestive system creates images of your esophagus, stomach and small intestine. During the X-ray, you swallow a white liquid (containing barium) that coats your digestive tract and makes an ulcer more visible.

• Laboratory tests for H. pylori – Your doctor may recommend tests to determine whether the bacterium H. pylori is present in your body. He or she may look for H. pylori using a blood, stool or breath test. The breath test is the most accurate. Blood tests are generally inaccurate and should not be routinely used.
• Barium swallow – You drink a thick white liquid (barium) that coats your upper gastrointestinal tract and helps your doctor see your stomach and small intestine on X-rays.
• Endoscopy (EGD) – A thin, lighted tube is inserted through your mouth and into the stomach and the first part of the small intestine. This test is used to look for ulcers, bleeding, and any tissue that looks abnormal.
• Endoscopic biopsy – A piece of stomach tissue is removed so it can be analyzed in a lab.

If your doctor detects an ulcer, small tissue samples (biopsy) may be removed for examination in a lab. A biopsy can also identify whether H. pylori is in your stomach lining.

Differential diagnosis of Peptic Ulcer 

Conditions that may appear similar include

Treatment of Peptic Ulcer 

The type of treatment usually depends on what caused the peptic ulcer. Treatment will focus on either lowering stomach acid levels so that the ulcer can heal, or eradicating the H. pylori infection.

Medications

There are several medications that can be used to treat . They include:

• H. pylori infection treatment-

Patients infected with H. pylori will usually need PPIs and antibiotics. This treatment is effective in most patients, and the ulcer will start to disappear within days. When treatment is over, the individual will have to be tested again to make sure the H. pylori have gone. If necessary, they will undergo another course of different antibiotics.

• Non-steroidal anti-inflammatory drugs

  If the ulcer comes from NSAIDs, the patient will have to stop taking them. Alternatives include acetaminophen. If the person cannot stop taking NSAIDs, the doctor may minimize the dosage and review the patient’s need for them later. Another medication may be prescribed long term, alongside the NSAID.

• Over-the-counter acid buffers — Buffers neutralize acid. They include Mylanta, Maalox, Tums, Rolaids, and Gaviscon. The liquid forms of these medications work faster But the tablets may be more convenient.Antacids that contain magnesium can cause diarrhea. And antacids that contain aluminum can cause constipation. Your doctor may advise you to alternate antacids to avoid these problems. These medicines work for a short time and they do not heal the inflammation of the esophagus.
• Over-the-counter proton pump inhibitors — Proton pump inhibitors shut off the stomach’s acid production.Proton pump inhibitors are very effective. They can be especially helpful in patients who do not respond to H2 blockers and antacids. These drugs are more potent acid-blockers than are H2 blockers, but they take longer to begin their effect.
• Proton pump inhibitors – should not be combined with an H2 blocker. The H2 blocker can prevent the proton pump inhibitor from working.These are prescribed at higher doses than those available in over-the-counter forms.
• Motility drugs – These medications may help to decrease esophageal reflux. But they are not usually used as the only treatment for peptic ulcers .They help the stomach to empty faster, which decreases the amount of time during which reflux can occur.
• Mucosal protectors – These medications coat, soothe and protect the irritated esophageal lining. One example is sucralfate (Carafate).

Over-the-counter and prescription medicines of  Peptic Ulcer 

You can buy many peptic ulcers medicines without a prescription. However, if you have symptoms that will not go away, you should see your doctor.

Antacids – Doctors often first recommend antacids to relieve heartburn and other mild   peptic ulcers. Antacids include over-the-counter medicines such as. Antacids can have side effects, including diarrhea and constipation.

H2 blockers – H2 blockers decrease acid production. They provide short-term or on-demand relief for many people with peptic ulcers. They can also help heal the esophagus, although not as well as other medicines. You can buy H2 blockers over-the-counter or your doctor can prescribe one. Types of H2 blockers include

• cimetidine 
• famotidine 
• nizatidine 
• ranitidine 

Proton pump inhibitors (PPIs) – PPIs lower the amount of acid your stomach makes. PPIs are better at treating  peptic ulcers than H2 blockers. They can heal the esophageal lining in most people with peptic ulcers. Doctors often prescribe PPIs for long-term  peptic ulcers treatment. Such as

• Esomeprazole 
• Lansoprazole 
• Omeprazole 
• Pantoprazole 
• Rabeprazole 

Talk with your doctor about taking lower-strength omeprazole or lansoprazole, sold over the counter.

Antibiotics – Antibiotics, including erythromycin , can help your stomach empty faster. Erythromycin has fewer side effects than prokinetics; however, it can cause diarrhea.

Prokinetics – Prokinetics help your stomach empty faster. Prescription prokinetics include

• bethanechol 
• metoclopramide 

Both of these medicines have side effects, including

• nausea
• diarrhea
• fatigue, or feeling tired
• depression 
• anxiety
• delayed or abnormal physical movement

Prokinetics can cause problems if you mix them with other medicines, so tell your doctor about all the medicines you’re taking.

Prevention of Peptic Ulcer 

There are a lot of things you can do to prevent the symptoms of GERD. Some simple lifestyle changes include

• Elevate the head of your bed at least six inches. If possible, put wooden blocks under the legs at the head of the bed. Or, use a solid foam wedge under the head portion of the mattress. Simply using extra pillows may not help.
• Avoid foods that cause the esophageal sphincter to relax during their digestion. These include:
  • Coffee
  • Chocolate
  • Fatty foods
  • Whole milk
  • Peppermint
  • Spearmint
• Limit acidic foods that make the irritation worse when they are regurgitated. These include citrus fruits and tomatoes.
• Excess pounds put pressure on your abdomen, pushing up your stomach and causing acid to reflux into your esophagus.
• Smoking decreases the lower esophageal sphincter’s ability to function properly.
• If you regularly experience heartburn while trying to sleep, place wood or cement blocks under the feet of your bed so that the head end is raised by 6 to 9 inches. If you can’t elevate your bed, you can insert a wedge between your mattress and box spring to elevate your body from the waist up. Raising your head with additional pillows isn’t effective.
• Wait at least three hours after eating before lying down or going to bed.
• Put down your fork after every bite and pick it up again once you have chewed and swallowed that bite.
• Common triggers include fatty or fried foods, tomato sauce, alcohol, chocolate, mint, garlic, onion, and caffeine.
• Clothes that fit tightly around your waist put pressure on your abdomen and the lower esophageal sphincter.
• Avoid carbonated beverages. Burps of gas force the esophageal sphincter to open and can promote reflux.
• Eat smaller, more frequent meals.
• Do not eat during the three to four hours before you go to bed.
• Avoid drinking alcohol. It loosens the esophageal sphincter.
• Lose weight if you are obese. Obesity can make it harder for the esophageal sphincter to stay closed.
• Avoid wearing tight-fitting garments. Increased pressure on the abdomen can open the esophageal sphincter.
• Use lozenges or gum to keep producing saliva.
• Do not lie down after eating.

Complications of Peptic Ulcer 

• Perforation – A hole develops in the lining of the stomach or small intestine and causes an infection. A sign of a perforated ulcer is sudden, severe abdominal pain.
• Internal bleeding – Bleeding ulcers can result in significant blood loss and thus require hospitalization. Signs of a bleeding ulcer include lightheadedness, dizziness, and black stools.
• Scar tissue – This is thick tissue that develops after an injury. This tissue makes it difficult for food to pass through your digestive tract. Signs of scar tissue include vomiting and weight loss.
• Gastrointestinal bleeding is the most common complication. Sudden large bleeding can be life-threatening. It occurs when the ulcer erodes one of the blood vessels, such as the gastroduodenal artery.
• Perforation (a hole in the wall of the gastrointestinal tract) often leads to catastrophic consequences if left untreated. Erosion of the gastro-intestinal wall by the ulcer leads to spillage of the stomach or intestinal content into the abdominal cavity. Perforation at the anterior surface of the stomach leads to acute peritonitis, initially chemical and later bacterial peritonitis. The first sign is often sudden intense abdominal pain; an example is Valentino’s syndrome, named after the silent-film actor who experienced this pain before his death. Posterior wall perforation leads to bleeding due to the involvement of gastroduodenal artery that lies posterior to the first part of the duodenum.
• Penetration is a form of perforation in which the hole leads to and the ulcer continues into adjacent organs such as the liver and pancreas.
• Gastric outlet obstruction is a narrowing of the pyloric canal by scarring and swelling of the gastric antrum and duodenum due to peptic ulcers. The person often presents with severe vomiting without bile.
• Cancer is included in the differential diagnosis (elucidated by biopsy), Helicobacter pylori as the etiological factor making it 3 to 6 times more likely to develop stomach cancer from the ulcer.

References

Nasal Congestion or Runny Nose & Sneezing is excess drainage produced by nasal and adjacent tissues and blood vessels in the nose. This drainage may range from a clear fluid to thick mucus.Stuffy nose is a term often used to refer to obstruction to the flow of air in and out of the nose, while runny nose refers to a discharge (fluid) coming from the nasal passages. This is often a watery, clear liquid but may be thicker and viscous. Both stuffy and runny nose are associated with inflammation and swelling (congestion) of the inner lining of the nasal passages and sinuses.

Causes of Nasal Congestion

• Hay fever – Hay fever, an allergic reaction to outdoor pollens and molds, causes nasal congestion, itchy eyes, and more.
• Nasal congestion – Nasal congestion is a stuffy nose, and can be accompanied by blocked ears, sore throat, and more.
• Acute sinusitis – Acute sinusitis, an inflammation of the sinuses, causes sinus pain and tenderness, facial redness and more.
• Common cold – The common cold is a viral respiratory infection causing sore throat, stuffy or runny nose, headache and more.
• Allergic reaction -Allergic reaction causes sneezing, runny nose and hives and can lead to anaphylaxis, a whole body reaction.
• Dust exposure – Dust exposure can cause congestion, runny nose, cough, shortness of breath, tightness in the chest, and more.
• Nasal polyps – Nasal polyps, sacs of inflamed tissue in the nasal passages, can cause cold symptoms, snoring, and more.
• Nonallergic rhinitis – Non-allergic rhinitis causes congestion, sneezing, runny nose, or itchy red eyes for no apparent reason.
• Respiratory syncytial virus – Respiratory syncytial virus (RSV) is a virus that causes symptoms similar to the common cold.
• Foreign object in the nose – Symptoms of a foreign body in the nose include trouble breathing, pain, discharge, and bleeding.
• Drug allergy – A drug allergy is an allergic reaction to a medication and can cause a rapid heartbeat and difficulty breathing.
• Narcotic abuse – Narcotic abuse can cause fatigue, shallow breathing, anxiety, euphoria, vomiting, confusion, and constipation.
• Whooping cough – Whooping cough, a contagious respiratory infection, causes a runny nose, a mild fever, and a severe cough.
• West nile virusn – West Nile virus is an infection spread by mosquitoes, and can cause diarrhea, fever, abdominal pain, and more.
• Mesenteric lymphadenitis – Mesenteric lymphadenitis is an inflammation of abdominal lymph nodes causing pain, diarrhea, fever, and more.
• Ricin poisoning – Ricin is a dangerous poison in castor beans, and causes trouble breathing, nausea, fever and sweating.

Others Causes of Nasal Congestion

• Cold Weather or Sudden Temperature Changes
• Consumption of Spicy Foods
• Enlarged Adenoids
• Environmental Irritants
• Foreign Bodies in the Nose
• Hormonal Changes
• Injury/Trauma to the Nose
• Kartagener Syndrome
• Medications
• Nasal Polyps
• Nonallergic rhinitis (chronic congestion or sneezing not related to allergies)
• Occupational asthma
• Pregnancy
• Respiratory syncytial virus (RSV)
• Spinal fluid leak
• Structural Abnormalities
• Tumors of the Nasal Passages
• Vasomotor Rhinitis
• Viral Infection

Symptoms of Nasal Congestion

Addition symptoms to watch for that may signal something more serious than a stuffy nose include:

• Being unable to breathe through your nose
• Feeling like there is something in your nose
• Clear or yellow discharge from your nose
• Clear or yellow discharge in the back of your throat
• Cough, especially when lying down
• Green mucus draining from the nose
• Facial pain
• Pain in the ear
• Headache
• Fever
• Difficulty seeing or double vision
• Trouble eating
• Loss of appetite
• Nausea
• Pain in the back (can indicate pneumonia)
• Fever
• Coughing
• Chest tightness

Diagnosis of Nasal Congestion

• History of present illness should determine the nature of the discharge and whether discharge is chronic or recurrent. If recurrent, any relation to patient location, season, or exposure to potential triggering allergens (numerous) should be determined.
• Examination focuses on the nose and area over the sinuses. The face is inspected for focal erythema over the frontal and maxillary sinuses; these areas are also palpated for tenderness. Nasal mucosa is inspected for color , swelling, color and nature of discharge, and  presence of any foreign body.
• Unilateral discharge, particularly if purulent or bloody
• Culture will guide any antibiotic therapy.
• X-ray of sinuses may show clouding from infection.
• Nasal discharge cytology is sometimes used to diagnose allergic fungal sinusitis.
• Specialist investigation (eg, CT scanning and screening tests for cystic fibrosis) may be required to rule out the rarer causes.
• Facial pain, tenderness, or both

Treatment of Nasal Congestion

Heart failure is a chronic, progressive condition in which the heart muscle is unable to pump enough blood through to meet the body’s needs for blood and oxygen. It is inability of the heart to keep up with the demands on it and, specifically, failure of the heart to pump blood with normal efficiency. When this occurs, the heart is unable to provide adequate blood flow to other organs such as the brain, liver and kidneys. Heart failure may be due to failure of the right or left or both ventricles.

