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The H1N1 (Swine) Flu shots for children 3 years and up are in!!

The shot for children 3 years of age and up for the H1N1 (aka Swine flu) are now available! If you are interested in having your child vaccinated please call the office to schedule an appointment. We are making every effort to get everyone in as quickly as possible, but due to the large number of vaccines we need to administer in a short period of time we have alloted certain times we are scheduling these appointments. Thank you in advance for your understanding and cooperation.
If you have questions regarding the vaccines please follow this link: http://www.cdc.gov/vaccines/pubs/vis/default.htm.for the vaccine information sheets to help you make an informed decision.

Treating Depression or Anxiety without Presciptions?

CAM for your depressed patient: 6 recommended options

Sy Atezaz Saeed, MD

Professor and chair, Department of psychiatric medicine, Brody School of Medicine at East Carolina University, Greenville, NC

Richard M. Bloch, PhD

Professor and director of research, Department of psychiatric medicine, Brody School of Medicine at East Carolina University, Greenville, NC

Diana J. Antonacci, MD

Associate professor and director of residency training, Department of psychiatric medicine, Brody School of Medicine at East Carolina University, Greenville, NC


Americans with depression turn to complementary and alternative medicine (CAM) more often than conventional psychotherapy or FDA-approved medication. In a nationally representative sample, 54% of respondents with self-reported “severe depression”—including two-thirds of those receiving conventional therapies—reported using CAM during the previous 12 months.1

Unfortunately, popular acceptance of CAM for depression is disproportionate to the evidence base, which—although growing—remains limited. As a result, your patients may be self-medicating with poorly supported treatments that are unlikely to help them recover from depression.

In reviewing CAM treatments for depression, we found some with enough evidence of positive effect that we feel comfortable recommending them as evidence-based options. These promising, short-term treatments are supported by level 1a or 1b evidence and at least 1 study that demonstrates an ability to induce remission (Table 1).2

For patients seeking “natural” or nonprescription treatments—or when you wish to augment standard treatments that are not working adequately—you might recommend fatty acids, St. John’s wort, or S-adenosyl-L-methionine (SAMe). Similar recommendations can be made for yoga, exercise, and bibliotherapy, as we discuss here.


Table 1
Evidence these authors required to recommend a CAM treatment

Minimum requirements

Level of evidence

Recommendation

Systematic review showing superiority to placebo or standard treatment
Plus
1 study showing CAM treatment can induce remission

1a +

1b or 2b

A

At least 2 RCTs showing superiority to placebo or standard treatment
Plus
1 study showing CAM treatment can induce remission

1b

1b or 2b

A–

CAM: complementary and alternative medicine; RCT: randomized controlled trial

Source:Reference 2

Reviewing CAM evidence

This article refers to as “alternative” any treatment other than a form of psychotherapy or an FDA-approved medication that substitutes for a standard psychiatric treatment. When used to augment standard psychiatric treatments, these approaches are considered “complementary.”

Our search for evidence on CAM treatments for depressive disorders raised questions about what constitutes acceptable and convincing methodology:

  • Studies often had problems with blinding and suitable placebos. Many were small, with short duration and no long-term follow-up.

  • Comparisons with active treatments that showed no differences were assumed to imply comparability, even though the studies were powered to detect only large differences.

Clinical Point

Multiple RCTs have shown consistent superiority of some CAM treatments over comparison conditions

On the other hand, multiple randomized controlled trials (RCTs) have shown consistent superiority of some CAM treatments over comparison conditions.

Applying the evidence. Because CAM use is widespread, be sure to ask psychiatric patients if they are using CAM treatments. If the answer is “yes,” a risk-benefit assessment is needed. Inform patients who are using poorly supported CAM approaches that they could consider better-supported CAM options as well as standard effective antidepressants.

Monitor patients for an adequately prompt positive response to an evidence-based CAM approach that has shown efficacy for their level of depression. As with any treatment, consider other evidence-based options when CAM treatments are inadequate or unsuccessful in achieving remission of depressive symptoms.

Sufficient evidence of efficacy

Yoga. In their systematic review of yoga’s effectiveness for depression, Pilkington et al3 analyzed 5 RCTs that met 3 criteria:

  • participants had mild to severe depression or depressive disorders

  • yoga or yoga-based exercises alone were used for treatment

  • depression rating scales were used as outcome measures.

They found evidence that yoga can reduce depressive symptoms and induce remission (Table 2). The studies were generally small and of short duration, and depression severity and interventions varied widely. Most participants were young and relatively fit, raising questions about yoga’s applicability to older or less fit patients. Reporting of adverse events was limited, but no safety issues or adverse effects were identified.

Conclusion. Yoga has been studied primarily as an alternative treatment, but its physical health and group participation benefits and lack of side effects make it a suitable complementary treatment as well.

