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Why the Necessity for Them?

Managing Pain

Originally published in Mayo Clinic Health Letter. Last updated June 10, 1999.

Pain is universal. You can trace its trail through time--from a toothache evident in fossil remains of a human jawbone to today's drugstore shelves packed with pain relievers. Almost half of all Americans seek treatment for pain each year, 7 million from newly diagnosed back pain alone. Pain is complex. Sometimes it's beneficial. A sharp stab alerts you to injury when you burn your finger, hurt your back or break a bone. But other pain--the day-after-day ache of arthritis or the anguish of cancer--serves no useful purpose, and its relentlessness can become overwhelming. Above all, pain is unique. The varieties of misery are as many as its sufferers. Your pain is an interplay of your own particular biological, psychological and cultural makeup. New insight into these components is changing the concept of pain management. Pain is no longer seen as just a companion of disease or injury. It can become a damaging process in its own right that requires early and aggressive treatment. In addition, effective management increasingly focuses on your attitude as well as medication and other therapies.

You must understand the reasons for your pain and how to control it. By working closely with your doctor and health-care team, you can learn to manage your pain and enjoy a more fulfilling family, work and leisure life. Exercise, relaxation techniques, and physical, occupational and psychological therapies play important treatment and prevention roles. And new drug-delivery systems can keep some types of pain under continuous control. But despite these advances, some painful conditions are still inadequately treated.

The Physical Sensation

Most pain originates when special nerve endings, called nociceptors (no-si-SEP-turs), detect an unpleasant stimulus. You have millions of nociceptors in your skin, bones, joints, muscles and internal organs. There may be as many as 1,300 in just one square inch of skin. Some nociceptors sense sharp blows, others heat. One type senses pressure, temperature and chemical changes. Nociceptors can also detect inflammation due to injury, disease or infection. Nociceptors use nerve impulses to relay pain messages to networks of nearby nerve cells (your peripheral nervous system). Messages then travel along nerve pathways to your spinal cord and brain (your central nervous system). Each cell-to-cell relay is almost instantaneous, thanks to chemical facilitators called neurotransmitters. These chemicals flow from one nerve cell to the next in less than a thousandth of a second. Some nerve pathways are faster than others. One type makes connections with many surrounding nerve cells en route. They transmit more slowly. You feel this type of pain as dull, aching and generalized. Another type relays impulses almost instantaneously and signals sharp pain focused in one spot.

Scientists believe that pain signals must reach a threshold before they're relayed. This "gate control" theory holds that specialized nerve cells in your spinal cord act as gates that open to allow pain messages to pass, depending on the strength and nature of the pain signal.

A Message-Routing Section in Your Brain

Pain signals travel from your peripheral nerves to your spinal cord to your thalamus, a message sorting and switching station in your brain. The thalamus sends two types of messages. One goes to your cerebral cortex, the thinking part of your brain, which assesses the location and severity of damage. The second is a "stop-pain" message back to the injury site to tell local nociceptors to stop sending any more pain messages. Once alerted, your brain doesn't need additional warning. But sometimes, this mechanism fails and pain persists. Meanwhile, your cerebral cortex relays the pain message it received to your brain's limbic center. Your limbic center produces emotions, such as sadness or anger, in response to pain messages. Your limbic center can affect the way your cerebral cortex perceives pain messages, and can lessen or intensify your pain. Your cerebral cortex also sends messages to your autonomic nervous system, which controls vital body functions such as breathing, blood flow and pulse rate.

Several types of neurotransmitters (proteins and hormones produced in your brain or nervous system) can increase or decrease pain signals. A hormone--one of the prostaglandins--speeds transmission of pain messages and makes nerve endings more sensitive to pain. And a protein called substance P continuously stimulates nerve endings at the injury site and within your spinal cord, increasing pain messages. Serotonin and norepinephrine (nor-ep-i-NEF-rin) seem to decrease pain by causing nociceptors to release natural pain-relievers called endorphins (see "Stimulating your body's natural painkillers"). The emotional component Pain is not simply a matter of passing messages up and down your spinal cord.

