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Category Archives: Mental Health

Intermezzo: Just Another Way to Market an Old Drug?

November 28, 2011 Dr. Pullen

Intermezzo is the brand name of a new formulation of the familiar drug zolpidem, better known as Ambien. Unfortunately the most interesting thing about Intermezzo may be its name. Intermezzo is also a term for in an opera or play for a composition of music or drama that fits between two other pieces. As a drug Intermezzo is indicated for patients who awaken earlier than desired and want to get back to sleep, i.e. between two “pieces” of the night’s sleep. I like the name but question paying a premium for the generic product. Intermezzo was brought to market buy Transcept Pharmaceuticals as a sublingual product, designed to be placed under the tongue and to dissolve there. The recommended dose is different for men than for women, with a dose of 1.75 mg. for women and 3.5 mg for men recommended. The explanation for this by the manufacturer is that men clear zolpidem from the blood stream faster than women.

Zolpidem has been available as a generic for the branded sleeping medication Ambien since the patent expired last year. Zolpidem is among the shortest acting of the sleep aides available, and has been marketed as an extended release product, Ambien CR to try to extend the duration of sleep for patients who find zolpidem effective at inducing sleep but who reawaken earlier than they desire. Now solpidem has been repackaged as a low dose sublingual product that is approved for use if in patients who tend to reawaken far too early after getting to sleep. You can take Intermezzo to get back to sleep with the anticipation that as long as you have at least 4 hours until you need to wake up you can take the Intermezzo and not be overly sedated in the morning.

Patients have been taking a half dose of a 5 or 10 mg zolpidem for this purpose for some time, although it is not an FDA approved indication. The effect of zolpidem taken orally in most people is only about 3-4 hours anyway, although in some people the effect can be longer. Does the sublingual route of administration make much difference? It is possible that if the drug is absorbed directly into the bloodstream through the oral mucosa that the serum levels are achieved more quickly than with oral ingestion, and if so in theory the medication may be more quickly cleared from the bloodstream and the hypnotic effect may last slightly less time.

Zolpidem as a generic product is relatively inexpensive at $17.99/ 30 tablets for both the 5 mg and 10 mg doses on drugstore.com. In cannot find a price online for Intermezzo but undoubtedly as a branded product it will be much higher than generic zolpidem. I’ll be interested to hear if patients find Intermezzo more effective than low dose generic zolpidem for getting back to sleep after early awakening, but I suspect that a 2.5 mg or 5 mg dose orally will be pretty similar in efficacy, and much easier on the pocketbook.

Please leave a comment if you have tried Intermezzo, especially if you have also used oral zolpidem for the same symptoms. Comparative experience will be interesting.

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It’s the SAD Time of Year Again

November 17, 2011 Dr. Pullen

SAD is the acronym for seasonal affective disorder, and as we head into the long nights and short days of the northern winter that at least in Washington are made even darker by overcast skies nearly every day I see my usual patients for SAD. Some come in with a clear history of becoming depressed, tired, irritable and even suicidal each winter, and the diagnosis is very clear. Other patients don’t recognize the pattern, or have recently moved to the north, and it can be more difficult to recognize the problem. At any rate SAD is one of the problems that we have become quite good at treating, with many of the selective serotonin reuptake inhibitors (SSRI) being very effective. Some patients even feel that frequent trips to the sunny south are helpful, but for most this is not a viable option.

SAD was really only documented and make a diagnosis since 1984, and in the last couple of decades has become better understood. It is great that we now have SSRI antidepressants to treat this with, but many patients either prefer not to take medication, have side effects from the drugs, or just want a more natural remedy. Full sunlight wavelength light therapy has been shown to help in these patients, and although it is neither easy nor convenient, it does have good evidence of effectiveness. Patients can purchase lights for therapy in many shapes and sizes, or can build their own light boxes. I came across yet another great post by Tara Parker-Pope in the N.Y. Times you may enjoy and learn from:

Light Therapy for Dark Days

By TARA PARKER-POPE

For the millions of Americans who suffer from mild to severe winter blues — a condition called seasonal affective disorder, or S.A.D. — bright-light therapy is the treatment of choice, with response rates comparable with those of antidepressants, reports today’s Consumer column. read more

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The Unexpected Health Benefits of Running

September 12, 2011 Dr. Pullen

The Unexpected Health Benefits of Running

by Charles Boren

The ancient Greeks used running as a form of training and competition. It was a way to test personal fortitude and improve physical health. Many of the health benefits of running were known even in those ancient times. In modern times, many start running for the same reasons. They run to improve their physical endurance, lose weight and build muscle. While these common health benefits of running influence many to start running, runners are surprised to learn just how extensive the health benefits are. Running improves the quality of sleep, fights off depression and anxiety, and improves joint health and stability.