Clinical Point

Yoga’s positive effects suggest that exercise does not have to be aerobic to provide an antidepressant benefit

Exercise. Extensive literature has examined the relationship between exercise and depression. We identified 7 reviews published between 1993 and 2008 (Table 3). All supported positive effects of exercise except for patients age <20.>

  • 45% with supervised exercise

  • 40% with home-based exercise

  • 47% with sertraline, 50 to 200 mg/d

  • 31% with placebo.4


Table 2
5 RCTs of yoga’s effectiveness in treating depression

RCT

Interventions

Conclusion

Broota and Dhir, 1990

Yoga and PMR vs control

Yoga and PMR were more effective than control, with yoga more effective than PMR

Khumar et al, 1993

Shavasana yoga vs no intervention

College students with severe depression improved during and after yoga treatment

Janakiramaiah et al, 2000

SKY vs ECT vs imipramine

Reductions in BDI scores for all 3 groups; ECT > SKY or imipramine, SKY=imipramine

Rohini et al, 2000

Full SKY vs partial SKY

30 individuals with MDD improved with either therapy, but results were not statistically significant

Woolery, 2004

Iyengar yoga vs wait list

28 mildly depressed individuals benefitted from yoga, as measured by BDI scores at midpoint and throughout treatment

BDI: Beck Depression Inventory; ECT: electroconvulsive therapy; MDD: major depressive disorder; PMR: progressive muscle relaxation; RCT: randomized controlled trial; SKY: Sudarshan Kriya yoga

Source:
Broota A, Dhir R. Efficacy of two relaxation techniques in depression. Journal of Personality and Clinical Studies. 1990;6(1):83-90.
Khumar SS, Kaur P, Kaur S. Effectiveness of Shavasana on depression among university students. Indian J Clin Psychol. 1993;20(2):82-87.
Janakiramaiah N, Gangadhar BN, Naga Venkatesha Murthy PJ, et al. Antidepressant efficacy of Sudarshan Kriya yoga (SKY) in melancholia: a randomized comparison with electroconvulsive therapy (ECT) and imipramine. J Affect Disord. 2000;57(1-3):255-259.
Rohini V, Pandey RS, Janakiramaiah N, et al. A comparative study of full and partial Sudarshan Kriya yoga (SKY) in major depressive disorder. NIMHANS Journal. 2000;18(1):53-57.
Woolery A, Myers H, Sternlieb B, et al. A yoga intervention for young adults with elevated symptoms of depression. Altern Ther Health Med. 2004;10(2):60-63.


Table 3
Evidence of the antidepressant effect of exercise

Literature review

Methodology

Conclusion

Byrne and Byrne, 1993

13 studies, clinical samples, measured changes in depressed mood

90% of studies reported beneficial effects, especially in clinical populations

Scully et al, 1998

4 literature reviews, 1 monograph, 1 study

Positive relationship of physical activity and depression in healthy and clinical samples, increased over time

Lawlor and Hopker, 2001

14 RCTs from 1966 to 1999 with depression as an outcome

Significant methodologic weaknesses, but exercise effect > no treatment and=cognitive therapy

Dunn et al, 2001

Examined dose effect in 37 studies; subjects diagnosed with depressive disorders, mild-to-moderate symptoms, and no medical comorbidity

Only level B and C evidence; positive effects with exercise from light to heavy intensity; aerobic=nonaerobic; improvement may or may not be related to improved fitness

Brosse et al, 2002

12 RCTs from 1979 to 1999

Significant methodologic limitations, but authors concluded evidence supports a positive effect of exercise in healthy and clinical populations

Larun et al, 2006

4 RCTs in children and youth age <20

Exercise effect same as no intervention, low-intensity relaxation, or psychosocial intervention

Barbour et al, 2007

2 meta-analyses, 1 RCT, 2 studies

Positive effect; high-energy was optimal dose; aerobic=nonaerobic; improvement may or may not be related to improved fitness

RCT: randomized controlled trial

Source:
Byrne AE, Byrne DG. The effect of exercise on depression, anxiety and other mood states: A review. J Psychosom Res. 1993;37(6):565-574.
Scully D, Kremer J, Meade MM, et al. Physical exercise and psychological well being: a critical review. Br J Sports Med. 1998;32(2):111-120.
Lawlor DA, Hopker SW. The effectiveness of exercise as an intervention in the management of depression: systematic review and meta-regression analysis of randomised controlled trials. BMJ. 2001;322(7289):763-767.
Dunn AL, Trivedi MH, O’Neal HA. Physical activity dose-response effects on outcomes of depression and anxiety. Med Sci Sports Exerc. 2001;33(6):S587.
Brosse AL, Sheets ES, Lett HS, et al. Exercise and the treatment of clinical depression in adults: recent findings and future directions. Sports Med. 2002;32(12):741-760.
Larun L, Nordheim LV, Ekeland E, et al. Exercise in prevention and treatment of anxiety and depression among children and young people. Cochrane Database Syst Rev. 2006;3:CD004691.
Barbour KA, Edenfield TM, Blumenthal JA. Exercise as a treatment for depression and other psychiatric disorders: a review. J Cardiopulm Rehabil Prev. 2007;27(6):359-367.

Conclusion. Evidence supports exercise for short-term treatment of mild or moderate depression in adults. Studies tend to be small and brief, to enroll young physically -sound patients, and to include little follow-up. Studies of subjects age <20>

At least 2 studies suggest that high-energy exercise and aerobic or resistance training provide greater reductions in depressive symptoms than exercises such as walking.5,6 Yoga’s positive effects suggest, however, that an aerobic effect is not necessary for an antidepressant benefit.

Exercise has not been adequately tested as a complementary treatment but likely is safe for most psychiatric patients. Perspiration and dehydration might alter therapeutic blood levels of lithium or other medications. Advise patients to drink water before, during, and after exercise and to avoid outdoor exercise in extreme temperatures. More vigorous monitoring might be indicated in specific cases.

Tailor exercise programs to individual needs, considering the patient’s age and health status. Refer a patient with a known heart problem or increased cardiovascular risk to his or her physician for selective exercise testing.