When a pain signal reaches your brain, it passes through a filter of your personal experience. Your emotional and psychological state at the moment, memory of past pain experiences, outlook and stress level all affect how you interpret a pain message and your ability to tolerate it. Your upbringing and cultural attitude toward pain also play a role. And your age, level of information about your pain, and even lack of sleep may have an impact. The emotional responses of shock, fear and anxiety can increase your perception of pain. For example, a minor pain sensation, such as a dentist's probe, combined with anxiety can cause undue pain. But your emotional state can also diminish major pain messages.

One pain study compared survivors of a major battle in World War II with men in the general population of a major U.S. city, matched injury for injury. The combat veterans required less pain relief than those in the general population. People who learn from upbringing and cultural background that the normal response to pain is great suffering and distress actually experience more pain than people who grow up in an environment where pain is often ignored. The common expressions "suffer in silence," "bite the bullet," "grin and bear it," and "no pain, no gain" point to American cultural patterns that discourage acknowledgment of pain.

Types and Characteristics of Pain

In general, doctors divide pain into two general categories--acute and chronic.

Acute--Acute pain is temporary, related to the physical sensation of tissue damage. It can last from a few seconds to several months, but generally subsides as normal healing occurs. Examples include a burn, a fracture, an overused muscle, or pain after surgery. Cancer pain may be long-lasting but acute due to ongoing tissue damage.

Chronic--Chronic pain lingers long beyond the time of normal healing. Some chronic pain is due to damage or injury to nerve fibers themselves (neuropathic pain). Although it may begin as acute pain, neuropathic pain often develops gradually and becomes chronic pain that's difficult to treat. Chronic pain can result from diseases, such as shingles and diabetes, or from trauma, surgery or amputation (phantom pain). It can also occur without a known injury or disease. Like a gate that's blocked open, nerves continue to send pain messages even though there is no continuing tissue damage. Chronic pain ranges from mild to disabling and can last from a few months to many years. Significant emotional and psychological components may develop. The essential ingredient is that the chronic pain changes your behavior.

For example: You experience the actual physical sensation of acute pain--the immediate, sharp stab in arthritic finger joints as you try to open a lid. Next is the emotional response--your anger and frustration with fumbling fingers. Eventually, behavior changes may occur. You may avoid using aching fingers and hands. Your hands become weak from inactivity, and you depend on others for assistance. Chronic pain can result in lowered self-esteem, sadness, anger and depression. Over the long term, a sense of helplessness to control chronic pain can lead you to develop characteristic "pain behavior." Behavioral changes can become habitual--crutches that can undermine your ability to effectively manage your pain (see "Caution: Pain behavior can become addicting").

Evaluating Pain

Pain is subjective, but there are ways to measure it. Doctors may use questionnaires, have you fill out a pain-rating scale, or have you select words that best describe your pain (see "The language of pain".) When repeated attempts to find a cause fail, and treatments aren't effective, you may benefit from a team approach offered by a pain clinic. A thorough evaluation may involve specialists in anesthesiology, neurology, psychology and psychiatry, rheumatology, physiatry and physical therapy. The goal is to treat all facets of your pain. Specialized tests can evaluate how your body senses nerve impulses and how the impulses travel through your nervous system. Imaging techniques, such as X-rays, computed tomography (CT), magnetic resonance imaging (MRI), bone scans and ultrasound, may help detect problems in bones, muscles, joints and soft tissue.

Treat Pain Early and Aggressively

For many years, standard practice called for treating moderate to severe acute pain with injections of narcotic medication "as needed." This method often resulted in delays and widely varying levels of pain relief. Your pain rose and fell based on the dose timing. For most people, pain relief was effective only part of the time. Even today, pain is often undertreated. Inadequate pain control can occur for many reasons. The choice, dose and timing of medication are critical in obtaining effective relief. Also, patients and their doctors may be unduly concerned about the use of narcotics in treating acute pain. But addiction is rare when narcotics are used for short-term relief of acute pain. It may become a problem when narcotics are inappropriately used for chronic pain relief. Addiction is not an issue in treatment of pain from a terminal illness.Adequate acute pain control following surgery is important because it can allow you to recover your strength faster and start walking earlier. This can help you avoid problems, such as pneumonia and blood clots, due to inactivity. Inadequately treated acute pain can prolong recovery and make you more susceptible to chronic pain. Continued pain messages enhance subsequent pain responses. Peripheral pain receptors become more sensitive. And continued pain may cause long-lasting modifications in nerve cells along spinal cord pain pathways. These changes make established pain harder to suppress. As pain persists, feelings of anxiety, stress, anger, helplessness and depression can worsen. Tension and pain may initiate a downward pain spiral that's difficult to break. Early, aggressive treatment, and working with your doctor to prepare a pain plan, can help prevent this (see "Make a pain plan").