At first the heart tries to make up for this by

• Enlarging. The heart stretches to contract more strongly and keep up with the demand to pump more blood. Over time this causes the heart to become enlarged.
• Developing more muscle mass. The increase in muscle mass occurs because the contracting cells of the heart get bigger. This lets the heart pump more strongly, at least initially.
• Pumping faster. This helps to increase the heart’s output.

The body also tries to compensate in other ways:

• The blood vessels narrow to keep blood pressure up, trying to make up for the heart’s loss of power.
• The body diverts blood away from less important tissues and organs (like the kidneys), and towards the heart and brain.

These temporary measures mask the problem of heart failure, but they don’t solve it. Heart failure continues and worsens until these substitute processes no longer work.

Classification of Heart Failure

There are many different ways to categorize heart failure, including

• the side of the heart involved (left heart failure versus right heart failure). Right heart failure compromises pulmonary flow to the lungs. Left heart failure compromises aortic flow to the body and brain. Mixed presentations are common; left heart failure often leads to right heart failure in the longer term.
• whether the abnormality is due to insufficient contraction (systolic dysfunction), or due to insufficient relaxation of the heart (diastolic dysfunction), or to both.
• whether the problem is primarily increased venous back pressure (preload), or failure to supply adequate arterial perfusion (afterload).
• whether the abnormality is due to low cardiac output with high systemic vascular resistance or high cardiac output with low vascular resistance (low-output heart failure vs. high-output heart failure).
• the degree of functional impairment conferred by the abnormality (as reflected in the New York Heart Association Functional Classification)
• the degree of coexisting illness: i.e. heart failure/systemic hypertension, heart failure/pulmonary hypertension, heart failure/diabetes, heart failure/kidney failure, etc.

Functional classification generally relies on the New York Heart Association functional classification. The classes (I-IV) are:

• Class I: no limitation is experienced in any activities; there are no symptoms from ordinary activities.
• Class II: slight, mild limitation of activity; the patient is comfortable at rest or with mild exertion.
• Class III: marked limitation of any activity; the patient is comfortable only at rest.
• Class IV: any physical activity brings on discomfort and symptoms occur at rest.

This score documents the severity of symptoms and can be used to assess response to treatment. While its use is widespread, the NYHA score is not very reproducible and does not reliably predict the walking distance or exercise tolerance on formal testing.

In its 2001 guidelines the American College of Cardiology/American Heart Association working group introduced four stages of heart failure

• Stage A: Patients at high risk for developing HF in the future but no functional or structural heart disorder.
• Stage B: a structural heart disorder but no symptoms at any stage.
• Stage C: previous or current symptoms of heart failure in the context of an underlying structural heart problem, but managed with medical treatment.
• Stage D: advanced disease requiring hospital-based support, a heart transplant or palliative care.

The ACC staging system is useful in that Stage A encompasses “pre-heart failure” – a stage where intervention with treatment can presumably prevent progression to overt symptoms. ACC Stage A does not have a corresponding NYHA class. ACC Stage B would correspond to NYHA Class I. ACC Stage C corresponds to NYHA Class II and III, while ACC Stage D overlaps with NYHA Class IV.

Obesity is a medical condition in which excess body fat has accumulated to the extent that it may have a negative effect on health. People are generally considered obese when their body mass index (BMI), a measurement obtained by dividing a person’s weight by the square of the person’s height, is over 30 kg/m², with the range 25–30 kg/m² defined as overweight. Some East Asian countries use lower values. Obesity increases the likelihood of various diseases and conditions, particularly cardiovascular diseases, type 2 diabetes, obstructive sleep apnea, certain types of cancer, osteoarthritis and depression.

Calculation of obesity

Body Mass Index (BMI) is a mathematical calculation involving height and weight, irrespective of family history, gender, age or race. BMI is calculated by dividing a person’s body weight in kilograms by their height in meters squared (weight [kg] height [m]2) or by using the conversion with pounds (lbs) and inches (in) squared as shown below, This number can be  misleading, however, for very muscular people, or for pregnant or lactating women.

[Weight (lbs) ÷ height (in)2  ] x 704.5 =BMI

BMI calculator

The BMI cutoffs are

Health Canada classifies BMI according to the associated risk of developing health problems

Causes of Obesity

There are many causes that directly and indirectly contribute to obesity. Behavior, environment and genetics are among the main contributors to obesity. The Centers for Disease Control has identified these three as the main causes to the complexity of the obesity epidemic.

Behavior

In today’s fast-paced environment, it is easy to adopt unhealthy behaviors. Behavior, in the case of obesity, relates to food choices, amount of physical activity you get and the effort to maintain your health.

Americans are consuming more calories on average than in past decades. The increase in calories has also decreased the nutrients consumed that are needed for a healthy diet. This behavioral problem also relates to the increase in portion sizes at home and when dining out.

Environment

Environment plays a key role in shaping an individual’s habits and lifestyle. There are many environmental influences that can impact your health decisions. Today’s society has developed a more sedentary lifestyle. Walking has been replaced by driving cars, physical activity has been replaced by technology and nutrition has been overcome by convenience foods.

Genetics

Science shows that genetics play a role in obesity. Genes can cause certain disorders which result in obesity. However, not all individuals who are predisposed to obesity become affected by obesity. Research is currently underway to determine which genes contribute most to obesity.

Gut bacteria

The study of the effect of infectious agents on metabolism is still in its early stages. Gut flora has been shown to differ between lean and obese humans. There is an indication that gut flora in obese and lean individuals can affect the metabolic potential. This apparent alteration of the metabolic potential is believed to confer a greater capacity to harvest energy contributing to obesity.

Sedentary lifestyle

A sedentary lifestyle plays a significant role in obesity.Worldwide there has been a large shift towards less physically demanding work,and currently at least 30% of the world’s population gets insufficient exercise.This is primarily due to increasing use of mechanized transportation and a greater prevalence of labor-saving technology in the home.In children, there appear to be declines in levels of physical activity due to less walking and physical education.

Other illnesses

Certain physical and mental illnesses and the pharmaceutical substances used to treat them can increase risk of obesity. Medical illnesses that increase obesity risk include several rare genetic syndromes (listed above) as well as some congenital or acquired conditions: hypothyroidism, Cushing’s syndrome, growth hormone deficiency,^[129] and the eating disorders: binge eating disorder and night eating syndrome.

Physiological influences

Some researchers believe that every person has a predetermined weight that the body resists moving away from. Also, people of the same age, sex and body size often have different metabolic rates. This means their bodies burn food differently. Someone with a low metabolic rate may require fewer calories to maintain approximately the same weight as someone whose metabolic rate is high.

• Medical problems. In some people, obesity can be traced to a medical cause, such as Prader-Willi syndrome, Cushing’s syndrome and other conditions. Medical problems, such as arthritis, also can lead to decreased activity, which may result in weight gain.
• Certain medications – Some medications can lead to weight gain if you don’t compensate through diet or activity. These medications include some antidepressants, anti-seizure medications, diabetes medications, antipsychotic medications, steroids and beta blockers.
• Social and economic issues –  Research has linked social and economic factors to obesity. Avoiding obesity is difficult if you don’t have safe areas to exercise. Similarly, you may not have been taught healthy ways of cooking, or you may not have money to buy healthier foods. In addition, the people you spend time with may influence your weight — you’re more likely to become obese if you have obese friends or relatives.
• Age  – Obesity can occur at any age, even in young children. But as you age, hormonal changes and a less active lifestyle increase your risk of obesity. In addition, the amount of muscle in your body tends to decrease with age. This lower muscle mass leads to a decrease in metabolism. These changes also reduce calorie needs, and can make it harder to keep off excess weight. If you don’t consciously control what you eat and become more physically active as you age, you’ll likely gain weight.
• Pregnancy – During pregnancy, a woman’s weight necessarily increases. Some women find this weight difficult to lose after the baby is born. This weight gain may contribute to the development of obesity in women.
• Quitting smoking – Quitting smoking is often associated with weight gain. And for some, it can lead to enough weight gain that the person becomes obese. In the long run, however, quitting smoking is still a greater benefit to your health than continuing to smoke.
• Lack of sleep – Not getting enough sleep or getting too much sleep can cause changes in hormones that increase your appetite. You may also crave foods high in calories and carbohydrates, which can contribute to weight gain.

Others Cause of Obesity 

• Eating large amounts of processed or fast food– that’s high in fat and sugar
• Drinking too much alcohol– alcohol contains a lot of calories, and people who drink heavily are often overweight
• Eating out a lot – you may be tempted to also have a starter or dessert in a restaurant, and the food can be higher in fat and sugar
• Eating larger portions than you need – you may be encouraged to eat too much if your friends or relatives are also eating large portions
• drinking too many sugary drinks– including soft drinks and fruit juice
• comfort eating– if you have low self-esteem or feel depressed, you may eat to make yourself feel better
• an increased intake of energy-dense foods that are high in fat; and
• an increase in physical inactivity due to the increasingly sedentary nature of many forms of work, changing modes of transportation, and increasing urbanization.

Obesity caused others health problem

Obesity can cause a number of further problems, including difficulties with daily activities and serious health conditions.

• High blood pressure
• High cholesterol
• breathlessness
• increased sweating
• snoring
• difficulty doing physical activity
• often feeling very tired
• joint and back pain
• low confidence and self-esteem
• feeling isolated

Being obese can also increase your risk of developing many potentially serious health conditions, including:

• type 2 diabetes – a condition that causes a person’s blood sugar level to become too high
• high blood pressure
• high cholesterol and atherosclerosis (where fatty deposits narrow your arteries), which can lead to coronary heart diseaseand stroke
• asthma
• metabolic syndrome – a combination of diabetes, high blood pressure and obesity
• several types of cancer, including bowel cancer, breast cancerand womb cancer
• gastro-oesophageal reflux disease (GORD) – where stomach acid leaks out of the stomach and into the oesophagus (gullet)
• gallstones – small stones, usually made of cholesterol, that form in the gallbladder
• reduced fertility
• osteoarthritis – a condition involving pain and stiffness in your joints
• sleep apnoea – a condition that causes interrupted breathing during sleep, which can lead to daytime sleepiness with an increased risk of road traffic accidents, as well as a greater risk of diabetes, high blood pressure and heart disease
• liver disease and kidney disease
• pregnancy complications, such as gestational diabetes or pre-eclampsia (when a woman experiences a potentially dangerous rise in blood pressure during pregnancy)

Symptoms of Obesity 

The primary warning sign of obesity is an above-average body weight.

• breathing disorders (e.g., sleep apnea, chronic obstructive pulmonary disease)
• certain types of cancers (e.g., prostate and bowel cancer in men, breast and uterine cancer in women)
• coronary artery (heart) disease
• depression
• diabetes
• gallbladder or liver disease
• gastroesophageal reflux disease (GERD)
• high blood pressure
• high cholesterol
• Trouble sleeping
• Sleep apnea. This is a condition in which breathing is irregular and periodically stops during sleep.
• Shortness of breath
• Varicose veins
• Skin problems caused by moisture that accumulates in the folds of your skin
• Gallstones
• Osteoarthritis in weight-bearing joints, especially the knees
• High levels of blood sugar (diabetes)
• High triglycerides levels

Diagnosis of Obesity 

These exams and tests generally include

• Taking your health history – Your doctor may review your weight history, weight-loss efforts, exercise habits, eating patterns, what other conditions you’ve had, medications, stress levels and other issues about your health. Your doctor may also review your family’s health history to see if you may be predisposed to certain conditions.
• A general physical exam – This includes also measuring your height; checking vital signs, such as heart rate, blood pressure and temperature; listening to your heart and lungs; and examining your abdomen.
• Calculating your BMI – Your doctor will check your body mass index (BMI) to determine your level of obesity. This should be done at least once a year. Your BMI also helps determine your overall health risk and what treatment may be appropriate.
• Measuring your waist circumference – Fat stored around your waist, sometimes called visceral fat or abdominal fat, may further increase your risk of diseases, such as diabetes and heart disease. Women with a waist measurement (circumference) of more than 35 inches (80 centimeters, or cm) and men with a waist measurement of more than 40 inches (102 cm) may have more health risks than do people with smaller waist measurements.
• Checking for other health problems – If you have known health problems, your doctor will evaluate them. Your doctor will also check for other possible health problems, such as high blood pressure and diabetes.
• Blood tests – What tests you have depend on your health, risk factors and any current symptoms you may be having. Tests may include a cholesterol test, liver function tests, a fasting glucose, a thyroid test and others. Your doctor may also recommend certain heart tests, such as an electrocardiogram.