Bibliotherapy—reading self-help books, usually about cognitive-behavioral approaches to depressive disorders—has been relatively well studied. A recent meta-analysis examined 29 studies with pre-post designs. Group differences in the 17 controlled studies yielded a large effect size of 0.77. Participants who read the materials benefitted similarly whether they met in groups or applied the information on their own. Older adults tended to be less depressed at baseline and made smaller treatment gains.7

Clinical Point

Self-administered CBT learned from reading books has been shown to be an effective treatment for mild-to-moderate depression

A study of 31 patients age >60 with mild-to-moderate depression8 compared 16 sessions of professionally administered cognitive-behavioral therapy (CBT) with self-administered cognitive therapy learned from reading a book.9 Both groups showed greater improvement in depressive symptoms compared with a control group. Subjects in the CBT group did somewhat better during the trial, but at 3-month follow-up most patients in both treatment groups no longer met diagnostic criteria for MDD.

Conclusion. Evidence supports bibliotherapy as an effective treatment for mild-to-moderate depression. No convincing data support its use as a complementary treatment, but it poses virtually no risk.

St. John’s wort (Hypericum perforatum) has been extensively studied for depressive disorders, with 29 RCTs in a meta-analysis of MDD trials through July 2008.10 Another meta-analysis compared St. John’s wort with selective serotonin reuptake inhibitors (SSRIs) in 13 studies through June 2008.11 These and most RCTs have found St. John’s wort significantly more effective than placebo in reducing depressive symptoms.

Data selected from double-blind RCTs totaling 217 patients with mild depression [Hamilton Depression Rating Scale (HDRS) scores <20]>12 Studies routinely show that treating MDD with St. John’s wort is comparable to using tricyclic or SSRI antidepressants.

Side effects with St. John’s wort generally are no different than with placebo and significantly less than with comparison treatments. Even so, using St. John’s wort instead of SSRIs for MDD remains controversial.

Studies vs SSRIs. Many of the favorable St. John’s wort trials were conducted in Europe, particularly in Germany. Two large RCTs conducted in the United States reported that the St. John’s wort standardized extract LI-160 was not more effective than placebo, but neither could be clearly interpreted as negative for St. John’s wort:

  • In an 8-week trial, St. John’s wort and placebo groups improved significantly but at unusually low rates. The remission rate with St. John’s wort was small but significantly higher than with placebo.13

  • A study sponsored by the National Institute of Mental Health compared St. John’s wort, 900 to 1,500 mg/d; sertraline, 50 to 100 mg/d; and placebo in 340 adults with MDD. No positive effects were found for St. John’s wort or sertraline.14

Side effects. St. John’s wort can affect blood levels of circulating medications metabolized by the cytochrome P450 liver enzyme system, including tricyclic antidepressants. Case studies have reported pregnancy from oral contraceptive failure, skin rashes, headache, and mania with St. John’s wort use. Although these reports are disturbing, St. John’s wort’s side effects when compared with SSRIs have been less frequent (40% vs 49%) and milder (clinical trial dropout rate 2% vs 7%).11

Conclusion. Standardized extracts of St. John’s wort—particularly WS5570, 300 mg tid, and ZE117, 250 mg bid—appear to be effective treatments, especially for mild-to-moderate MDD. Because St. John’s wort is available without prescription and can interact with SSRIs or other antidepressants:

  • care is required for its complementary use

  • it is important to ask if patients are using St. John’s wort on their own.

St. John’s wort is used as a first-line depression treatment in Europe, but U.S. physicians may be less familiar with its potential interactions with other medications. We recommend that you consider St. John’s wort:

Clinical Point

Consider St. John’s wort for first-line use only when you can adequately gauge its effects on your patient’s other medications

  • for first-line use only when you can adequately gauge its effects on your patient’s other medications

  • especially for depressed patients who cannot tolerate SSRIs.

SAMe is a metabolite involved in bio-synthesis of norepinephrine, serotonin, and dopamine.15 SAMe salts (such as 1,4-butanedisulfonate) are used as an over-the-counter supplement for depression treatment. Dozens of RCTs show SAMe has greater efficacy than placebo and positive effects comparable to those of standard antidepressants. In a meta-analysis of 28 RCTs by the Agency for Healthcare Quality and Research, SAMe produced significantly greater symptom improvement compared with placebo.16

SAMe has become a popular alternative treatment for depression since its introduction to the United States in the late 1990s, but it has been studied in only 2 U.S. open trials. One showed SAMe to be very effective in reducing depressive symptoms in patients with HIV/AIDS.17 The other found a 50% response rate and 43% remission rate with adjunctive SAMe, 800 to 1,600 mg/d for 6 weeks, in 30 adults with MDD who failed to respond adequately to SSRIs or the serotonin-norepinephrine reuptake inhibitor (SNRI) venlafaxine. The most common side effects were gastrointestinal (GI) symptoms and headaches.18 This open trial led to an ongoing National Institutes of Health-sponsored RCT on the safety and efficacy of SAMe for patients with treatment-resistant depression.

Conclusion. SAMe appears to have a faster onset of antidepressant effect than standard SSRIs or SNRIs and a favorable side-effect profile, which make the lack of rigorous trials in the United States striking. We recommend that you consider SAMe:

Clinical Point

SAMe could be useful as a complementary treatment to speed the onset of antidepressant effects

  • as an adjunct in patients with incomplete response to standard treatments

  • as a complementary treatment to speed onset of antidepressant effects.

Polyunsaturated fatty acids (PUFAs), usually from fish oils, have long been popular nutritional supplements because of their beneficial effects on cholesterol and cardiovascular health. Omega-3 and omega-6 fatty acids are the most common PUFAs. The omega-3 PUFAs include eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA).