Sleep disorders affect a surprising percent of the population today. There is good news to those who suffer from them. Running can actually improve the decrease the symptoms of sleep disorders and improve the quality of sleep. It also appears to help people sleep more efficiently. That is, the amount of time spent actually sleeping while in bed increases. Running helps people fall asleep more quickly, toss-and-turn less through the night, and wake up more rested than those who do not run.

The runner’s high is a well-documented phenomenon, and major benefit, of running. This is a unique feeling often reported during long, strenuous amounts of exercise. The feeling can range from relaxed and peaceful to intensely euphoric. It is produced when endorphins flood the brain as part of a stress response to running. These endorphins are the natural drugs of the body. They reduce pain and are responsible for the happy and content feelings similar to many those produced by narcotics. While many runners experience this phenomenon, many do not realize the long-term positive effect that is has. Over time, the regular doses of endorphins to the brain can combat both anxiety and depression. In fact, many studies have shown that following a regular running program markedly reduces the symptoms of these disorders.

A common misconception is that the high-impact nature of running negatively affects the joints in the body. The truth is that running may actually improve joint health and stability. (1) This is done in a number of ways. First, running helps keep excess weight off. Just a ten-pound increase in body weight can cause a 45-pound increase in stress on the knees (2). Second, running causes cartilage to expand and contract with the natural movements created while running. This forces nutrients and oxygen into the cartilage cells. Without this, the cells will slowly die from oxygen depletion and starvation. Third, running strengthens the tendons and ligaments that support and stabilize joints. This prevents injury in the long-term. Overall, running greatly improves joints and prevents the onset of arthritis.

Building muscle, losing weight, and strengthening the heart are the health benefits that motivate people to start running. However, it is the unspoken benefits that keep them running. As a whole, runners have better sleep, improved mental states, and healthier joints. Many runners feel that they are taking responsibility for their health by running. They physically feel better, less stressed and they have peace of mind. This is a reward all in itself.

Bio: Charles spends much of his free time running. On the side he also runs an automotive company, where he purchases vehicles.

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Viibryd: A New Antidepressant without Sexual Dysfunction?

July 8, 2011 Dr. Pullen

This month a new antidepressant came to market. Viibryd continues the trend of ever stranger new drug names (generic name vilazodone) and comes with the claim that it won’t lead to sexual dysfunction in the vast majority of users. Whether this turns out to be the case will likely determine whether Viibryd is a hugely popular new drug or just another strangely named addition to an already saturated field of SSRI type antidepressants. Viibryd is technically in a class of its own, having both serotonin reuptake properties and functioning as a post synaptic partial serotonin agonist.

The SSRI drugs prevent the reuptake of serotonin from the space between nerve endings, and lead to an increased concentration of serotonin in this space. Viibryd in addition to this function is a partial serotonin agonist. An agonist is any drug that simulates the activity of a chemical in the body. This additional function could at least in theory alter the usually side effects of an SSRI as well as alter its potential benefits.

In two relatively small studies Viibryd was found to be effective as an antidepressant, but had a very low incidence of sexual dysfunction. Specifically the incidence of orgasmic dysfunction in women and ejaculatory delay or dysfunction in men was less than 3% and very near the rates with placebo. The published rates of these side effects with all of the currently available SSRIs, including fluoxitine (Prozac), sertraline (Zoloft), paroxitine (Paxil) and others, as well as with the SNRIs like venlafaxine (Effexor) and Cymbalta are greater than 15%, and in my experience prescribing these drugs are even higher. By far the most common SSRI and venlafaxine side effects are various aspects of sexual dysfunction, especially orgasmic dysfunction. These are common enough and annoying enough that I often see patients in the office who have stopped their antidepressant medications because of their sexual dysfunction side effects.