Treatment of Obesity 

Weight reduction is achieved by

• Consuming fewer calories
• Increasing activity and exercise

Structured approaches and therapies to reduce weight include:

• A modified diet. A reasonable weight loss goal is 1 to 2 pounds per week. This can usually be achieved by eating 500 to 1,000 fewer calories each day. Whether you concentrate on eating less fat or fewer carbohydrates is up to you. Fats have more than twice as many calories per ounce than carbohydrates or protein. If you cut out carbohydrates, you still need to limit fat intake. Choose healthy fats, such as monounsaturated and polyunsaturated oils.
• Regular exercise – To effectively lose weight, most people need to do moderate intensity exercise for 60 minutes most days of the week. Add more activity during the day. Take the stairs and get up often from your desk or sofa.
• Non-prescription orlistat (Alli) – Orlistat inhibits fat absorption in the intestine. Until recently, this medication was only available by prescription (Xenical). The over-the-counter medicine is sold at a lower dose than Xenical. But the active ingredient is the same.
• Other non-prescription diet pills –  Over-the-counter diet pills often contain ingredients that can increase heart rate and blood pressure. It is not clear how effective they are in producing weight loss that can be maintained over time. Common side effects include feeling jittery and nervous and having heart palpitations. Some experts believe they may be associated with an increased risk of stroke.
• Prescription diet pills. To help you lose weight, your doctor may prescribe medications along with a calorie-restricted diet. Almost all people regain weight when they stop using these medications. The effects of long-term use of these drugs have not been determined.
• Exercise. People who are overweight or obese need to get at least 150 minutes a week of moderate-intensity physical activity to prevent further weight gain or to maintain the loss of a modest amount of weight. To achieve more-significant weight loss, you may need to exercise 300 minutes or more a week. You probably will need to gradually increase the amount you exercise as your endurance and fitness improve.
• Keep moving – Even though regular aerobic exercise is the most efficient way to burn calories and shed excess weight, any extra movement helps burn calories. Making simple changes throughout your day can add up to big benefits. Park farther from store entrances, rev up your household chores, garden, get up and move around periodically, and wear a pedometer to track how many steps you actually take over the course of a day.

Dietary changes to treat obesity include

• Cutting calories – The key to weight loss is reducing how many calories you take in. You and your health care providers can review your typical eating and drinking habits to see how many calories you normally consume and where you can cut back. You and your doctor can decide how many calories you need to take in each day to lose weight, but a typical amount is 1,200 to 1,500 calories for women and 1,500 to 1,800 for men.
• Feeling full on less – The concept of energy density can help you satisfy your hunger with fewer calories. All foods have a certain number of calories within a given amount (volume). Some foods — such as desserts, candies, fats and processed foods — are high in energy density. This means that a small volume of that food has a large number of calories. In contrast, other foods, such as fruits and vegetables, have lower energy density.
• Making healthier choices – To make your overall diet healthier, eat more plant-based foods, such as fruits, vegetables and whole-grain carbohydrates. Also emphasize lean sources of protein — such as beans, lentils and soy — and lean meats. If you like fish, try to include fish twice a week.
• Restricting certain foods  – Certain diets limit the amount of a particular food group, such as high-carbohydrate or full-fat foods. Ask your doctor which diet plans have been found effective and which might be helpful for you.
• Meal replacements –These plans suggest that you replace one or two meals with their products — such as low-calorie shakes or meal bars — and eat healthy snacks and a healthy, balanced third meal that’s low in fat and calories.

Surgery of Obesity 

In general, weight-loss surgery (called bariatric surgery) may be considered if your BMI is 40 or greater, or your BMI is 30-35 or greater and you have at least one medical condition directly related to obesity. In addition, you must have participated in a structured weight loss program without success.

Common weight-loss surgeries include

• Gastric bypass surgery – In gastric bypass (Roux-en-Y gastric bypass), the surgeon creates a small pouch at the top of your stomach. The small intestine is then cut a short distance below the main stomach and connected to the new pouch. Food and liquid flow directly from the pouch into this part of the intestine, bypassing most of your stomach.
• Laparoscopic adjustable gastric banding (LAGB) – In this procedure, your stomach is separated into two pouches with an inflatable band. Pulling the band tight, like a belt, the surgeon creates a tiny channel between the two pouches. The band keeps the opening from expanding and is generally designed to stay in place permanently.
• Biliopancreatic diversion with duodenal switch – This procedure begins with the surgeon removing a large part of the stomach. The surgeon leaves the valve that releases food to the small intestine and the first part of the small intestine (duodenum). Then the surgeon closes off the middle section of the intestine and attaches the last part directly to the duodenum. The separated section of the intestine is reattached to the end of the intestine to allow bile and digestive juices to flow into this part of the intestine.
• Gastric sleeve – In this procedure, part of the stomach is removed, creating a smaller reservoir for food. It’s a less complicated surgery than gastric bypass or biliopancreatic diversion with duodenal switch.
• Gastroplasty – also known as stomach stapling. A surgeon creates a small pouch in the stomach that allows only limited amounts of food to be eaten at one time.
• Laparoscopic adjustable gastric banding – A surgeon places an adjustable band around the stomach with minimally invasive surgery.

Complications of Obesity 

Other complications from obesity or becoming overweight are:

1. Neurological – headaches, stroke, dementia , vision loss from diabetes complications, false brain tumors, and diabetic neuropathy

2. Psychological – depression, anxiety, unnecessary stress, and eating disorders

3. Respiratory – asthma, sleep apnea, pulmonary embolism, and pulmonary hypertension

4. Urological – may lead to kidney cancer and diabetic kidney disease.

5. Circulatory – high blood pressure, high cholesterol, irregular heartbeat, atherosclerosis, poor circulation, heart problems, blood clots, peripheral artery disease, and certain lymph node cancers

6. Muskuloskeletal – arthritis (hips, knees, and ankles), lower back pain, and vertebral disk disease.

7. Gastrointestinal – acid reflux disease, esophageal cancer, colon cancer, colon polyps, fatty liver disease, cirrhosis, gallstones, liver cancer, and gallbladder cancer.

8. Digestive – pancreatitis, pancreatic cancer, and type 2 diabetes.

9. Reproductive – for women irregular menstruation, infertility, ovarian cancer, endometrial cancer, cervical cancer, breast cancer, and polycystic ovarian syndrome. For men: erectile dysfunction, infertility, and prostate cancer.

Heartburn is a sensation of burning in the chest caused by stomach acid backing up into the esophagus (food pipe). It is also known as acid indigestion, is a burning sensation in the central chest or upper central abdomen. The pain often rises in the chest and may radiate to the neck, throat, or angle of the jaw.  The burning is usually in the central part of the chest, just behind the sternum (breastbone). The burning can worsen or can be brought on by lying flat or on the right side. Pregnancy tends to aggravate heartburn.

Causes of Heartburn

Heartburn is actually a symptom of GERD (gastroesophageal reflux disease), and is caused by acid refluxing back into the esophagus. Risk factors include those that increase the production of acid in the stomach, as well as structural problems that allow acid reflux into the esophagus.

• Some common foods that we eat and drink, stimulate increased stomach acid secretion setting the stage for heartburn. Over-the-counter medications also may precipitate heartburn. Examples of these irritants include:
  • caffeine,
  • aspirin
  • buprofen
  • Naproxen
  • carbonated beverages,
  • acidic juices (grapefruit, orange, pineapple)
  • acidic foods (tomatoes, grapefruit, and oranges)
• Smoking and the consumption of high-fat content foods tend to affect function of the lower esophageal sphincter (LES), causing it to relax from the stomach and allow acid to reflux into the esophagus.
• A hiatal hernia where a portion of the stomach lies within the chest instead of the in abdomen, can affect the way the LES works and is a risk factor for reflux. Hiatal hernias by themselves cause no symptoms. It is only when the LES fails that heartburn occurs.
• Pregnancy can cause increased pressure within theabdominal cavity and affect LES function and predispose it to reflux.
• Obesity may also cause increased pressure in the abdomen, and thus reflux in the same way.
• Primary diseases of the esophagus can also present with heartburn as a symptom. These include, among others, scleroderma and sarcoidosis.
• Some types of food aggravate heartburn, including:
  • Alcohol, which relaxes the oesophageal sphincter
  • Coffee and chocolate
  • Orange juice and other acidic juices
  • Acidic foods, such as tomatoes, oranges, and grapefruits
  • Fatty or fried foods
  • Black pepper, mustard, and spicy foods
  • Large meals or portion sizes.

Symptoms of Heartburn

• You have a sharp, burning feeling just below your breastbone or ribs.The chest pain can be accompanied by an acidic taste in your mouth, regurgitation of food, or a burning in your throat.
• Pain generally doesn’t spread to your shoulders, neck, or arms, but it can.
• Pain usually comes after meals, particularly after foods or drinks that trigger reflux in you.
• Pain also comes when you lie down or exercise on a full stomach.
• Symptoms usually get better quickly after taking an antacid.
• You rarely get a cold sweat or shortness of breath along with your other symptoms.
• Burning sensation in the middle of the chest.
• Rising pain, possibly reaching the jaw.
• Burning and indigestion-like pain.
• Foul, acrid taste in the mouth.

Diagnosis of Heartburn

To evaluate if there is any damage and how severe your heartburn is, the doctor my suggest some of the following tests:

• Endoscopy – A flexible scope is passed down the esophagus to examine the esophagus as well as the stomach. Biopsies can be taken if indicated. This lets the doctor see if there is any obvious damage, and also eliminate other reasons for the patient’s symptoms (foreign body, malignancy).
• Upper GI series (upper GI series) – After drinking a liquid that coats the inside of the digestive tract, X-ray sare taken. These X-rays will show the outline of the digestive system.
• Ambulatory pH testing – This test measures the acidity in the esophagus via a small tube that goes through the nose into the stomach.
• Manometry and pH testing – Less commonly, when conventional therapy has failed to confirm the diagnosis, or when symptoms are atypical, use of pressure monitors and acid measurements from within the esophagus may be helpful in making the diagnosis.

Treatment of Heartburn

Common OTC antacids such as Rolaids, Tums or Maalox are effective for some individuals;

Other people may do well with proton pump inhibitors (PPIs) such as

• Omeprazole
• Lansoprazole
• Rabeprazole
• Esomeprazole  
• Pantoprazole

There are many over-the-counter and prescription medications available. These fall into three major categories

Medications that neutralize stomach acid (antacids) 

Antacids  provide quick relieve because they decrease the acid. These medications don’t heal existing damage to your esophagus nor prevent future episodes of heartburn.

Medications that reduce the production of acid 

These medications are named after the receptor they block (H-2 blockers) and are available as over-the-counter as well as prescription medications. Their symptom relief tends to last longer than antacids, but it also takes longer for them to start working.

Others may need H2 receptor antagonists such as

• Ranitidine
• Cimetidine
• Famotidine
• Nizatidine

Medications that block acid production  

Proton pump inhibitors (for example, omeprazole , lansoprazole  block the production of acid. This then allows healing of the damaged esophagus.

Prevention of Heartburn

Food and drink tips for night-time heartburn relief

• Reduce heartburn risk by limiting acidic foods such as grapefruit, oranges, tomatoes, and vinegar.
• Spicy foods giving you heartburn? Cut back on pepper and chillies.
• Don’t lie down for at least three hours after you eat. When you are sitting up, gravity helps prevent food and stomach acid from going up into the gullet (oesophagus) and causing heartburn.
• Enjoy lean meats and non-fatty foods. Greasy foods – such as chips and burgers – can trigger heartburn.
• Avoid or reduce drinks that can trigger reflux such as alcohol, drinks with caffeine and fizzy drinks.
• Size matters – eat smaller meals and you may avoid triggering heartburn symptoms.
• Enjoy an after-work drink? You may want to turn teetotal – alcohol can relax the oesophageal sphincter, worsening heartburn.
• Crazy about colas? It may be time to cut back. Colas can be related to reflux and to heartburn symptoms.
• Avoid snacking at bedtime. Eating close to bedtime can trigger heartburn symptoms.

Lifestyle tips for night-time heartburn relief

• Steer clear of tight clothes. Tight belts, waistbands and underwear can press on your stomach triggering heartburn.
• Strive for a less stressful life. Stress may increase stomach acids, increasing heartburn symptoms.
• Heavy? Try losing weight. The pressure of excess weight increases the chance stomach acid will reflux back up into the oesophagus causing heartburn.
• Popping antacids more than once a week? You may have GORD and need specific treatment.
• Try chewing gum at night. This can boost the production of saliva, which helps neutralise stomach acid.
• Not all “trigger” foods cause heartburn symptoms in everyone. Keep track of your symptoms to find your personal triggers.
• Pregnant? You may experience heartburn or GORD. Seek medical adviceabout finding relief.
• Heartburn worse after exercise? Drink plenty of water. It helps with hydration and digestion.
• Try keeping a diary or heartburn log to keep track of activities that might trigger attacks.
• Wait for your work-out if you don’t want to trigger heartburn. Wait at least two hours after a meal before exercising.
• Nicotine can cause your oesophageal sphincter to relax. If you smoke, stop smoking.
• Some medicines can worsen reflux and heartburn. Seek medical advice about alternatives.
• Use blocks or bricks under the bedpost to raise the head of your bed 15cm (6in) so you can sleep with head and chest elevated. You can also try a wedge pillow.
• Bend with your knees. Bending over at the waist tends to increase reflux and heartburn symptoms.