Four meta-analyses independently looked at largely the same dozen RCTs through 2006 and found that 1 to 2 grams daily of omega-3 PUFAs was significantly more effective at reducing depressive symptoms than placebo.1922 Other data suggest that omega-3 PUFAs can induce depression remission in depressed Parkinson’s disease patients23 and depressed pregnant women.24 Since 2006, however, findings have been inconsistent. Several trials have found PUFAs no more effective than placebo.2527

An 8-week double-blind study compared EPA, 1 gram daily; fluoxetine, 20 mg/d; or both agents in 60 outpatients with MDD. Response rates—as measured by ≥50% reduction in baseline HDRS scores—were 50% with fluoxetine, 56% with EPA, and 81% with combination therapy.28

Clinical Point

Although PUFAs’ therapeutic effects remain unclear, they appear safe to use as adjuncts if standard treatment is not satisfactory

Conclusion. Questions remain about dosing, ratio of EPA to DHA, patient selection, and baseline blood levels of PUFAs compared with response. PUFAs have a benign side-effect profile, with occasional reports of diarrhea or GI upset. Although their therapeutic effects are being clarified, PUFAs appear safe to recommend as an adjunct treatment if standard care is not satisfactory.

Insufficient evidence

L-tryptophan. It seems reasonable to expect a serotonin precursor to increase serotonin in the CNS and improve depressive symptoms. Of 111 trials on L-tryptophan for depression, however, only 2 met the quality criteria for inclusion in a recent meta-analysis.29 Combining the 2 trials showed L-tryptophan alone and in combination with a tricyclic antidepressant was more effective than placebo for treating depressive disorders in adults.

Conclusion. Very little research continues to test L-tryptophan as a viable CAM for depressive disorder. Its serious side effect of eosinophilia-myalgia syndrome makes clinical use of this agent unlikely.

Acupuncture. Numerous small studies with questionable controls, different needling placements, and poor allocation concealment and blinding limit the ability to draw conclusions about acupuncture for treating depression (Table 4). A recent meta-analysis by Wang et al30 added 2 Chinese trials not included in an earlier review31 and found acupuncture significantly reduced depressive symptoms. No consistent differences were detected in response or remission rates, however.

Conclusion. Evidence is methodologically weak, and the use of acupuncture as an alternative or complementary treatment of depression is questionable.


Table 4
Acupuncture: Insufficient evidence of antidepressant effect

Literature review

Methodology

Conclusion

Mukaino et al, 2005

Systematic review of 7 RCTs including 509 patients; compared either manual or electroacupuncture with any control procedure

Inconsistent evidence of manual acupuncture’s effectiveness vs sham; electroacupuncture’s effect may be similar to that of antidepressant medication and merits further study

Leo and Ligot, 2007

Systematic review of 9 RCTs, 5 considered low quality; some focused on very specific populations (ie, hospitalized stroke patients or pregnant depressed patients)

Evidence inconclusive because of study designs and methodologies

Smith and Hay, 2005

Meta-analysis of 7 trials including 517 adults with mild-to-moderate depression; 5 trials (409 participants) compared acupuncture with medication; 2 trials compared acupuncture with wait list or sham acupuncture

No difference between acupuncture and medication; study quality too poor to support acupuncture’s efficacy

Wang et al, 2008

Meta-analysis of 8 small RCTs totalling 477 subjects (256 received active acupuncture, remainder received sham acupuncture); sham acupuncture design, number of acupuncture sessions, and duration varied among studies

Significant reduction in HRSD or BDI scores for acupuncture vs sham, but no significant effect of acupuncture on response or remission rates

BDI: Beck Depression Inventory; HRSD: Hamilton Rating Scale for Depression; RCT: randomized controlled trial

Source:
Mukaino Y, Park J, White A, et al. The effectiveness of acupuncture for depression—a systematic review of randomised controlled trials. Acupunct Med. 2005;23(2):70-76.
Leo RJ, Ligot JS Jr. A systematic review of randomized controlled trials of acupuncture in the treatment of depression. J Affect Disord. 2007;97(1-3):13-22.
Smith CA, Hay PPJ. Acupuncture for depression. Cochrane Database Syst Rev. 2005;(2):CD004046.
Wang H, Qi H, Wang BS, et al. Is acupuncture beneficial in depression? A meta-analysis of 8 randomized controlled trials. J Affect Disord. 2008;111(2-3):125-134.

Related resources

Drug brand names

    Fluoxetine • Prozac
    Imipramine • Tofranil
    Lithium • Eskalith, Lithobid
    Sertraline • Zoloft
    Venlafaxine • Effexor