The major factor that Viibryd is going to have to overcome is that there are several highly effective generic SSRI antidepressants on the market that are available on the discount pharmacy $4./ month offerings. As a branded antidepressant which will almost certainly be much higher priced Viibryd is going to have to show a clear benefit to gain traction in this highly competitive and saturated market. If Viibryd is found by patients and physicians to be as effective as the currently available SSRIs at treatment of depression, and really not cause orgasmic dysfunction in women and have a very low incidence of sexual dysfunction overall it is going to be a nice addition to our options for treatment of depression. I’ll reserve my judgement at this time, as prior releases of new SSRIs were touted as having lower likelyhood of these side effects. I remember the claim that Celexa side effects of sexual dysfunction were low, but in aftermarket experience Celexa (citalopram) turned out to cause only minimal if any less frequent sexual dysfunction that the SSRIs already on the market.

Viibryd is reported to have a bit higher incidence of gastrointestinal side effects than most of the SSRIs, and to avoid these side effects it is recommended that patients taper up fairly quickly in dosage. It will be interesting to see if this leads to taking an extra week or two for clinical efficacy. One of the issues we face in prescribing antidepressants in general is that they don’t work immediately, rather tend to take 2-4 weeks to start to help. Adding another week or two of ramp up in dosing may be a bit of a drawback to acceptance or Viibryd by patients. I expect the role of Viibryd to be as a second choice of an antidepressant in patients who experience bothersome sexual dysfunction on another SSRI, and Viibryd is tried as a way to avoid that problem.

Viibryd was developed by Clinical Data which was acquired by Forrest Laboratories earlier this year. Forrest also has Lexapro and Celexa as branded antidepressants, and is expected to make a big marketing push for this new product. From the surge of drug reps at my office it certainly seems like they are throwing all of their weight behind I’m anxious to see if Viibryd lives up to its marketing hype and really does work without causing sexual dysfunction. If so I expect it to be hugely successful. The market for antidepressants is huge, with Effexor and Cymbalta, two branded SNRIs having sales of over $2 billion annually. Expect the $1.1 billion Forrest paid for Clinical Data to be a bargain if Viibryd works as advertised. I plan to go slow and see how this all pans out.

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Health Benefits of Meditation

May 20, 2011 Dr. Pullen

Health Benefits of Meditation by Jenni Sunde, guest author

Meditation, when used as a health tool, can significantly increase an individual’s sense of well-being, while simultaneously reducing stress. Abundant research has shown that meditation can lower blood pressure, ease chronic pain, reduce stress and depression, improve concentration, and even boost the immune system. All of this from the basic practice of sitting and quieting the mind. There are so many external stressors in today’s society that finding a way to slow down and focus the mind will do wonders for the body.

Charles L. Raison, MD is the clinical director of the Mind-Body program at Emery University School of Medicine in Atlanta and has participated in a study on just how meditation can improve physical and emotional responses to stress. What he has found is that stress reduction is the key component of the health benefits of meditation. No matter who the patient is they will benefit from stress reduction because it will enable their minds and bodies to better handle any health issues that may be present. Even if the only concern is an inability to sleep, meditation can help with that too.

Stress is a contributor to all major modern killers like cancer. When you think about it, it is actually quite hard to have a disease that does not include or create stress in some way. In severe cases, stress can even be a cause of the ailment. Finding a way to minimize or remove stress altogether can only be of great benefit to the entirety of a person’s health.

Many people view meditative practices as hippy dippy techniques, and don’t give them adequate credit for their proven positive impact on overall health. Many are under the impression that sitting with legs crossed fingertips touching saying “ohm” is the only way to practice meditation, when in reality the only requirement of the practice is to narrow your mental focus and still the body. This does not necessarily require a specific posture, although some are known to be more effective than others. You can find alternative ways to achieve the same end. Some popular, less demanding methods include counting breaths, staring at a candle, or sitting quietly – the only real challenge is finding a way that works for you.

It feels like common sense that taking ten or twenty minutes out of your day to sit quietly, breathing deeply is a great way to unwind and relax, but so many people are unable or unaware of the benefits of meditation. Call it mediation, call it sitting, call it quiet time; taking a moment to focus your energy and calm the mind will reduce stress, promote well-being, and help bring you back into the present which is all your ever have anyway. People that live in the present experience a greater sense of well-being, and are much less prone to stress. Try for yourself and experience the health benefits of medication personally.