How can I reduce heartburn during pregnancy

Prevention is your best bet to reduce heartburn during your pregnancy. Though you may not be able to avoid the condition entirely, here are some ways to prevent it and minimize any discomfort:

• Avoid food and drinks that upset your stomach – These include carbonated drinks, alcohol, caffeine, chocolate, citrus fruits and juices, tomatoes, mustard, vinegar, mint products, processed meats, and foods that are fatty, spicy, fried, or highly seasoned.
• Eat small meals – Instead of three large meals, eat several small ones throughout the day. Take your time eating and chew thoroughly.
• Drink water in between meals – It’s important to drink plenty of water daily during pregnancy, but too much liquid can distend your stomach. Stay hydrated by drinking most of your water in between meals.
• Chew gum after eating – Chewing gum stimulates your salivary glands, and saliva can help neutralize acid.
• Eat two or three hours before bedtime – This gives your body time to digest before you lie down.
• Sleep propped up – Elevate your upper body by about 6 inches with several pillows or a wedge when you sleep. This helps stomach acid stay down and aids digestion.
• Dress comfortably – Wear loose, relaxed clothing. Don’t wear clothes that are tight around your waist and tummy.
• Ask your provider about heartburn medicines – An antacid that contains magnesium or calcium may ease discomfort. Check with your provider before taking one because some brands are high in sodium or contain aluminum or aspirin. You can also talk to your provider about prescription heartburn medications that are safe during pregnancy.
• Don’t smoke – In addition to contributing to serious health problems, smoking boosts the acid in the stomach.

References

GERD (Gastroesophageal reflux disease ) also known as acid reflux, is a long-term condition where stomach contents come back up into the esophagus resulting in either symptoms or complications. Symptoms include the taste of acid in the back of the mouth, heartburn, bad breath, chest pain, vomiting, breathing problems, and wearing away of the teeth.Complications include esophagitis, esophageal strictures, and Barrett’s esophagus.

Types of GERD/Acid Reflux

Most people experience occasional acid reflux or GER. However, in some cases the digestive condition is chronic. It’s considered gastroesophageal reflux disease (GERD) if it occurs more than twice a week.

Acid reflux can affect infants and children as well as adults. Children under 12 usually don’t experience heartburn. Instead they have alternative symptoms like:

• trouble swallowing
• dry cough
• asthma
• laryngitis (loss of voice)

These alternative symptoms can also appear in adults.

Infant of GERD/Acid Reflux

Adults aren’t the only ones affected by acid reflux. According to the National Digestive Diseases Information Clearinghouse (NDDIC), more than half of all babies experience infant acid reflux during their first three months of life. It’s important for your pediatrician to differentiate between normal reflux and GERD.

Spitting up and even vomiting is normal and may not bother the baby. Other signs of normal reflux include:

• irritability
• discomfort
• arching the back during or immediately after feedings
• poor feeding
• coughing

Causes of GERD/Acid Reflux

• Lifestyle – Use of alcohol or cigarettes, obesity, poor posture (slouching)
• Medications – Calcium channel blockers, theophylline nitrates, antihistamines
• Diet – Fatty and fried foods, chocolate, garlic and onions, drinks with caffeine, acidic foods such as citrus fruits and tomatoes, spicy foods, mint flavorings
• Eating habits – Eating large meals, eating quickly or soon before bedtime
• Other medical conditions – Hiatal hernia, pregnancy, diabetes, rapid weight gain
• Hiatal hernia – which increases the likelihood of GERD due to mechanical and motility factors.
• Obesity – increasing body mass index is associated with more severe GERD. In a large series of 2,000 patients with symptomatic reflux disease, it has been shown that 13% of changes in esophageal acid exposure is attributable to changes in body mass index.
• Zollinger-Ellison syndrome – which can be present with increased gastric acidity due to gastrin production.
• A high blood calcium level  – which can increase gastrin production, leading to increased acidity.
• Scleroderma and systemic sclerosis –  which can feature esophageal dysmotility.
• Visceroptosis or Glénard syndrome –  in which the stomach has sunk in the abdomen upsetting the motility and acid secretion of the stomach.
• Gallstones  – which can impede the flow of bile into the duodenum, which can affect the ability to neutralize gastric acid
• Obstructive sleep apnea

Symptoms can also be caused by certain medicines, such as

• Anticholinergics (for example, seasickness medicine)
• Bronchodilators for asthma
• Calcium channel blockers for high blood pressure
• Dopamine-active drugs for Parkinson disease
• Progestin for abnormal menstrual bleeding or birth control
• Sedatives for insomnia or anxiety
• Tricyclic antidepressants
• The use of medicines such as prednisolone.

Symptoms of GERD/Acid Reflux

GERD sometimes causes injury of the esophagus. These injuries may include one or more of the following:

• Sharp or burning chest pain behind the breastbone. This is also known as heartburn. It is the most common symptom of GERD. Heartburn may be worse when you eat, bend over or lie down.
• Reflux esophagitis – inflammation of esophageal epithelium which can cause ulcers near the junction of the stomach and esophagus
• Esophageal strictures – the persistent narrowing of the esophagus caused by reflux-induced inflammation
• Barrett’s esophagus – intestinal metaplasia (changes of the epithelial cells from squamous to intestinal columnar epithelium) of the distal esophagus
• Esophageal adenocarcinoma – a form of cancer
• Chest pain
• Difficulty swallowing
• Regurgitation of food or sour liquid
• Sensation of a lump in your throat
• Chronic cough
• Laryngitis
• New or worsening asthma
• Disrupted sleep
• A burning sensation in your chest (heartburn), usually after eating, which might be worse at night
• Tightness in your chest or upper abdomen. The pain may wake you up in the middle of the night.
  Regurgitation, the backflow of stomach fluids into your mouth
• Nausea
• A recurring sour or bitter taste in the mouth
• Difficulty swallowing
• Sore throat
• Coughing, wheezing or repeatedly needing to clear your throat
• Hoarseness, especially in the morning

Some researchers have proposed that recurrent ear infections, and idiopathic pulmonary fibrosismight be tied, in some cases, to GERD; however, a causative role has not been established. GERD does not appear to be linked to chronic sinusitis.

Diagnosis of GERD/Acid Reflux

• Upper endoscopy – Your doctor inserts a thin, flexible tube equipped with a light and camera (endoscope) down your throat, to examine the inside of your esophagus and stomach. Test results can often be normal when reflux is present, but an endoscopy may detect inflammation of the esophagus (esophagitis) or other complications. An endoscopy can also be used to collect a sample of tissue (biopsy) to be tested for complications such as Barrett’s esophagus.
• Endoscopy – Endoscopy, the looking down into the stomach with a fibre-optic scope, is not routinely needed if the case is typical and responds to treatment. It is recommended when people either do not respond well to treatment or have alarm symptoms, including dysphagia, anemia, blood in the stool (detected chemically), wheezing, weight loss, or voice changes.Some physicians advocate either once-in-a-lifetime or 5- to 10-yearly endoscopy for people with longstanding GERD, to evaluate the possible presence of dysplasia or Barrett’s esophagus.
• Ambulatory acid (pH) probe test – A monitor is placed in your esophagus to identify when, and for how long, stomach acid regurgitates there. The monitor connects to a small computer that you wear around your waist or with a strap over your shoulder. The monitor might be a thin, flexible tube (catheter) that’s threaded through your nose into your esophagus, or a clip that’s placed in your esophagus during an endoscopy and that gets passed into your stool after about two days.
• Esophageal manometry – This test measures the rhythmic muscle contractions in your esophagus when you swallow. Esophageal manometry also measures the coordination and force exerted by the muscles of your esophagus.
• X-ray of your upper digestive system – X-rays are taken after you drink a chalky liquid that coats and fills the inside lining of your digestive tract. The coating allows your doctor to see a silhouette of your esophagus, stomach and upper intestine.
• A special X-ray called a barium swallow radiograph  – can help doctors see whether liquid is refluxing into the esophagus. It can also show whether the esophagus is irritated or whether there are other abnormalities in the esophagus or the stomach that can make it easier for someone to reflux. With this test, the person drinks a special solution (barium, a kind of chalky liquid); this liquid then shows up on the X-rays.
• A gastric emptying scan – can help show whether a person’s stomach is emptying too slowly, which can make reflux more likely to happen. This test is done either by drinking milk that has a tracer in it or eating scrambled eggs that have a tracer mixed in. A special machine that doesn’t use radiation can detect the tracer to see where it goes and how fast it empties the stomach.
• Eosinophilic inflammation (usually due to reflux) – The presence of intraepithelial eosinophils may suggest a diagnosis of eosinophilic esophagitis (EE) if eosinophils are present in high enough numbers. Less than 20 eosinophils per high-power microscopic field in the distal esophagus, in the presence of other histologic features of GERD, is more consistent with GERD than EE.
• Barium swallow – An X-ray test that outlines the esophagus.
• Cardiac evaluation  – To check for heart disease.
• Esophageal manometry or motility studies – To check the squeezing motion of your esophagus when you are swallowing.
• Esophageal pH monitoring – Uses electrodes to measure the pH (acid level) in the esophagus. It is usually done over a 24-hour period.
• Ambulatory acid (pH) test –  (monitors the amount of acid in the esophagus)
• Esophageal impedance test – (measures the movement of substances in the esophagus)
• Edema and basal hyperplasia (nonspecific inflammatory changes)
• Lymphocytic inflammation (nonspecific)
• Neutrophilic inflammation (usually due to reflux or Helicobacter gastritis)
• Goblet cell intestinal metaplasia or Barrett’s esophagus
• Elongation of the papillae
• Thinning of the squamous cell layer
• Dysplasia
• Carcinoma

Treatment of GERD/Acid Reflux

Treatment for most people with GERD includes lifestyle changes as described above and medication. If symptoms persist, surgery or endoscopy treatments are other options.

Medications

There are several medications that can be used to treat GERD. They include:

• Over-the-counter acid buffers — Buffers neutralize acid. They include Mylanta, Maalox, Tums, Rolaids, and Gaviscon. The liquid forms of these medications work faster But the tablets may be more convenient.Antacids that contain magnesium can cause diarrhea. And antacids that contain aluminum can cause constipation. Your doctor may advise you to alternate antacids to avoid these problems. These medicines work for a short time and they do not heal the inflammation of the esophagus.
• Over-the-counter proton pump inhibitors — Proton pump inhibitors shut off the stomach’s acid production.Proton pump inhibitors are very effective. They can be especially helpful in patients who do not respond to H2 blockers and antacids. These drugs are more potent acid-blockers than are H2 blockers, but they take longer to begin their effect.
• Proton pump inhibitors – should not be combined with an H2 blocker. The H2 blocker can prevent the proton pump inhibitor from working.These are prescribed at higher doses than those available in over-the-counter forms.
• Motility drugs – These medications may help to decrease esophageal reflux. But they are not usually used as the only treatment for GERD. They help the stomach to empty faster, which decreases the amount of time during which reflux can occur.
• Mucosal protectors – These medications coat, soothe and protect the irritated esophageal lining. One example is sucralfate (Carafate).

Over-the-counter and prescription medicines

You can buy many GERD medicines without a prescription. However, if you have symptoms that will not go away, you should see your doctor.

Antacids – Doctors often first recommend antacids to relieve heartburn and other mild GER and GERD symptoms. Antacids include over-the-counter medicines such as. Antacids can have side effects, including diarrhea and constipation.

H2 blockers – H2 blockers decrease acid production. They provide short-term or on-demand relief for many people with GER and GERD symptoms. They can also help heal the esophagus, although not as well as other medicines. You can buy H2 blockers over-the-counter or your doctor can prescribe one. Types of H2 blockers include

• cimetidine 
• famotidine 
• nizatidine 
• ranitidine 

Proton pump inhibitors (PPIs) – PPIs lower the amount of acid your stomach makes. PPIs are better at treating GERD symptoms than H2 blockers. They can heal the esophageal lining in most people with GERD. Doctors often prescribe PPIs for long-term GERD treatment. Such as

• Esomeprazole 
• Lansoprazole 
• Omeprazole 
• Pantoprazole 
• Rabeprazole 

Talk with your doctor about taking lower-strength omeprazole or lansoprazole, sold over the counter.

Antibiotics – Antibiotics, including erythromycin , can help your stomach empty faster. Erythromycin has fewer side effects than prokinetics; however, it can cause diarrhea.

Prokinetics – Prokinetics help your stomach empty faster. Prescription prokinetics include

• bethanechol 
• metoclopramide

Both of these medicines have side effects, including

• nausea
• diarrhea
• fatigue, or feeling tired
• depression 
• anxiety
• delayed or abnormal physical movement

Prokinetics can cause problems if you mix them with other medicines, so tell your doctor about all the medicines you’re taking.