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

References

  1. Kessler RC, Soukup J, Davis RB, et al. The use of complementary and alternative therapies to treat anxiety and depression in the United States. Am J Psychiatry. 2001;158(2):289–294.
  2. Phillips B, Ball C, Sackett D, et al. Oxford University Centre for Evidence Based Medicine levels of evidence and grades of recommendation (March 2009). Available at: http://www.cebm.net/index.aspx?o=1025#levels. Accessed August 19, 2009.
  3. Pilkington K, Kirkwood G, Rampes H, et al. Yoga for depression: the research evidence. J Affect Disord. 2005;89(1-3):13–24.
  4. Blumenthal JA, Babyak MA, Doraiswamy PM, et al. Exercise and pharmacotherapy in the treatment of major depressive disorder. Psychosom Med. 2007;69(7):587–596.
  5. Dunn AL, Trivedi MH, Kampert JB, et al. Exercise treatment for depression: efficacy and dose response. Am J Prev Med. 2005;28(1):1–8.
  6. Legrand F, Heuze JP. Antidepressant effects associated with different exercise conditions in participants with depression: a pilot study. J Sport Exercise Psychol. 2007;29(3):348–364.
  7. Gregory RJ, Schwer Canning S, Lee TW, et al. Cognitive bibliotherapy for depression: a meta-analysis. Professional Psychology: Research and Practice. 2004;35(3):275–280.
  8. Floyd M, Scogin F, McKendree-Smith NL, et al. Cognitive therapy for depression: a comparison of individual psychotherapy and bibliotherapy for depressed older adults. Behav Modif. 2004;28(2):297–318.
  9. Burns DD. Feeling good: the new mood therapy.New York, NY: HarperCollins; 1980.
  10. Linde K, Berner MM, Kriston L. St John’s Wort for major depression. [update of Cochrane Database Syst Rev. 2005;(2):CD000448; PMID: 15846605].Cochrane Database Syst Rev. 2008(4):000448.
  11. Rahimi R, Nikfar S, Abdollahi M. Efficacy and tolerability of Hypericum perforatum in major depressive disorder in comparison with selective serotonin reuptake inhibitors: a meta-analysis. Prog Neuropsychopharmacol Biol Psychiatry. 2009;33(1):118–127.
  12. Kasper S, Gastpar M, Müller WE, et al. Efficacy of St. John’s wort extract WS 5570 in acute treatment of mild depression: a reanalysis of data from controlled clinical trials. Eur Arch Psychiatry Clin Neurosci. 2008;258(1):59–63.
  13. Shelton RC, Keller MB, Gelenberg A, et al. Effectiveness of St John’s wort in major depression: a randomized controlled trial. JAMA. 2001;285(15):1978–1986.
  14. Hypericum Depression Trial Study Group. Effect of Hypericum perforatum (St. John’s wort) in major depressive disorder: a randomized controlled trial. JAMA. 2002;287(14):1807–1814.
  15. Mischoulon D, Fava M. Role of S-adenosyl-L-methionine in the treatment of depression: a review of the evidence. Am J Clin Nutr. 2002;76(suppl):1158S–1161S.
  16. Hardy ML, Coulter I, Morton SC, et al. S-adenosyl-L-methionine for treatment of depression, osteoarthritis, and liver disease [comment in ACP J Club. 2003;139(1):20]. Evid Rep Technol Assess (Summ). 2003;Aug(64):1–3.
  17. Shippy RA, Mendez D, Jones K, et al. S-adenosylmethionine (SAM-e) for the treatment of depression in people living with HIV/AIDS. BMC Psychiatry. 2004;4:38.
  18. Alpert JE, Papakostas G, Mischoulon D, et al. S-adenosyl-L-methionine (SAMe) as an adjunct for resistant major depressive disorder: an open trial following partial or nonresponse to selective serotonin reuptake inhibitors or venlafaxine. J Clin Psychopharmacol. 2004;24(6):661–664.
  19. Lin PY, Su KP. A meta-analytic review of double-blind, placebo-controlled trials of antidepressant efficacy of omega-3 fatty acids. J Clin Psychiatry. 2007;68(7):1056–1061.
  20. Freeman MP, Hibbeln JR, Wisner KL, et al. Omega-3 fatty acids: evidence basis for treatment and future research in psychiatry [published correction appears in J Clin Psychiatry. 2007;68(2):338]. J Clin Psychiatry. 2006;67(12):1954–1967.
  21. Ross BM, Seguin J, Sieswerda LE. Omega-3 fatty acids as treatments for mental illness: which disorder and which fatty acid? Lipids Health Dis. 2007;6:21.
  22. Appleton KM, Hayward RC, Gunnell D, et al. Effects of n-3 long-chain polyunsaturated fatty acids on depressed mood: systematic review of published trials [comment in Am J Clin Nutr. 2007;85(6):1665-1666; author reply 1666]. Am J Clin Nutr. 2006;84(6):1308–1316.
  23. da Silva TM, Munhoz RP, Alvarez C, et al. Depression in Parkinson’s disease: a double-blind, randomized, placebo-controlled pilot study of omega-3 fatty-acid supplementation. J Affect Disord. 2008;111(2-3):351–359.
  24. Su KP, Huang SY, Chiu TH, et al. Omega-3 fatty acids for major depressive disorder during pregnancy: results from a randomized, double-blind, placebo-controlled trial. J Clin Psychiatry. 2008;69(4):644–651.
  25. Grenyer BF, Crowe T, Meyer B, et al. Fish oil supplementation in the treatment of major depression: a randomised double-blind placebo-controlled trial. Prog Neuropsychopharmacol Biol Psychiatry. 2007;31(7):1393–1396.
  26. Rees AM, Austin MP, Parker GB. Omega-3 fatty acids as a treatment for perinatal depression: randomized double-blind placebo-controlled trial. Aust N Z J Psychiatry. 2008;42(3):199–205.
  27. Rogers PJ, Appleton KM, Kessler D, et al. No effect of n-3 long-chain polyunsaturated fatty acid (EPA and DHA) supplementation on depressed mood and cognitive function: a randomised controlled trial. Br J Nutr. 2008;99(2):421–431.
  28. Jazayeri S, Tehrani-Doost M, Keshavarz SA, et al. Comparison of therapeutic effects of omega-3 fatty acid eicosapentaenoic acid and fluoxetine, separately and in combination, in major depressive disorder. Aust N Z J Psychiatry. 2008;42(3):192–198.
  29. Shaw K, Turner J, Del Mar C. Tryptophan and 5-Hydroxytryptophan for depression. Cochrane Database Syst Rev. 2002;(1):CD003198.
  30. Wang H, Qi H, Wang BS, et al. Is acupuncture beneficial in depression: a meta-analysis of 8 randomized controlled trials? J Affect Disord. 2008;111(2-3):125–134.
  31. Smith CA, Hay PPJ. Acupuncture for depression. Cochrane Database Syst Rev. 2005;(2):CD004046.