About the author: Jenni Sunde is a freelance fashion writer and pop culture junkie. Jenni specializes in all things lifestyle-related. From home and design to health and beauty. With her love of art and all things beautiful, she delights in sharing her sense of style from her life to your computer monitor. Her title pegs her as an editor at a website that specializes in providing people with a car insurance quote, but her passion leads her into writing with a little more substance and a lot more heart.

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Carpe Diem

March 16, 2011 Dr. Pullen

I’ve always loved the phrase Carpe Diem.

From the Free online dictionary:

car·pe di·em

interj.

Used as an admonition to seize the pleasures of the moment without concern for the future.

In Latin it literally means “pluck the day” or “seize the day”

I have always been struck by Carpe Diem as a great phrase to keep front and center in the way to approach life. As the various twists and turns of life strike out at us this focus will rarely serve us poorly. As a family physician I see patients who spend much of their lives wracked with anguish and anxiety over the future. It’s a cliché, but it’s so true that the only day we ever have is today. Much of what family physicians do is to try to help patients live longer, i.e. have more tomorrows. It is easy to lose focus on the present. So how does Carpe Diem work in the practice of medicine?

Most of what we ask patients to do really doesn’t make today much better. Sometimes it makes today a lot worse. Most surgery patients feel worse immediately after surgery than they did before surgery. Most medications don’t work immediately. So how does health care align with the idea of making every day the very best it can be?

Sometimes it’s easy. Clearly when a condition is making the current day miserable, like appendicitis, diverticulitis, pneumonia, migraine headache, etc. interventions that lead to fairly quick resolution of symptoms fit the Carpe diem philosophy. In the middle of the spectrum are things like high blood pressure and diabetes. Treatment needs to be focused on disease control without making each day a dreaded affair of strict rules and medication side effects. As we get to things like weight loss and smoking cessation you have to decide what you are seizing. One way to think is do the most enjoyable things you can today, and don’t worry about the consequences of today’s behavior on tomorrow. A healthier attitude might be to seize the opportunity today to improve yourself and to get healthier. Eat five a day, quit smoking today, get a workout in today, and remember to take your medicine today. Then keep it up again when tomorrow becomes today.

Like most things in life finding the right balance and using some degree of moderation is likely the best choice for most of us. I think the whole trick is to be intentional in what you do today. Don’t simply let today happen, rather make today a great day. Make intentional decisions, and take purposeful steps to make today better than it would be if you passively let today slip by without being cherished.

So what can you do today to make it better? It’s not likely that worrying about tomorrow, or putting off opportunities to laugh, love or smile will make today better. Pluck the opportunities of the day and gobble them down. Gorge yourself with all the small things you can do to improve yourself. Make great decisions today and today will be better and all of your tomorrows are likely to be better too.

While you’re here be sure to follow @DrEdPullen on Twitter, like DrPullen.com on Facebook or subscribe so you don’t miss a post. Carpe diem.

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Halloween – Fun! Panic Disorder – Not!

October 31, 2010 Dr. Pullen

Every Halloween you can find the latest horror movies at the theater. Did you see The Texas Chain Saw Massacre?

How about Invasion of the Body Snatchers:

The feeling you get if you like these movies: Racing heart rate, chest tightness, and shortness of breath; these are part of the thrill of a good horror movie. The issue in patients with panic disorder is that they get a similar set of symptoms, related to the same physiologic phenomenon, release of large amounts of adrenalin, but at inopportune times and without apparent cause. This release of adrenalin, also known as epinephrine, from the adrenal glands leads to the things needed in a life threatening emergency. This is known as the fight-or-flight response, needed when a chainsaw murderer or ghoul is chasing you, exciting if you like a horror movie, but very frightening when it happens seemingly out of nowhere. In panic disorder patients repeatedly have the physical symptoms like racing heartbeat, increased respiration often leading to hyperventilation, chest pressure or pain, and a sense of impending doom. They often describe feeling like they are going to die. Even after understanding what is happening during these panic attacks patients are often unable to control these symptoms and the fear of having an attack can itself be extremely distressing. Panic disorder is very common. It’s estimated by the National Institute of Mental Health that in any given year 2.7% of adult Americans experience panic disorder, with a lifetime incidence of about 5%.