Prevention of GERD/Acid Reflux

There are a lot of things you can do to prevent the symptoms of GERD. Some simple lifestyle changes include

• Elevate the head of your bed at least six inches. If possible, put wooden blocks under the legs at the head of the bed. Or, use a solid foam wedge under the head portion of the mattress. Simply using extra pillows may not help.
• Avoid foods that cause the esophageal sphincter to relax during their digestion. These include:
  • Coffee
  • Chocolate
  • Fatty foods
  • Whole milk
  • Peppermint
  • Spearmint
• Limit acidic foods that make the irritation worse when they are regurgitated. These include citrus fruits and tomatoes.
• Excess pounds put pressure on your abdomen, pushing up your stomach and causing acid to reflux into your esophagus.
• Smoking decreases the lower esophageal sphincter’s ability to function properly.
• If you regularly experience heartburn while trying to sleep, place wood or cement blocks under the feet of your bed so that the head end is raised by 6 to 9 inches. If you can’t elevate your bed, you can insert a wedge between your mattress and box spring to elevate your body from the waist up. Raising your head with additional pillows isn’t effective.
• Wait at least three hours after eating before lying down or going to bed.
• Put down your fork after every bite and pick it up again once you have chewed and swallowed that bite.
• Common triggers include fatty or fried foods, tomato sauce, alcohol, chocolate, mint, garlic, onion, and caffeine.
• Clothes that fit tightly around your waist put pressure on your abdomen and the lower esophageal sphincter.
• Avoid carbonated beverages. Burps of gas force the esophageal sphincter to open and can promote reflux.
• Eat smaller, more frequent meals.
• Do not eat during the three to four hours before you go to bed.
• Avoid drinking alcohol. It loosens the esophageal sphincter.
• Avoid drinking alcohol. It loosens the esophageal sphincter.
• Lose weight if you are obese. Obesity can make it harder for the esophageal sphincter to stay closed.
• Avoid wearing tight-fitting garments. Increased pressure on the abdomen can open the esophageal sphincter.
• Use lozenges or gum to keep producing saliva.
• Do not lie down after eating.

References

Generalized anxiety disorder (GAD) is an anxiety disorder characterized by excessive, uncontrollable and often irrational worry, that is, apprehensive expectation about events or activities. This excessive worry often interferes with daily functioning, as individuals with GAD typically anticipate disaster, and are overly concerned about everyday matters such as health issues, money, death, family problems, friendship problems, interpersonal relationship problems, or work difficulties. Individuals may exhibit a variety of physical symptoms, including feeling tired, fidgeting, headaches, numbness in hands and feet, muscle tension, difficulty swallowing, upset stomach, vomiting, diarrhea, breathing difficulty, difficulty concentrating, trembling, irritability, sweating, restlessness, sleeping difficulties, hot flashes, rashes, and inability to fully control the anxiety. These symptoms must be consistent and ongoing, persisting at least six months, for a formal diagnosis of GAD.

Causes of Generalized Anxiety Disorder

GAD affects the way a person thinks, but the anxiety can lead to physical symptoms, as well. Symptoms of GAD can include:

• Excessive, ongoing worry and tension
• An unrealistic view of problems
• Restlessness or a feeling of being “edgy”
• Irritability
• Muscle tension
• Headaches
• Sweating
• difficulty concentrating
• difficulty sleeping
• irritability
• fatigue and exhaustion
• muscle tension
• repeated stomachaches or diarrhea
• sweaty palms
• shaking
• rapid heartbeat
• neurological symptoms, such as numbness or tingling in different parts of the body
• Difficulty concentrating
• Nausea
• The need to go to the bathroom frequently
• Tiredness
• Trouble falling or staying asleep
• Trembling
• Being easily startled

Symptoms of Generalized Anxiety Disorder

Diagnosis of Generalized Anxiety Disorder

DSM-5 criteria

The diagnostic criteria for GAD as defined by the Diagnostic and Statistical Manual of Mental Disorders DSM-5 (2013),published by the American Psychiatric Association, are paraphrased as follows

No major changes to GAD have occurred since publication of the Diagnostic and Statistical Manual of Mental Disorders (2004); minor changes include the wording of diagnostic criteria.

ICD-10 criteria

ICD-10 Generalized anxiety disorder “F41.1” Note: For children different criteria may be applied

Antidepressants 

Antidepressants including medications in the selective serotonin reuptake inhibitor (SSRI) and serotonin and norepinephrine reuptake inhibitor (SNRI) classes are the first line medication treatments. Examples of antidepressants used to treat generalized anxiety disorder include escitalopram , duloxetine, venlafaxine  and paroxetine . Your doctor also may recommend other antidepressants.

Buspirone

An anti-anxiety medication called buspirone may be used on an ongoing basis. As with most antidepressants, it typically takes up to several weeks to become fully effective.

Selective serotonin reuptake inhibitors

Pharmaceutical treatments for GAD include selective serotonin reuptake inhibitors (SSRIs). These are the preferred first line of treatment. SSRIs used for this purpose include escitalopram and paroxetine

Benzodiazepines

Benzodiazepines are most often prescribed to people with generalized anxiety disorder. Research suggests that these medications give some relief, at least in the short term. However, they carry some risks, mainly impairment of both cognitive and motor functioning, and psychological and physical dependence that makes it difficult for patients to stop taking them. It has been noted that people taking benzodiazepines are not as alert on their job or at school. Additionally, these medications may impair driving and they are often associated with falls in the elderly, resulting in hip fractures. These shortcomings make the use of benzodiazepines optimal only for short-term relief of anxiety. CBT and medication are of comparable efficacy in the short-term but CBT has advantages over medication in the longer term.

Pregabalin and gabapentin

Pregabalin (Lyrica) acts on the voltage-dependent calcium channel to decrease the release of neurotransmitters such as glutamate, norepinephrine and substance P. Its therapeutic effect appears after 1 week of use and is similar in effectiveness to lorazepam, alprazolam and venlafaxine but pregabalin has demonstrated superiority by producing more consistent therapeutic effects for psychic and somatic anxiety symptoms. Long-term trials have shown continued effectiveness without the development of tolerance and additionally, unlike benzodiazepines, it does not disrupt sleep architecture and produces less severe cognitive and psychomotor impairment.

Other psychiatric medications

• 5-HT_1A receptor partial agonists, such as buspirone and tandospirone.
• Serotonin-norepinephrine reuptake inhibitors (SNRIs), such as venlafaxine and duloxetine.
• Newer, atypical serotonergic antidepressants, such as vilazodone and agomelatine.
• Tricyclic antidepressants (TCAs), such as imipramine and clomipramine.
• Certain monoamine oxidase inhibitors (MAOIs), such as moclobemide and phenelzine.

Other medications

• Hydroxyzine – Antihistamine, 5-HT_2A receptor antagonist.

• Propranolol – Sympatholytic, beta blocker.
• Clonidine – Sympatholytic, α₂-adrenergic receptor agonist.
• Guanfacine – Sympatholytic, α₂-adrenergic receptor agonist.
• Prazosin – Sympatholytic, alpha blocker.

References

1. Show More

   • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3651952/
   • https://www.ncbi.nlm.nih.gov/books/NBK441870/
   • https://www.ncbi.nlm.nih.gov/books/NBK441870/
   • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1828319/

Premenstrual dysphoric disorder (PMDD) is a condition in which a woman has severe depression symptoms, irritability, and tension before menstruation. The symptoms of PMDD are more severe than those seen with premenstrual syndrome (PMS).PMS refers to a wide range of physical or emotional symptoms that most often occur about 5 to 11 days before a woman starts her monthly menstrual cycle. In most cases, the symptoms stop when, or shortly after, her period begins.

The disorder consists of a “cluster of affective, behavioral and somatic symptoms” that recur monthly during the luteal phase of the menstrual cycle. PMDD was added to the list of depressive disorders in the Diagnostic and Statistical Manual of Mental Disorders in 2013. The exact pathogenesis of the disorder is still unclear and is an active research topic. Treatment of PMDD relies largely on antidepressants that modulate serotonin levels in the brain via serotonin reuptake inhibitors as well as ovulation suppression using contraception.

Diagnosis of Premenstrual Dysphoric Disorder

Authoritative diagnostic criteria for PMDD are provided by a number of expert medical guides, notably the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5). The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), established seven criteria (A through G) for the diagnosis of PMDD.

Diagnostic Criteria

Criterion A – is that in most menstrual cycles during the past year, at least 5 of the following 11 symptoms (including at least 1 of the first 4 listed) must be present in the final week before the onset of menses, start to improve within a few days after the onset of menses, and become minimal or absent in the week postmenses.

1. Marked lability (e.g., mood swings)
2. Marked irritability or anger
3. Markedly depressed mood
4. Marked anxiety and tension
5. Decreased interest in usual activities
6. Difficulty in concentration
7. Lethargy and marked lack of energy
8. Marked change in appetite (e.g., overeating or specific food cravings)
9. Hypersomnia or insomnia
10. Feeling overwhelmed or out of control
11. Physical symptoms (e.g., breast tenderness or swelling, joint or muscle pain, a sensation of ‘bloating’ and weight gain)

Criterion B one (or more) of the following symptoms must be present

1. Marked affective lability (e.g., mood swings; feeling suddenly sad or tearful, or increased sensitivity to rejection).
2. Marked irritability or anger or increased interpersonal conflicts.
3. Marked depressed mood, feelings of hopelessness, or self-deprecating thoughts.
4. Marked anxiety, tension, and/or feelings of being keyed up or on edge.

Criterion C one (or more) of the following symptoms must be present additionally, to reach a total of five symptoms when combined with symptoms from Criterion B above.

1. Decreased interest in usual activities (e.g., work, school, friends, hobbies).
2. Subjective difficulty in concentration.
3. Lethargy, easy fatigability, or marked lack of energy.
4. Marked change in appetite; overeating; or specific food cravings.
5. Hypersomnia or insomnia.
6. A sense of being overwhelmed or out of control.
7. Physical symptoms such as breast tenderness or swelling, joint or muscle pain, a sensation of “bloating,” or weight gain.

The symptoms in Criteria A-C must have been met for most menstrual cycles that occurred in the preceding year.

Criterion D – The symptoms are associated with clinically significant distress or interference with work, school, usual social activities, or relationships with others (e.g., avoidance of social activities; decreased productivity and efficiency at work, school, or home).

Criterion E – The disturbance is not merely an exacerbation of the symptoms of another disorder, such as major depressive disorder, panic disorder, persistent depressive disorder (dysthymia), or a personality disorder (although it may co-occur with any of these disorders).

Criterion F – Criterion A should be confirmed by prospective daily ratings during at least two symptomatic cycles. 

Criterion G – The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment) or another medical condition (e.g., hyperthyroidism).

According to the DSM-5, a diagnosis of PMDD requires the presence of at least five of these symptoms with one of the symptoms being number 1-4 (marked lability, irritability, depressed mood, anxiety and tension). These symptoms should occur during the week before menses and remit after initiation of menses.

Laboratory studies should include the following:

• Thyroid function tests
• Complete blood count (CBC)
• Follicle-stimulating hormone (FSH) level

Treatments of Premenstrual Dysphoric Disorder

Several common treatments include

Antidepressants (SSRIs)  

Several members of the selective serotonin reuptake inhibitor (SSRI) class of medications are effective in the treatment of PMDD.SSRI antidepressants such as fluoxetine , sertraline , paroxetine  and citalopram These medications work by regulating the levels of the neurotransmitter serotonin in the brain. SSRIs that have shown to be effective in the treatment of PMDD includeUp to 75% of women report relief of symptoms when treated with SSRI medications. Side effects can occur in up to 15% of women and include nausea, anxiety, and headache. SSRI medications to treat PMDD may be prescribed to be taken continuously or only during the 14-day luteal phase (second half) of the menstrual cycle. Other types of antidepressants (tricyclic antidepressants and monoamine oxidase inhibitors) and lithium (Lithobid) have not been shown to be effective in the treatment of PMDD.

Miscellaneous Pharmacologic Interventions for PMDD

GnRH analogs or GnRH agonists have also been used to treat PMDD.These drugs suppress estrogen production by the ovaries by inhibiting the secretion of regulatory hormones from the pituitary gland. As a result, menstrual periods stop, mimicking menopause. Nasal and injection forms of GnRH agonists are available . Gonadotropin-releasing hormone analogs such as leuprolide , nafarelin  and goserelin

Birth control pills 

Taking birth control pills with no pill-free interval or with a shortened pill-free interval may reduce PMS and PMDD symptoms for some women.

Nutritional supplements

Consuming 1,200 milligrams of dietary and supplemental calcium daily may possibly reduce symptoms of PMS and PMDD in some women. Vitamin B-6, magnesium and L-tryptophan also may help, but talk with your doctor for advice before taking any supplements.

Danazol (Danocrine) 

Danazol (Danocrine) is a synthetic drug that creates a high androgen (male type hormone) and low estrogen hormonal environment by interfering with ovulation and ovarian production of estrogen.

Herbal remedies

Some research suggests that chasteberry (Vitex agnus-castus) may possibly reduce irritability, mood swings, breast tenderness, swelling, cramps and food cravings associated with PMDD, but more research is needed. The Food and Drug Administration doesn’t regulate herbal supplements, so talk with your doctor before trying one.

Lifestyle changes

Regular exercise often reduces premenstrual symptoms. Cutting back caffeine, avoiding alcohol and stopping smoking may ease symptoms, too. Decreasing intake of sugar, salt, caffeine and alcohol and increasing protein and carbohydrate intake

Getting enough sleep 

Using relaxation techniques, such as mindfulness, meditation and yoga, also may help. Avoid stressful and emotional triggers, such as arguments over financial issues or relationship problems, whenever possible.

Dietary supplementation 

With calcium, vitamin B6, magnesium and vitamin E

Estrogen

Another option is to inhibit ovulation with estrogen, which can be delivered via a skin patch or via a subcutaneous implant. Doses of estrogen tend to be higher than those prescribed for hormone therapy during menopause, but lower than those used for contraception in childbearing years. If estrogen is prescribed, it should be taken along with a progestogen to reduce risk of uterine cancer — except for women who have had a hysterectomy.