Swine Flu Mist is now in!

Hi,

If you are interested in getting the Swine Flu Mist for your child, it is now in. Please remember that the children have to be 2 years old or more and have no chronic illnesses such as asthma or serious egg allergies. Also, if your child has recently had the the Seasonal Flu Mist, you must wait 28 days or more before getting the swine flu mist.

Also, please remember that this is a live virus vaccine, which is what makes it a more effective vaccine than the shot. We do not yet have any confirmation from the Sarasota Health Department about the availability of the Swine Flu shot (killed virus).

Please call the office for an appointment for the nasal mist vaccine. We are making every effort to give as many vaccines as quickly as the demand dictates, including Saturday mornings. We have been allotted 300 doses, so supply is not infinite. Call 365-5898 and ask to be scheduled for the Swine Flu Mist if you would like to get this done. Thanks,

Dr Ted, Nancy, Jen, Kay and all of us at Meyer Pediatrics

Things to Know About MRSA Infections

Recognize and Prevent MRSA Infections

photo: A mother holding her child. As kids head back to classrooms and sports venues, parents are encouraged to learn how to recognize and prevent skin infections caused by methicillin-resistant Staphylococcus aureus (MRSA), a type of staph bacteria that is resistant to certain antibiotics.

It is estimated that Americans of all ages visit the doctor more than 12 million times per year for skin infections that are typical of staph, more than half of which are MRSA. The good news is that a few simple steps can help parents protect their families.

Learn about MRSA

Visit www.cdc.gov/MRSA for posters, fact sheets, e-cards, graphics and more.

MRSA is methicillin-resistant Staphylococcus aureus, a potentially dangerous type of staph bacteria that is resistant to certain antibiotics and may cause skin and other infections. As with regular staph infections, recognizing the signs and receiving treatment for MRSA skin infections in the early stages reduces the chances of the infection becoming severe. MRSA is spread by:

  • Having direct contact with another person’s infection
  • Sharing personal items, such as towels or razors, that have touched infected skin
  • Touching surfaces or items, such as used bandages, contaminated with MRSA

Recognize the Signs and Symptoms of Infections

Most staph skin infections, including MRSA, appear as a bump or infected area on the skin that may be:

  • Red
  • Swollen
  • Painful
  • Warm to the touch
  • Full of pus or other drainage
  • Accompanied by a fever

Poster: A child's first line of defense against MRSA: A well-informed mom.
A series of educational posters contain prevention and control messages related to infectious diseases such as MRSA.

Take Action if You Suspect an MRSA Skin Infection

Cover the area with a bandage and contact your healthcare professional. It’s especially important to contact your healthcare professional if signs and symptoms of an MRSA skin infection are accompanied by a fever.

Protect Yourself and Your Family from MRSA Skin Infections

  • Know the signs of MRSA skin infections and get treated early
  • Keep cuts and scrapes clean and covered
  • Encourage good hygiene such as cleaning hands regularly
  • Discourage sharing of personal items such as towels and razors

National MRSA Education Initiative

The National MRSA Education Initiative is a comprehensive public education campaign to help parents and healthcare providers recognize, treat, and prevent MRSA skin infections in their families and patients. Through the Initiative, parents, healthcare providers and organizations have access to education materials – including printed posters, fact sheets, brochures and flyers, and Web-based e-cards, content and graphics. To access materials, visit www.cdc.gov/MRSA.

More Information

Did You Hear About Tim Tebow’s Concussion?

Learn to Prevent & Recognize Concussions

Photo: A coach talking to her young athletesCDC’s youth sports tool kit teaches coaches, athletes, and parents to play it safe when it comes to concussions.

A concussion is a brain injury caused by a bump or blow to the head that can change the way your brain normally works. Even what seems to be a mild bump or blow to the head can be serious.

To help ensure the health and safety of young athletes, CDC developed the Heads Up: Concussion in Youth Sports initiative to offer information about concussions—a type of traumatic brain injury—to coaches, parents, and athletes involved in youth sports. The “Heads Up” initiative provides important information on preventing, recognizing, and responding to a concussion.

CDC wants to equip coaches, parents, and young athletes across the country with the “Heads Up: Concussion in Youth Sports” tool kit, which contains a:

  • Fact sheet for coaches on concussion
  • Fact sheet for athletes on concussion
  • Fact sheet for parents on concussion
  • Clipboard with concussion facts for coaches
  • Magnet with concussion facts for coaches and parents
  • Poster with concussion facts for coaches and sports administrators
  • Quiz for coaches, athletes, and parents to test their concussion knowledge

You can download the materials or request a free tool kit online.

More Information

When Do I Need Antibiotics, from the CDC

Get Smart: Know When Antibiotics Work

Photo: Pill bottle Antibiotics do not fight infections caused by viruses, like colds, flu, most sore throats and bronchitis, and some ear infections. Rest, fluids, and over-the-counter products may be your or your child’s best treatment option.