Epinephrine is a hormone naturally produced by the adrenal gland, and it is used therapeutically as an injected medication to stimulate the adrenergic receptors in the autonomic nervous system. (example – severe allergic food reactions or bee stings) There are several types of receptors that make up the adrenergic system. The alpha adrenergic receptors lead to constriction of the peripheral arterioles and elevation of blood pressure. The beta adrenergic receptors when stimulated lead to dilation of the bronchioles (Beta-2 receptors) and increased heart rate (Beta-1 receptors). Although we have medications to block these receptors they are not very effective in treating panic disorder.

We do have medications that are helpful in panic disorder. In addition psychotherapy to help patients learn to manage these attacks, we use the Selective Serotonin Reuptake Inhibitor (SSRI) medications to prevent these attacks, and the benzodiazapines to prevent the extreme anxiety that comes with these attacks. In addition beta-blockers are sometimes used if the attacks are primarily at predictable times like singing, musical performances or speaking, known as performance anxiety. One of the problems with benzodiazapines is that if they are used regularly a physical dependence develops, and the withdrawal symptoms mimic those of a panic attack. We try to avoid daily use of benzodiazapines in panic disorder if possible.

So this Halloween enjoy the brief and predictable adrenaline rushes of a good horror movie is you like, but if you have panic disorder symptoms that are not adequately controlled, see your physician and try to get some help.

Maybe you liked Night of the Living Dead:

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Tricare to Provide Free Confidential Counseling for Military Dependents

July 29, 2010 Dr. Pullen

As our US Military personnel face not only harm’s way in Afghanistan and Iraq, but repeated tours of duty, their families, dependents in military jargon, also face the difficulty of separation and anxiety and depression. Effective just hours ago, through TriWest, the Western US region of Tricare, the government provided health plan for eligible military dependents, has opened secure on-line and telephone counseling services for dependents. This can be accessed confidentially and without cost to eligible military dependents. The new Behavioral Health Portal offers a live-chat line by phone or instant messaging with professional counselors called the Tricare Behavioral Health Contact Center. IT offers the Tricare Assistance Program, with the acronym TRIAP, much like many private EAP (employee assistance programs) for confidential immediate access to help. It even offers video conferencing with professional behavioral health providers in a program called Tri-West Tele-behavioral Health Care Network for those who prefer a visual aspect to their on-line counseling. For those more interested in just finding on-line resources in a library format, they have a virtual library of resources called Tri-West’s Behavioral Health Portal.

This is good news for military dependents in the Tri-West region. Look for similar programs in other Tri-Care regions also. There is increasing concern about the suicide rates among active duty personnel in Iraq and Afghanistan. In 2009, for the first time, the suicide rate among active duty males was higher than in age-matched civilians. In 2009 through late November more active duty personnel died of suicide than were killed in either Afghanistan or Iraq (at least 234 suicides vs. 297 killed in Afghanistan and 144 killed in Iraq). Numbers are not available for civilian dependents of active duty personnel, but this has to be a concern for them also.

If you know of any military dependents who may benefit from these services please forward this article to them, or let them know of this newly available service. Our armed forces members and their families face tremendous stresses as the deployments happen over and over again. They deserve the best we can offer, and this seems to be a step in the right direction.

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Living With Cancer

July 3, 2010 Dr. Pullen

This is a topic close to home. My wife was diagnosed with Stage 3C cancer of the ovary a bit over a year ago. She was a chemotherapy superstar, had few complications, and has been in remission since her treatment finished last October. Still we know her chances of a cure are fairly low. Understanding statistics is a mixed blessing. Even though her chances of this cancer never recurring are pretty low, her chances of living quite some time with cancer if it recurs, while maintaining a reasonably good quality of life are high.

We tend to think of cancer as a disease that you may get, have treatment for, and either be cured of the disease or die from the disease. In a way that’s correct, but what’s easy to forget is that there are lots of people who get cancer, are treated, don’t get a cure, but for whom treatments are fairly effective at holding the cancer in some degree of control and they live for long periods of time with cancer. Living with cancer is different than living after cancer. This is more common now than ever before, as new medications are developed that can treat cancer and often give short or moderate duration remissions, or simply prevent progression of the cancer.