GnRH agonists

Gonadotropin-releasing hormone (GnRH) agonists, which are usually prescribed for endometriosis and infertility, suppress the hormonal cycle — and may be helpful for women whose PMDD symptoms have not responded to other drugs.

Councelling

Talking to a therapist may also help you deal with coping strategies. And relaxation therapy, meditation, reflexology, and yoga might provide you relief, but these haven’t been widely studied.

Acupuncture

In a systematic review of 10 trials with methodologic limitations comparing acupuncture versus sham acupuncture, medication, or no treatment for premenstrual syndrome, acupuncture was associated with improved symptoms compared with any control in an analysis of 8 trials with 429 patients.

Cognitive-behavioral therapy

Cognitive therapy is based on the view that behavioral disorders are influenced by negative or extreme thought patterns, which are so habitual that they become automatic and are unnoticed by the individual.

Light therapy

The light emitted by conventional fluorescent lamps is deficient in many of the colors and wavelengths of natural sunlight. The basis of light therapy is replacing such lamps with full-spectrum fluorescent lamps whose light (referred to as bright light) is more similar to sunlight.

Sleep deprivation

Most patients with major depressive disorder respond to a night of total sleep deprivation. Because of the relation of this disorder to PMDD, treatments for major depressive disorder may also be effective for PMDD.

Relaxation techniques

The relaxation response is a physiologic response that results in decreased metabolism, a lower heart rate, reduced blood pressure, a lower rate of breathing, and slower brain waves. The repetition of a word, sound, prayer, phrase, or muscular activity is required to elicit the relaxation response.

• Changes in diet
• Regular exercise
• Stress management
• Vitamin supplements
• Anti-inflammatory medicines
• Oral contraceptives
• Chasteberry extract

Efficacy Rating of Current Treatments for PMS/PMDD

Herbal formulations often used by women in self-treatment of PMS symptoms include the following:

• Cayenne
• Dong quai
• Siberian ginseng
• Pulsatilla
• Raspberry leaves
• St. John’s wort
• Sepia
• Blessed thistle
• American valerian
• Wild yam

References

Causes of Persistent Depressive Disorder

The exact cause of persistent depressive disorder isn’t known. As with major depression, it may involve more than one cause, such as:

• Biological differences – People with persistent depressive disorder may have physical changes in their brains. The significance of these changes is still uncertain, but they may eventually help pinpoint causes.
• Brain chemistry –  Neurotransmitters are naturally occurring brain chemicals that likely play a role in depression. Recent research indicates that changes in the function and effect of these neurotransmitters and how they interact with neurocircuits involved in maintaining mood stability may play a significant role in depression and its treatment.
• Inherited traits – Persistent depressive disorder appears to be more common in people whose blood relatives also have the condition. Researchers are trying to find genes that may be involved in causing depression.
• Life events – As with major depression, traumatic events such as the loss of a loved one, financial problems or a high level of stress can trigger persistent depressive disorder in some people.
• Genetics – having a first degree relative with a depressive disorder increases the risk
• Environmental/life events – loss of a parent during childhood, traumatic events such as loss, financial problems, and high levels of stress can trigger dysthymia
• Personality traits that include negativity – low self-esteem, pessimistic, self-critical, dependent upon others
• Brain chemistry—Exposure to severe or long-lasting stress can change the balance of chemicals in the brain that control mood.
• Heredity—Depressive disorders can be inherited from one or both parents.
• Environmental factors—Experiencing a trauma, loss, or hardship may trigger depressive symptoms in people who have an inherited susceptibility to developing the disorder.

Symptoms of Persistent Depressive Disorder

Symptoms of persistent depressive disorder can cause significant impairment and may include:

• Loss of interest in daily activities
• Sadness, emptiness or feeling down
• Tiredness and lack of energy
• Low self-esteem, self-criticism or feeling incapable
• Trouble concentrating and trouble making decisions
• Irritability or excessive anger
• Insomnia or hypersomnia
• Low energy or fatigue
• Low self-esteem, self-criticism, or feeling incapable
• Poor concentration or difficulty making decisions
• Feelings of hopelessness
• Decreased activity and/or productivity
• Social isolation
• Sadness or feeling down
• In children, depressed mood and irritability are often primary symptoms. 
  
• Decreased activity, effectiveness and productivity
• Avoidance of social activities
• Feelings of guilt and worries over the past
• Poor appetite or overeating
• Sleep problems

In children, symptoms of persistent depressive disorder may include depressed mood and irritability.

Diagnosis of Persistent Depressive Disorder

The Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV), published by the American Psychiatric Association, characterizes dysthymic disorder. The essential symptom involves the individual feeling depressed for the majority of days, and parts of the day, for at least two years. Low energy, disturbances in sleep or in appetite, and low self-esteem typically contribute to the clinical picture as well. Sufferers have often experienced dysthymia for many years before it is diagnosed. People around them often describe the sufferer in words similar to “just a moody person”. Note the following diagnostic criteria

1. During a majority of days for two years or more, the adult patient reports depressed mood, or appears depressed to others for most of the day.
2. When depressed, the patient has two or more of:
   1. decreased or increased appetite
   2. decreased or increased sleep (insomnia or hypersomnia)
   3. Fatigue or low energy
   4. Reduced self-esteem
   5. Decreased concentration or problems making decisions
   6. Feelings of hopelessness or pessimism
3. During this two-year period, the above symptoms are never absent longer than two consecutive months.
4. During the duration of the two-year period, the patient may have had a perpetual major depressive episode.
5. The patient has not had any manic, hypomanic, or mixed episodes.
6. The patient has never fulfilled criteria for cyclothymic disorder.
7. The depression does not exist only as part of a chronic psychosis (such as schizophrenia or delusional disorder).
8. The symptoms are often not directly caused by a medical illness or by substances, including drug abuse or other medications.
9. The symptoms may cause significant problems or distress in social, work, academic, or other major areas of life functioning.

In children and adolescents, mood can be irritable, and duration must be at least one year, in contrast to two years needed for diagnosis in adults.

Early onset (diagnosis before age 21) is associated with more frequent relapses, psychiatric hospitalizations, and more co-occurring conditions. For younger adults with dysthymia, there is a higher co-occurrence in personality abnormalities and the symptoms are likely chronic. However, in older adults suffering from dysthymia, the psychological symptoms are associated with medical conditions and/or stressful life events and losses

Treatments of Persistent Depressive Disorder

The types of antidepressants most commonly used to treat dysthymia include the following:

• SSRIs (Selective serotonin reuptake inhibitors)
• TCAs (Tricyclic antidepressants)
• SNRIs (Serotonin and norepinephrine reuptake inhibitors)

It’s important to ask your doctor for detailed information about any potential side effects of medication and to discuss any history of suicidal thoughts or attempts. Though antidepressant medications can cause uncomfortable side effects for some, you should never abruptly stop taking these medications. Always consult your prescribing physician before making any changes to medication.

Psychotherapy

Talk therapy, or counseling, is a general form of treating dysthymia by discussing your symptoms and how they impact your life with a mental health provider. There are many benefits to psychotherapy, including:

• Crisis and symptom management
• Identifying triggers that contribute to your dysthymia and coping strategies to manage them
• Identifying negative beliefs and replacing them with positive ones
• Learning adaptive problem solving skills
• Exploring ways to build positive relationships with others
• Improving self-esteem
• Learning to set and attain personal goals

There are different kinds of psychotherapy available, and many people require a combination of treatments. Talk to your mental health provider about the following options:

• Cognitive Behavioral Therapy (CBT)
• Family therapy
• Group therapy
• Process oriented talk therapy

What can I do to help myself feel better?

Methods of improving symptoms of persistent depressive disorder include:

• Maintaining a healthy diet.
• Getting enough sleep.
• Exercising on a regular basis.
• Engaging in enjoyable/creative activities.
• Taking prescribed medications correctly and discussing any potential side effects with your healthcare providers.
• Watching for early signs that your symptoms may be worsening, and having a plan in place for how to respond if they do.
• Surrounding yourself with positive and supportive influences.
• Talking to trusted family members and friends about how you are feeling.
• Avoiding alcohol and illegal drugs which can negatively affect mood and impair judgment.

Lifestyle and Home Remedies of Persistent Depressive Disorder

Persistent depressive disorder generally isn’t a condition that you can treat on your own. But, in addition to professional treatment, these self-care steps can help:

• Stick to your treatment plan – Don’t skip psychotherapy sessions or appointments, and even if you’re feeling well, don’t skip your medications. Give yourself time to improve gradually.
• Learn about persistent depressive disorder – Education about your condition can empower you and motivate you to stick to your treatment plan. Encourage your family to learn about the disorder to help them understand and support you.
• Pay attention to warning signs –  Work with your doctor or therapist to learn what might trigger your symptoms. Make a plan so that you know what to do if symptoms get worse or return. Contact your doctor or therapist if you notice any changes in symptoms or how you feel. Consider involving family members or friends to watch for warning signs.
• Take care of yourself –  Eat healthy, be physically active and get plenty of sleep. Consider walking, jogging, swimming, gardening or another activity that you enjoy. Sleeping well is important for both your physical and mental well-being. If you’re having trouble sleeping, talk to your doctor about what you can do.
• Avoid alcohol and recreational drugs – It may seem like alcohol or drugs lessen depression-related symptoms, but in the long run they generally worsen depression and make it harder to treat. Talk with your doctor or therapist if you need help with alcohol or drug abuse.

References

Major depressive disorder also known as unipolar or major depression is characterized by a persistent feeling of sadness or a lack of interest in outside stimuli. It is a mental disorder characterized by at least two weeks of low mood that is present across most situations. It is often accompanied by low self-esteem, loss of interest in normally enjoyable activities, low energy, and pain without a clear cause. People may also occasionally have false beliefs or see or hear things that others cannot. Some people have periods of depression separated by years in which they are normal while others nearly always have symptoms present. Major depressive disorder can negatively affect a person’s personal, work, or school life, as well as sleeping, eating habits, and general health. Between 2–7% of adults with major depression die by suicide, and up to 60% of people who die by suicide had depression or another mood disorder.

Subtypes of Major Depressive Disorder

The DSM-IV-TR recognizes five further subtypes of MDD, called specifiers, in addition to noting the length, severity and presence of psychotic features:

• Melancholic depression –  is characterized by a loss of pleasure in most or all activities, a failure of reactivity to pleasurable stimuli, a quality of depressed mood more pronounced than that of grief or loss, a worsening of symptoms in the morning hours, early-morning waking, psychomotor retardation, excessive weight loss (not to be confused with anorexia nervosa), or excessive guilt.
• Atypical depression – is characterized by mood reactivity (paradoxical anhedonia) and positivity, significant weight gain or increased appetite (comfort eating), excessive sleep or sleepiness (hypersomnia), a sensation of heaviness in limbs known as leaden paralysis, and significant social impairment as a consequence of hypersensitivity to perceived interpersonal rejection.
• Catatonic depression – is a rare and severe form of major depression involving disturbances of motor behavior and other symptoms. Here, the person is mute and almost stuporous, and either remains immobile or exhibits purposeless or even bizarre movements. Catatonic symptoms also occur in schizophrenia or in manic episodes or may be caused by the neuroleptic malignant syndrome.
• Postpartum depression –  or mental and behavioral disorders associated with the puerperium, not elsewhere classified, refers to the intense, sustained and sometimes disabling depression experienced by women after giving birth. Postpartum depression has an incidence rate of 10–15% among new mothers. The DSM-IV mandates that, in order to qualify as postpartum depression, onset occur within one month of delivery. It has been said that postpartum depression can last as long as three months.
• Persistent depressive disorder (also called dysthymia) is a depressed mood that lasts for at least two years. A person diagnosed with a persistent depressive disorder may have episodes of major depression along with periods of less severe symptoms, but symptoms must last for two years to be considered a persistent depressive disorder.
• Seasonal affective disorder (SAD) –  is a form of depression in which depressive episodes come on in the autumn or winter, and resolve in spring. The diagnosis is made if at least two episodes have occurred in colder months with none at other times, over a two-year period or longer.
• Psychotic depression –  often develops if you have been hallucinating or you believe in delusions that are not cohesive with reality. This can be caused by a traumatic event or if you have already had a form of depression in the past.
• Postpartum depression – is a common occurrence among new mothers experiencing hormonal changes following childbirth. The stress of raising a new child and changes in and to your body can greatly affect your mood. Additionally, the Canadian Mental Health Association states that parents who adopt can also suffer some of the symptoms of postpartum depression.