Dangers of Antibiotic Resistance

Photo: A pharmacist assisting a customerIf antibiotics are used too often for things they can’t treat—like colds, flu, or other viral infections—they can stop working effectively against bacteria when you or your child really needs them. Antibiotic resistance—when antibiotics can no longer cure bacterial infections—has been a concern for years and is considered one of the world’s most pressing public health problems. Widespread overuse of antibiotics is fueling an increase in antibiotic-resistant bacteria. So the next time you or your child really needs an antibiotic for a bacterial infection, it may not work.

If You Have a Cold or Flu, Antibiotics Won’t Work for You!

Colds and flu are caused by viruses, not bacteria. Taking antibiotics when you or your child has a virus may do more harm than good. Get smart about when antibiotics are appropriate—to fight bacterial infections. Taking them for viral infections, such as a cold, most sore throats, the flu, or acute bronchitis:

  • Will not cure the infection;
  • Will not keep other people from getting sick;
  • Will not help you or your child feel better; and
  • May cause unnecessary and harmful side effects.

What Not to Do

  • Photo: A doctor consulting a father and child.Do not demand antibiotics when a healthcare provider says they are not needed.
  • Do not take an antibiotic for a viral infection like a cold or most sore throats.
  • Do not take antibiotics prescribed for someone else. The antibiotic may not be appropriate for your or your child’s illness. Taking the wrong medicine may delay correct treatment and allow bacteria to multiply.

If your healthcare provider prescribes an antibiotic for you or your child:

  • Do not skip doses.
  • Do not save any of the antibiotics for the next time you or your child gets sick.

What to Do

Snort, Sniffle, Sneeze.
View or download “Snort. Sniffle. Sneeze: No Antibiotics Please!” (video 3:47 mins)

Learn about appropriate antibiotic use and how to feel better when you or your child has a sore throat, ear or sinus pain, fever, cough, or runny nose.

Adults and kids should clean their hands often, especially before meals and after touching pets. And make sure both you and your child are up-to-date on recommended immunizations.

Talk with your healthcare provider about the best treatment for your or your child’s illness. To feel better when you or your child has an upper respiratory infection:

  • Increase fluid intake;
  • Get plenty of rest;
  • Use a cool-mist vaporizer or saline nasal spray to relieve congestion; and
  • Soothe a throat with ice chips, sore throat spray, or lozenges (do not give lozenges to young children).

Video: Snort. Sniffle. Sneeze. No Antibiotics Please!

CDC created a video to help you learn more about appropriate antibiotic use and how to feel better when you or your child has a sore throat, ear or sinus pain, fever, cough, or runny nose. This video features a doctor, who is also a concerned mom. You can download the video at CDC-TV, download the podcast, or access on your mobile phone.

More Information

Description of Swine Flu from the CDC

Clinical Features of H1N1 Influenza

Typical Signs and Symptoms

The incubation period for H1N1 influenza is 1-4 days, possibly as long as 7 days. The clinical features of influenza are well known and include:

  • Sudden onset of fever (usually high);
  • Headache;
  • Extreme tiredness;
  • Dry cough;
  • Sore throat;
  • Runny nose; and
  • Muscle aches and stomach symptoms — more common in children.

(CDC. Interim guidance for clinicians on identifying and caring for patients with swine-origin influenza A (H1N1) virus infection. June 2009. Available at: http://www.cdc.gov/h1n1flu/identifyingpatients.htm Accessed September 16, 2009.)

The symptoms of pandemic H1N1 influenza of 2009 are essentially the same as the seasonal flu, although some have noted an increased frequency of gastrointestinal symptoms, including vomiting and diarrhea, and others have noted the absence of fever in a significant number with virologically proven cases.

The CDC defines cases as influenza-like illness (ILI) if there is fever of ≥100° F (37.8° C) plus cough and/or sore throat in the absence of a known cause other than influenza. Another category is acute respiratory illness (ARI), defined by the presence of 2 of the following 4 symptoms: fever, cough, sore throat, or rhinorrhea. In the outbreak of pandemic influenza in New York City, 95% of virologically proven cases satisfied the ILI definition. (CDC. Swine-origin influenza A (H1N1) virus infections in a school — New York City, April 2009. MMWR Morb Mortal Wkly Rep Dispatch. 2009;58:1-3. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm58d0430a1.htm Accessed September 25, 2009.)

Patients with 2009 influenza A H1N1 infections have higher rates of gastrointestinal symptoms and lack of fever compared with those who have seasonal flu. Most patients have mild symptoms, but a small subset of previously healthy young adults have severe pulmonary disease that progresses to acute respiratory distress syndrome (ARDS); this may occur with or without underlying conditions.

Symptoms in virologically confirmed cases. During an outbreak of H1N1 in a New York City high school, a sample of New York City school students (median age, 15 years) with virologically confirmed cases were interviewed about their symptoms by telephone. They reported:

  • Cough (98%);
  • Subjective fever (96%);
  • Fatigue (89%);
  • Headache (82%);
  • Sore throat (82%);
  • Abdominal pain (50%);
  • Diarrhea (48%);
  • Dyspnea (48%); and
  • Joint pain (46%).

The measured mean peak fever in this group was 102.2° F. (CDC. Swine-origin influenza A (H1N1) virus infections in a school — New York City, April 2009. MMWR Morb Mortal Wkly Rep Dispatch. 2009;58:1-3. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm58d0430a1.htm Accessed September 25, 2009.)

Case Definitions for H1N1 Influenza

(CDC. Interim guidance for clinicians on identifying and caring for patients with swine-origin influenza A (H1N1) virus infection. June 2009. Available at: http://www.cdc.gov/h1n1flu/identifyingpatients.htm Accessed September 16, 2009.)