Several types of cancer are particularly common and also have treatments that while not curative can be effective enough to allow a person to live with their cancer for a long time. Among others these include breast cancer, ovarian cancer and prostate cancer. Living with cancer, as differentiated from living after having had cancer, requires rethinking how you approach life. We tend to think of our lives as having a youth, an early adulthood, the mid-life years, the older active adult years, and old age. Couples who have good relationships often plan to get old together, and think of a future in terms of decades, rather than in terms of years. All of the online retirement planners ask you what you want to use as a life expectancy. I’ve always entered something like 85 years, thre actuarially correct answer for a healthy 55 year old.

When a person has a disease that they know they will die from in a few months it requires rethinking how to spend your last days. This is a type of thinking that although painful and difficult, is a way that we intuitively understand. What’s really important to me. I cannot put off for tomorrow what needs to be done today. Short term planning and thinking is something that is conceptually concrete. Most of us can wrap our brains around this scenerio.

When a person has a cancer they have been told cannot be cured, but that they have a good chance of living with for some ill-defined number of years, maybe 2-3, possibly 5-10 or even more, this requires a different type of thinking. Oh, and by the way add that maybe you’ll be getting some sorts of treatments that will make you sick, or have low blood counts and require you to avoid being around lots of people, but we don’t know when or whether you’ll need these treatments. Living with both the relative certainty that you have a cancer that is not curable and also many uncertainties (how long you have, how will you tolerate the treatments, how good will your quality of life be, how will your family and loved ones cope, ….) is different and has its own challenges. Finding the right balance:

living in the present vs. planning for the future
addressing your feelings and needs to grieve while enjoying every day
needing support and help but wanting to be treated normally
laughing and crying
Enjoying the everyday pleasures vs. doing the things you’ve always wanted to do but never made time for

Lots more I’m sure I haven’t thought of yet.

I don’t profess to be an expert on how to live this life. under these circumstances. I expect I’ll learn more about it over the next few years. I pray that I’ll be up to whatever decisions come my way, but right that’s about as specific as my prayers have evolved.

Any advice, resources, and anecdotes are welcome in the comments. If you’d like to submit a guest post on this or other subjects use the contact tab above to send the post to me to consider for this blog.

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30 Years of Progress – Antipsychotic Therapy

April 28, 2010 Dr. Pullen

Last week I posted about the progress in the treatment of depression over the last 30 years. Today I’m going to discuss what I think is an even more dramatic improvement in pharmacologic management of psychiatric disease. The treatment of major psychosis, especially schizophrenia, but also bipolar disorder, has had revolutionary breakthroughs with the new generation of antipsychotics. Although these diagnoses are far less common than depression, they are a devastating problem for the individuals and families they affect. When I was in training, and really until the last 15-20 years, the antipsychotic medications were also called “major tranquilizers.” This is because when taking them patients were essentially tranquilized. Examples of these medications were thorazine, haloperidol and others. Patients taking these medications were sedated, slowed in their thinking, and very dull. (Think of scenes from “One Flew Over the Cuckoo’s Nest”) In addition to these poorly tolerated side effects the medications often led to irreversible involuntary movement disorders called tardive dyskinesias. This is when patients would develop lip smacking, twitching of muscles, and other involuntary muscle movements that sometimes did not go away on stopping the medications. As primary care physicians we were very reluctant to prescribe these medications, and psychiatrists had to closely monitor patients to try to balance the horrors of untreated major psychosis with the risk of development or worsening of very difficult and sometimes irreversible side effects. When treated with these meds patients may not have been psychotic, but they were rarely very functional.

In about 1990 a group of meds known as second generation antipsychotics were developed. The first of these was clozapine which is difficult to use because of the potential to cause agranulocytosis. It was followed shortly by risperidol, olanzapine and others. These were a huge improvement in our arsenal of antipsychotic meds, since they are much less sedating, often leave patients able to function in society, be fairly alert, and feel better on the meds than off. Many schizophrenic patients are now stable on long term antipsychotics and function in society far better than was possible on the older medications. Also the tardive dyskinesias are almost unheard of with these medications. Now we have to watch for other side effects like weight gain with some, and an increased risk of developing diabetes, but these are relatively tame side effects compared to treating a patient with a drug that made them nearly a walking zombie. With these drugs many patients are treated successfully by primary care physicians, and function out of institutions free of the intrusive and destructive psychotic problems of their disease. Even newer drugs continue to be developed and give us more options to fine tune treatment of major psychosis.

Also read: Depression: It Helps when the Treatment is Not Worse Than the Disease

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