Causes of Major Depressive Disorder

It’s not known exactly what causes depression. As with many mental disorders, a variety of factors may be involved, such as:

• Biological differences – People with depression appear to have physical changes in their brains. The significance of these changes is still uncertain, but may eventually help pinpoint causes.
• Brain chemistry – Neurotransmitters are naturally occurring brain chemicals that likely play a role in depression. Recent research indicates that changes in the function and effect of these neurotransmitters and how they interact with neurocircuits involved in maintaining mood stability may play a significant role in depression and its treatment.
• Hormones – Changes in the body’s balance of hormones may be involved in causing or triggering depression. Hormone changes can result with pregnancy and during the weeks or months after delivery (postpartum) and from thyroid problems, menopause or a number of other conditions.
• Inherited traits – Depression is more common in people whose blood relatives also have this condition. Researchers are trying to find genes that may be involved in causing depression.
• Personality/temperamental factors (predisposing toward depression) – neuroticism, rumination, stress vulnerability, impulsivity, negative cognitive style.
• Personality/temperamental factors (protective against depression) – openness, trust, acceptance, stress coping.
• External factors – early life events, provoking life events, seasonal changes, social support.
• Internal factors – hormones, biological rhythm generators, comorbid disorders

Symptoms of Major Depressive Disorder

• Negative thinking with inability to see positive solutions
• Anxiety, agitation or restlessness
• Agitation
• Inability to focus
• Lashing out at loved ones
• Irritability
• Feelings of sadness, tearfulness, emptiness or hopelessness
• Angry outbursts, irritability or frustration, even over small matters
• Loss of interest or pleasure in most or all normal activities, such as sex, hobbies or sports
• Sleep disturbances, including insomnia or sleeping too much
• Tiredness and lack of energy, so even small tasks take extra effort
• Reduced appetite and weight loss or increased cravings for food and weight gain
• Slowed thinking, speaking or body movements
• Feelings of worthlessness or guilt, fixating on past failures or self-blame
• Trouble thinking, concentrating, making decisions and remembering things
• Frequent or recurrent thoughts of death, suicidal thoughts, suicide attempts or suicide
• Unexplained physical problems, such as back pain or headaches
• Withdrawing from loved ones and regular activities
• Increase in sleeping
• Exhaustion and lethargy
• Morbid, suicidal thoughts
• Weight loss or gain
• Memory difficulties or personality changes
• Physical aches or pain
• Fatigue, loss of appetite, sleep problems or loss of interest in sex — not caused by a medical condition or medication
• Often wanting to stay at home, rather than going out to socialize or doing new things
• Suicidal thinking or feelings, especially in older men
• Difficulty concentrating, remembering, or making decisions
• Difficulty sleeping, early-morning awakening, or oversleeping
• Thoughts of death or suicide, or suicide attempts
• Aches or pains, headaches, cramps, or digestive problems without a clear physical cause and/or that do not ease even with treatment

Treatment of Major Depressive Disorder

Primary care providers often start treatment for MDD by prescribing antidepressant medications.

Selective serotonin reuptake inhibitors (SSRIs)

These antidepressants are frequently prescribed. SSRIs work by helping inhibit the breakdown of serotonin in the brain, resulting in higher amounts of this neurotransmitter.

Serotonin is a brain chemical that’s believed to be responsible for mood. It may help improve mood and produce healthy sleeping patterns. People with MDD often have low levels of serotonin. An SSRI can relieve symptoms of MDD by increasing the amount of available serotonin in the brain.

SSRIs include well-known drugs such as fluoxetine  and citalopram . They have a relatively low incidence of side effects that most people tolerate well.

Other medications of Major Depressive Disorder

Tricyclic antidepressants and medications known as atypical antidepressants may be used when other drugs haven’t helped. They can cause several side effects, including weight gain and sleepiness.

Note: Some medications used to treat MDD aren’t safe for women who are pregnant or breastfeeding. Make sure you speak with your healthcare provider if you become pregnant, you’re planning to become pregnant, or you’re breastfeeding your child.

Psychotherapy

Psychotherapy, also known as psychological therapy or talk therapy, can be an effective treatment for people with MDD. It involves meeting with a therapist on a regular basis to talk about your condition and related issues. Psychotherapy can help you:

• adjust to a crisis or other stressful event
• replace negative beliefs and behaviors with positive, healthy ones
• improve your communication skills
• find better ways to cope with challenges and solve problems
• increase your self-esteem
• regain a sense of satisfaction and control in your life

Electroconvulsive Therapy (ECT) 

It is a medical treatment most commonly used for patients with severe major depression or bipolar disorder who have not responded to other treatments. It involves a brief electrical stimulation of the brain while the patient is under anesthesia. A patient typically receives ECT two to three times a week for a total of six to 12 treatments. ECT has been used since the 1940s, and many years of research have led to major improvements. It is usually managed by a team of trained medical professionals including a psychiatrist, an anesthesiologist and a nurse or physician assistant.

Brain Stimulation Therapies for Major Depressive Disorder

If medications do not reduce the symptoms of depression, electroconvulsive therapy (ECT) may be an option to explore. Based on the latest research:

• Major Depressive Disorder
• Electroconvulsive therapy can be an effective treatment for depression. In some severe cases where a rapid response is necessary or medications cannot be used safely, ECT can even be a first-line intervention.
• Once strictly an inpatient procedure, today ECT is often performed on an outpatient basis. The treatment consists of a series of sessions, typically three times a week, for two to four weeks.
• ECT may cause some side effects, including confusion, disorientation, and memory loss. Usually these side effects are short-term, but sometimes memory problems can linger, especially for the months around the time of the treatment course. Advances in ECT devices and methods have made modern ECT safe and effective for the vast majority of patients. Talk to your doctor and make sure you understand the potential benefits and risks of the treatment before giving your informed consent to undergoing ECT.
• ECT is not painful, and you cannot feel the electrical impulses. Before ECT begins, a patient is put under brief anesthesia and given a muscle relaxant. Within one hour after the treatment session, which takes only a few minutes, the patient is awake and alert.

Lifestyle changes for Major Depressive Disorder

In addition to taking medications and participating in therapy, you can help improve MDD symptoms by making some changes to your daily habits.

• Eating right – Consider eating foods that contain omega-3 fatty acids, such as salmon. Foods that are rich in B vitamins, such as beans and whole grains, have also been shown to help some people with MDD. Magnesium has also been linked to fighting MDD symptoms. It’s found in nuts, seeds, and yogurt.
• Avoiding alcohol and certain processed foods – It’s beneficial to avoid alcohol, as it’s a nervous system depressant that can make your symptoms worse. Also, certain refined, processed, and deep-fried foods contain omega-6 fatty acids, which may contribute to MDD.
• Getting plenty of exercises – Although MDD can make you feel very tired, it’s important to be physically active. Exercising, especially outdoors and in moderate sunlight, can boost your mood and make you feel better.
• Sleeping well – It’s vital to get at least 6 to 8 hours of sleep per night. Talk to your doctor if you’re having trouble sleeping.

Beyond Treatment: Things You Can Do for Major Depressive Disorder

Here are other tips that may help you or a loved one during treatment for depression:

• Try to be active and exercise.
• Set realistic goals for yourself.
• Try to spend time with other people and confide in a trusted friend or relative.
• Try not to isolate yourself, and let others help you.
• Expect your mood to improve gradually, not immediately.
• Postpone important decisions, such as getting married or divorced, or changing jobs until you feel better. Discuss decisions with others who know you well and have a more objective view of your situation.
• Continue to educate yourself about depression.

Summary Of Practice Guideline For The Treatment Of Patients With Major Depressive Disorder. 3rd ed. – American Psychiatric Association (2010)

Rating Scheme for the Strength of the Recommendations

Each recommendation is identified as falling into one of three categories of endorsement, indicated by a bracketed Roman numeral following the statement. The three categories represent varying levels of clinical confidence:

• increase your self-esteem
• Recommended with substantial clinical confidence.
• Recommended with moderate clinical confidence.
• May be recommended on the basis of individual circumstances.

Major Recommendations for Major Depressive Disorder

Provide Education to the Patient and the Family

• With the patient’s permission, family members and others involved in the patient’s day-to-day life may also benefit from education about the illness, its effects on functioning (including family and other interpersonal relationships), and its treatment
• Common misperceptions about antidepressants (e.g., they are addictive) should be clarified.
• In addition, education about major depressive disorder should address the need for a full acute course of treatment, the risk of relapse, the early recognition of recurrent symptoms, and the need to seek treatment as early as possible to reduce the risk of complications or a full-blown episode of major depression
• Patients should also be told about the need to taper antidepressants, rather than discontinuing them precipitously, to minimize the risk of withdrawal symptoms or symptom recurrence.
• Patient education also includes general promotion of healthy behaviors such as exercise, good sleep hygiene, good nutrition, and decreased use of tobacco, alcohol, and other potentially deleterious substances.
• Educational tools such as books, pamphlets, and trusted websites can augment the face-to-face education provided by the clinician [I].

Treatment Of Acute Phase Of Major Depressive Disorder

Pharmacotherapy

• increase your self-esteem
• An antidepressant medication is recommended as an initial treatment choice for patients with mild to moderate major depressive disorder [I] and definitely should be provided for those with severe major depressive disorder unless ECT is planned.
• Because the effectiveness of antidepressant medications is generally comparable between classes and within classes of medications, the initial selection of an antidepressant medication will largely be based on the anticipated side effects, and additional factors such as medication response in prior episodes, cost, and patient preference.
• For most patients, a selective serotonin reuptake inhibitor (SSRI), serotonin-norepinephrine reuptake inhibitor (SNRI), mirtazapine, or bupropion is optimal.
• In general, the use of nonselective monoamine oxidase inhibitors (MAOIs) (e.g., phenelzine, tranylcypromine, isocarboxazid) should be restricted to patients who do not respond to other treatments [I], given the necessity for dietary restrictions with these medications and the potential for deleterious drug-drug interactions.
• In patients who prefer complementary and alternative therapies, S-adenosyl methionine (SAMe) [III] or St. John’s wort [III] might be considered, although evidence for their efficacy is modest at best.

Careful attention to drug-drug interactions is needed with St. John’s Wort

• Patients receiving pharmacotherapy should be systematically monitored on a regular basis to assess their response to treatment and assess patient safety.
• If antidepressant side effects do occur, an initial strategy is to lower the dose of the antidepressant or to change to an antidepressant that is not associated with that side effect.

Other Somatic Therapies

• ECT is recommended as a treatment of choice for patients with severe major depressive disorder that is not responsive to psychotherapeutic and/or pharmacological interventions, particularly in those who have significant functional impairment or have not responded to numerous medication trials .
• ECT is also recommended for individuals with major depressive disorder who have associated psychotic or catatonic features [I], for those with an urgent need for response (e.g., patients who are suicidal or nutritionally compromised due to refusal of food or fluids) , and for those who prefer ECT or have had a previous positive response to ECT .
• Bright light therapy might be used to treat seasonal affective disorder as well as nonseasonal depression .

Psychotherapy for Major Depressive Disorder

• Use of a depression-focused psychotherapy alone is recommended as an initial treatment choice for patients with mild to moderate major depressive disorder , with clinical evidence supporting the use of cognitive-behavioral therapy (CBT) , interpersonal psychotherapy , psychodynamic therapy , and problem-solving therapy  in individual and in group formats.
• In women who are pregnant, wish to become pregnant, or are breastfeeding, a depression-focused psychotherapy alone is recommended  and depending on the severity of symptoms, should be considered as an initial option .
• As with patients who are receiving pharmacotherapy, patients receiving psychotherapy should be carefully and systematically monitored on a regular basis to assess their response to treatment and assess patient safety .
• Marital and family problems are common in the course of major depressive disorder, and such problems should be identified and addressed, using marital or family therapy when indicated .
• The combination of psychotherapy and antidepressant medication may be used as an initial treatment for patients with moderate to severe major depressive disorder .
• Combining psychotherapy and medication may be a useful initial treatment even in milder cases for patients with psychosocial or interpersonal problems, intrapsychic conflict, or co-occurring personality disorder .

Assessing the Adequacy of Treatment Response

• Onset of benefit from psychotherapy tends to be a bit more gradual than that from medication, but no treatment should continue unmodified if there has been no symptomatic improvement after 1 month .
• Generally, 4-8 weeks of treatment are needed before concluding that a patient is partially responsive or unresponsive to a specific intervention .

Strategies to Address Nonresponse

• For individuals who have not responded fully to treatment, the acute phase of treatment should not be concluded prematurely, as an incomplete response to treatment is often associated with poor functional outcomes.
• If at least a moderate improvement in symptoms is not observed within 4-8 weeks of treatment initiation, the diagnosis should be reappraised, side effects assessed, complicating co-occurring conditions and psychosocial factors reviewed, and the treatment plan adjusted. It is also important to assess the quality of the therapeutic alliance and treatment adherence.
• For patients in psychotherapy, additional factors to be assessed include the frequency of sessions and whether the specific approach to psychotherapy is adequately addressing the patient’s needs.
• With some TCAs, a drug blood level can help determine if additional dose adjustments are required.
• For patients treated with an antidepressant, optimizing the medication dose is a reasonable first step if the side effect burden is tolerable and the upper limit of a medication dose has not been reached.
• Particularly for those who have shown minimal improvement or experienced significant medication side effects, other options include augmenting the antidepressant with a depression-focused psychotherapy or with other agents or changing to another non-MAOI antidepressant.
• Patients may be changed to an antidepressant from the same pharmacological class (e.g., from one SSRI to another SSRI) or to one from a different class (e.g., from an SSRI to a tricyclic antidepressant.
• For patients who have not responded to trials of SSRIs, a trial of an SNRI may be helpful.
• Augmentation of antidepressant medications can utilize another non-MAOI antidepressant, generally from a different pharmacological class, or a non-antidepressant medication such as lithium thyroid hormone, or a second-generation antipsychotic
• Additional strategies with less evidence for efficacy include augmentation using anticonvulsant, omega-3 fatty acids, folate, or a psychostimulant medication, including modafinil.
• If anxiety or insomnia are prominent features, consideration can be given to anxiolytic and sedative-hypnotic medications, including buspirone, benzodiazepines, and selective gamma-aminobutyric acid (GABA) agonist hypnotics (e.g., zolpidem, eszopiclone).
• For patients whose symptoms have not responded adequately to medication, ECT remains the most effective form of therapy and should be considered .
• In patients capable of adhering to dietary and medication restrictions, an additional option is changing to a nonselective MAOI  after allowing sufficient time between medications to avoid deleterious interactions .
• Transdermal selegiline, a relatively selective MAO B inhibitor with fewer dietary and medication restrictions, or transcranial magnetic stimulation could also be considered .
• Vagus nerve stimulation (VNS) may be an additional option for individuals who have not responded to at least four adequate trials of antidepressant treatment, including ECT .
• For patients treated with psychotherapy, consideration should be given to increasing the intensity of treatment or changing the type of therapy . If psychotherapy is used alone, the possible need for medications in addition to or in lieu of psychotherapy should be assessed .
• Patients who have a history of poor treatment adherence or incomplete response to adequate trials of single treatment modalities may benefit from combined treatment with medication and a depression-focused psychotherapy [II].