  • Confirmed case: Patient with ILI plus laboratory evidence confirmed by real-time RT-PCR or viral culture;
  • Probable case: ILI plus laboratory test positive for influenza A and negative for human H1 and H3 by RT-PCR; and
  • Optional: ILI without negative H1N1 test and (1) previously healthy person > 65 years hospitalized for ILI; (2) epidemiologic link to confirmed or probable case in past 7 days; or (3) ILI plus travel to a state or country with confirmed or probable cases.

Complications of H1N1 Influenza

  • Exacerbation of underlying chronic disease;
  • Complications related to the upper airways, including sinusitis or otitis;
  • Pulmonary complications, including bronchitis, asthma (sometimes with status asthmaticus), and acute exacerbations of chronic bronchitis; and
  • Miscellaneous conditions, including cardiac (myocarditis and pericarditis), myositis, rhabdomyolysis, central nervous system complications (encephalopathy, encephalitis, seizures), toxic shock syndrome, and secondary bacterial pneumonia.

Severe complications of H1N1 Influenza. In June 2009, the University of Michigan reported severe pulmonary complications of 2009 H1N1 influenza infection in 10 patients with a median age of 49 years. All 10 patients were referred for severe hypoxemia, ARDS, and inability to oxygenate with conventional ventilation methods. All had severe multilobar pneumonia on x-ray, none had evidence of bacterial pneumonia, and 4 had CT scan-confirmed pulmonary embolism. Lab findings included leukocytosis in 5 (median WBC 9500/mm3), elevated AST levels (41-109 IU/L) in all 10, and elevated CPK levels (51-6572 IU/L) in 6; none had evidence of disseminated intravascular coagulation. The major risk factor was obesity in 9 and morbid obesity (BMI > 40) in 7. All 10 required advanced mechanical ventilation with high-frequency oscillatory or bilevel ventilation with mean airway pressures of 32-55 cm H2O. Two required veno-venous extracorporeal membrane oxygenation (ECMO) support and 6 required dialysis. At the time of the report, 3 had died, 1 was still on ECMO, 1 was still on mechanical ventilation, and 5 had been transferred back to referring institutions. (CDC. Intensive care patients with severe novel influenza A (H1N1) virus infection — Michigan, June, 2009. MMWR Morb Mortal Wkly Rep. 2009;58:749-752.)

Neurologic complications. Neurologic complications were reported in 4 children ages 7-17 years with 2009 H1N1 influenza A. Findings included seizures in 2 children, encephalitis in 2, and ataxia in 1. All recovered without neurologic sequelae. The editorial comment in this report noted that the neurologic disease in these 4 patients was less severe than what has been described in previous reports of seasonal flu. (CDC. Neurological complications associated with novel influenza A (H1N1) infection in children — Dallas, Texas, May 2009. MMWR Morb Mortal Wkly Rep. 2009;58:773-778.; Maricich SM, Neuf JL, Lotze TE, et al. Neurologic complications association with influenza A in children during the 2003-2004 influenza season in Houston, Texas. Pediatrics. 2004;114:e626-e633.; Morishima T, Togashi T, Yokota S, et al. Encephalitis and encephalopathy associated with an influenza epidemic in Japan. Clin Infect Dis. 2002;35:512-517.)

Related Risk for Infection, Hospitalization, and Lethal Outcome

Age-related risk. These data are shown in Table 1.

Table 1. Rates for H1N1 for May-July 2009 by Age

Age Cases/100,000 Hospitalization/100,000 Death %
0-4 yrs 23 4.5 7 (2%)a
5-24 yrs 27 2.1 48 (16%)
25-49 yrs 7 1.1 124 (41%)
50-64 yrs 4 1.2 71 (24%)
> 65 yrs 1.3 1.7 26 (2%)

a % of total deaths. Age data not available for 15%.
Rate expressed /100,000 population

US age data

(Novel Swine-Origin Influenza A (H1N1) Virus Investigation Team; Dawood FS, Jain S, Finelli L, et al. Emergence of a novel swine-origin influenza A (H1N1) virus in humans. N Engl J Med. 2009;360:2605-2615.)

  • Median age of confirmed cases: 12 years
  • Median age of hospitalized cases: 20 years
  • Median age of lethal cases: 37 years

Additional Influenza Vaccine Information

Parents/Caregivers: If your child or adolescent has been diagnosed with Mononucleosis (Epstein-Barr Virus), Hepatitis or other serious viral illnesses within the past few months, please make sure our office is aware before obtaining the influenza vaccine (mist or shot). There may be some time constraints or contraindications. Contact us for any questions.

Update on combing H1N1 and seasonal flu vaccines

Hi

A live seasonal and a live H1N1 flu vaccine cannot be given at the same time. They need to be spaced at least 28 days apart. However, one live and one inactivated vaccine can be given at the same time. The H1N1 VIS is now available (at CDC.GOV) and it confirms that children age 9 and younger need two doses.

I am more than happy to answer any questions for you or anyone in the practice. Feel free to call or email me at any time. We are hoping to see the first shipment of H1N1 flu mist vaccine arrive by next week!

Thanks,

Anna Brereton-Hubbard, RN

Sarasota County Health Department
2200 Ringling Blvd.
Sarasota, FL 34237
941-861-2678
941-861-2676 (fax)

H1N1 Vaccine information sheets

Go to this CDC website for the vaccine information sheets for both types of H1N1 vaccines. We will update the website when we have the vaccines available.
http://www.cdc.gov/vaccines/pubs/vis/default.htm.