Treatment Of Continuation Phase Of Major Depressive Disorder

During the continuation phase of treatment, the patient should be carefully monitored for signs of possible relapse.

• Systematic assessment of symptoms, side effects, adherence, and functional status is essential and may be facilitated through the use of clinician- and/or patient-administered rating scales.
• To reduce the risk of relapse, patients who have been treated successfully with antidepressant medications in the acute phase should continue treatment with these agents for a 4-9 month.
• In general, the dose used in the acute phase should be used in the continuation phase
• To prevent a relapse of depression in the continuation phase, depression-focused psychotherapy is recommended, with the best evidence available for cognitive-behavioral therapy.
• Patients who respond to an acute course of ECT should receive continuation pharmacotherapy, with the best evidence available for the combination of lithium and nortriptyline. Alternatively, patients who have responded to an acute course of ECT may be given continuation ECT, particularly if medication or psychotherapy has been ineffective in maintaining remission.

Treatment Of Maintenance Phase Of Major Depressive Disorder

In order to reduce the risk of a recurrent depressive episode, patients who have had three or more prior major depressive episodes or who have chronic major depressive disorder should proceed to the maintenance phase of treatment after completing the continuation phase

• Maintenance therapy should also be considered for patients with additional risk factors for recurrence, such as the presence of residual symptoms, ongoing psychosocial stressors, early age at onset, and family history of mood disorders
• For many patients, particularly for those with chronic and recurrent major depressive disorder or co-occurring medical and/or psychiatric disorders, some form of maintenance treatment will be required indefinitely.
• During the maintenance phase, an antidepressant medication that produced symptom remission during the acute phase and maintained remission during the continuation phase should be continued at a full therapeutic dose.
• If a depression-focused psychotherapy has been used during the acute and continuation phases of treatment, maintenance treatment should be considered, with a reduced frequency of sessions.
• For patients whose depressive episodes have not previously responded to acute or continuation treatment with medications or a depression-focused psychotherapy but who have shown a response to ECT, maintenance ECT may be considered.
• Maintenance treatment with vagus nerve stimulation is also appropriate for individuals whose symptoms have responded to this treatment modality.

Due to the risk of recurrence, patients should be monitored systematically and at regular intervals during the maintenance phase . Use of standardized measurement aids is recommended for the early detection of recurrent symptoms .

Discontinuation of Treatment

When pharmacotherapy is being discontinued, it is best to taper the medication over the course of at least several weeks .

To minimize the likelihood of discontinuation symptoms, patients should be advised not to stop medications abruptly and to take medications with them when they travel or are away from home.

• A slow taper or temporary change to a longer half-life antidepressant (e.g., fluoxetine) may reduce the risk of discontinuation syndrome  when discontinuing antidepressants or reducing antidepressant doses.
• Before the discontinuation of active treatment, patients should be informed of the potential for a depressive relapse and a plan should be established for seeking treatment in the event of recurrent symptoms .
• After discontinuation of medications, patients should continue to be monitored over the next several months and should receive another course of adequate acute phase treatment if symptoms recur .

• For patients receiving psychotherapy, it is important to raise the issue of treatment discontinuation well in advance of the final session, although the exact process by which this occurs will vary with the type of therapy.

Clinical Factors Influencing Treatment for Major Depressive Disorder

Psychiatric Factors

Factors to consider in determining the nature and intensity of treatment include (but are not limited to) the nature of the doctor-patient alliance, the availability and adequacy of social supports, access to and lethality of suicide means, the presence of a co-occurring substance use disorder, and past and family history of suicidal behavior.

For suicidal patients, psychiatrists should consider an increased intensity of treatment, including hospitalization when warranted and/or combined treatment with pharmacotherapy and psychotherapy.

For patients who exhibit psychotic symptoms during an episode of major depressive disorder, treatment should include a combination of antipsychotic and antidepressant medications or ECT .

• When patients exhibit cognitive dysfunction during a major depressive episode, they may have an increased likelihood of future dementia, making it important to assess cognition in a systematic fashion over the course of treatment.
• Catatonic features that occur as part of a major depressive episode should be treated with a benzodiazepine or barbiturate typically in conjunction with an antidepressant. If catatonic symptoms persist, ECT is recommended. To reduce the likelihood of general medical complications, patients with catatonia may also require supportive medical interventions, such as hydration, nutritional support, prophylaxis against deep vein thrombosis, turning to reduce risks of decubitus ulcers, and passive range of motion to reduce the risk of contractures. If antipsychotic medication is needed, it is important to monitor for signs of the neuroleptic malignant syndrome, to which patients with catatonia may have a heightened sensitivity.
• Benzodiazepines may be used adjunctively in individuals with major depressive disorder and co-occurring anxiety although these agents do not treat depressive symptoms, and careful selection and monitoring is needed in individuals with co-occurring substance use disorders.

In patients who smoke, bupropion or nortriptyline may be options to simultaneously treat depression and assist with smoking cessation.

• When possible, a period of substance abstinence can help determine whether the depressive episode is related to substance intoxication or withdrawal [II]. Factors that suggest a need for antidepressant treatment soon after cessation of substance use include a family history of major depressive disorder and a history of major depressive disorder preceding the onset of the substance use disorder or during periods of sobriety.

• For patients who have a personality disorder as well as major depressive disorder, psychiatrists should institute treatment for the major depressive disorder and consider treatment for personality disorder symptoms

Demographic and Psychosocial Factors

When prescribing medications to women who are taking oral contraceptives, the potential effects of drug-drug interactions must be considered

For women in the perimenopausal period, SSRI and SNRI antidepressants are useful in ameliorating depression as well as in reducing somatic symptoms such as hot flashes.

• Both men and women who are taking antidepressants should be asked whether sexual side effects are occurring with these medications . Men for whom trazodone is prescribed should be warned of the risk of priapism
• For women who are currently receiving treatment for depression, a pregnancy should be planned, whenever possible, in consultation with the treating psychiatrist, who may wish to consult with a specialist in perinatal psychiatry
• In women who are pregnant, planning to become pregnant, or breastfeeding, depression-focused psychotherapy alone is recommended and should always be considered as an initial option, particularly for mild to moderate depression, for patients who prefer psychotherapy, or for those with a prior positive response to psychotherapy
• Antidepressant medication should be considered for pregnant women who have moderate to the severe major depressive disorder as well as for those who are in remission from a major depressive disorder, are receiving maintenance medication, and are deemed to be at high risk for a recurrence if the medication is discontinued

• When antidepressants are prescribed to a pregnant woman, changes in pharmacokinetics during pregnancy may require adjustments in medication doses
• Electroconvulsive therapy may be considered for the treatment of depression during pregnancy in patients who have psychotic or catatonic features, whose symptoms are severe or have not responded to medications, or who prefer treatment with ECT

• When a woman decides to nurse, the potential benefits of antidepressant medications for the mother should be balanced against the potential risks to the newborn from receiving antidepressant in the mother’s milk.
• For women who are depressed during the postpartum period, it is important to evaluate for the presence of suicidal ideas, homicidal ideas, and psychotic symptoms. The evaluation should also assess parenting skills for the newborn and for other children in the patient’s care
• In individuals with late-life depression, identification of co-occurring general medical conditions is essential, as these disorders may mimic depression or affect choice or dosing of medications. Older individuals may also be particularly sensitive to medication side effects (e.g., hypotension, anticholinergic effects) and require adjustment of medication doses for hepatic or renal dysfunction  In other respects, treatment for depression should parallel that used in younger age groups
• When antidepressants are prescribed, the psychiatrist should recognize that ethnic groups may differ in their metabolism and response to medications

• A family history of bipolar disorder or acute psychosis suggests a need for increased attention to possible signs of bipolar illness in the patient (e.g., with antidepressant treatment)
• A family history of recurrent major depressive disorder increases the likelihood of recurrent episodes in the patient and supports a need for maintenance treatment
• The family history of a response to a particular antidepressant may sometimes help in choosing a specific antidepressant for the patient
• Because problems within the family may become an ongoing stressor that hampers the patient’s response to treatment, and because depression in a family is a major stress in itself, such factors should be identified and strong consideration given to educating the family about the nature of the illness, enlisting the family’s support, and providing family therapy, when indicated .
• For patients who have experienced a recent bereavement, psychotherapy or antidepressant treatment should be used when the reaction to a loss is particularly prolonged or accompanied by significant psychopathology and functional impairment
• Support groups may be helpful for some bereaved individuals.

Co-occurring General Medical Conditions

Communication with other clinicians who are providing treatment for general medical conditions is recommended

• The clinical assessment should include identifying any potential interactions between medications used to treat depression and those used to treat general medical conditions.
• Assessment of pain is also important as it can contribute to and co-occur with depression. In addition, the psychiatrist should consider the effects of prescribed psychotropic medications on the patient’s general medical conditions, as well as the effects of interventions for such disorders on the patient’s psychiatric condition.
• In patients with preexisting hypertension or cardiac conditions, treatment with specific antidepressant agents may suggest a need for monitoring of vital signs or cardiac rhythm (e.g., electrocardiogram [ECG] with TCA treatment; heart rate and blood pressure assessment with SNRIs and TCAs).
• When using antidepressant medications with anticholinergic side effects, it is important to consider the potential for increases in heart rate in individuals with cardiac disease, worsening cognition in individuals with dementia, development of bladder outlet obstruction in men with prostatic hypertrophy, and precipitation or worsening of narrow-angle glaucoma.
• Some antidepressant drugs (e.g., bupropion, clomipramine, maprotiline) reduce the seizure threshold and should be used with caution in individuals with preexisting seizure disorders.
• In individuals with Parkinson’s disease, the choice of an antidepressant should consider that serotonergic agents may worsen symptoms of the disease, that bupropion has potential dopamine agonist effects (benefitting symptoms of Parkinson’s disease but potentially worsening psychosis) , and that selegiline has antiparkinsonian and antidepressant effects but may interact with L-dopa and with other antidepressant agents
• In treating the depressive syndrome that commonly occurs following a stroke, consideration should be given to the potential for interactions between antidepressants and anticoagulating (including antiplatelet) medications.
• Given the health risks associated with obesity and the tendency of some antidepressant medications to contribute to weight gain, longitudinal monitoring of weight (either by direct measurement or patient report) is recommended, as well as the calculation of body mass index (BMI). If significant increases are noted in the patient’s weight or BMI, the clinician and patient should discuss potential approaches to weight control such as diet, exercise, change in medication, nutrition consultation, or collaboration with the patient’s primary care physician.
• In patients who have undergone bariatric surgery to treat obesity, adjustment of medication formulations or doses may be required because of altered medication absorption
• For diabetic patients, it is useful to collaborate with the patient’s primary care physician in monitoring diabetic control when initiating antidepressant therapy or making significant dosing adjustments.
• Clinicians should be alert to the possibility of sleep apnea in patients with depression, particularly those who present with daytime sleepiness, fatigue, or treatment-resistant symptoms. In patients with known sleep apnea, treatment choice should consider the sedative side effects of medication, with minimally sedating options chosen whenever possible.
• Given the significant numbers of individuals with unrecognized human immunodeficiency virus (HIV) infection and the availability of effective treatment, consideration should be given to HIV risk assessment and screening. For patients with HIV infection who are receiving antiretroviral therapy, the potential for drug-drug interactions needs to be assessed before initiating any psychotropic medications. Patients who are being treated with antiretroviral medications should be cautioned about drug-drug interactions with St. John’s wort that can reduce the effectiveness of HIV treatments.
• In patients with hepatitis C infection, interferon can exacerbate depressive symptoms, making it important to monitor patients carefully for worsening depressive symptoms during the course of interferon treatment.
• Because tamoxifen requires active 2D6 enzyme function to be clinically efficacious, patients who receive tamoxifen for breast cancer or other indications should generally be treated with an antidepressant (e.g., citalopram, escitalopram, venlafaxine, desvenlafaxine) that has minimal effect on metabolism through the cytochrome P450 2D6 isoenzyme.
• When depression occurs in the context of chronic pain, SNRIs and TCAs may be preferable to other antidepressive agents.

• When ECT is used to treat major depressive disorder in an individual with a co-occurring general medical condition, the evaluation should identify conditions that could require modifications in ECT technique (e.g., cardiac conditions, hypertension, central nervous system lesions) ; these should be addressed insofar as possible and discussed with the patient as part of the informed consent process .

References