Pain-relieving Medications

Pain treatment often includes medications and nondrug therapies (see "Achieving pain relief without medication"). Over-the-counter pain-relieving (analgesic) drugs include: NSAIDs--Nonsteroidal anti-inflammatory drugs, or NSAIDs (en-SAYDS), are used to treat acute pain from inflammation, such as from arthritis. They relieve pain by inhibiting production of pain-intensifying neurotransmitters activated by tissue damage. NSAIDs include aspirin (Anacin, Bayer, Bufferin), ibuprofen (Motrin, Advil, Nuprin), naproxen sodium (Aleve) and ketoprofen (Orudis KT). All can cause gastrointestinal bleeding. All are also available in prescription form. Acetaminophen--Acetaminophen (Tylenol) is used to treat pain and control fever, but has only a limited effect on inflammation. It doesn't cause gastrointestinal bleeding like NSAIDs. Prolonged, high-dose use can cause kidney and liver damage. Drugs available only by prescription include: Narcotics--These drugs are the most effective medication for moderate to severe pain. They're used for cancer pain and acute pain when the cause is known and other medications are ineffective. Narcotics also have an important role in the treatment of pain associated with terminal illness. They're not approved for chronic pain.

Chronic pain - Reassessing the Role of Morphine

Narcotics include drugs derived from opium (opiates), such as morphine and codeine, and synthetic narcotics (opioids), such as oxycodone, methadone and meperidine (Demerol). Side effects can include drowsiness, nausea, constipation, mood changes, and with prolonged use, addiction.

Antidepressants--These medications may offer some relief for people with chronic pain, whether or not they also have depression. Amitriptyline (Elavil), trazodone (Desyrel) and imipramine (Tofranil) may be used with other analgesics. These drugs aren't addicting. They're especially useful for neuropathic, head and cancer pain. Side effects can include drowsiness, constipation and mouth dryness.

Anticonvulsants--Developed for epilepsy, these drugs, such as phenytoin (Dilantin) and carbamazepine (Tegretol), can also help control chronic nerve pain. Side effects include drowsiness and confusion. Other drugs may be used for specific types of pain. Corticosteroid medications may help relieve pain due to inflammation and swelling. Prolonged use can result in widespread problems, such as bone thinning, cataracts and increased blood pressure. Tramadol (Ultram) is a synthetic analgesic used primarily for chronic pain, but is also prescribed for acute pain. Side effects may include dizziness, drowsiness, nausea, constipation and sweating. Sumatriptan (Imitrex), now available in tablet form, may reduce pain from migraine headache by constricting blood vessels in your brain. Because the drug may increase blood pressure and constrict arteries to your heart, it's not used for people with uncontrolled high blood pressure or heart disease. Capsaicin (Zostrix), a topical cream made from an extract of red peppers, can help relieve skin sensitivity resulting from shingles. It's also used to treat pain from arthritis, cluster headaches, diabetic neuropathy and pain after mastectomy. You may have an initial burning sensation where the cream is applied. Benefits are temporary so you'll need repeated application. Capsaicin probably relieves pain by interrupting transmission of pain messages from nociceptors.

Managing Pain

Short-lived acute pain generally responds to medication and goes away with healing (see "Handling acute pain,"). But persistent pain can lead to depression, inactivity, deconditioning and increased dependence on others. Chronic pain can interfere with sleep and eating habits, exercise, social activity and work. Breaking this cycle usually requires a coordinated approach offered in a pain rehabilitation program. Physical, occupational and behavioral therapies, and assistance with the psychological components of chronic pain, are the cornerstones of successful treatment.

Here are some strategies for coping with chronic pain:

Relaxation techniques--Stress increases muscle tension and worsens pain.

Relaxation techniques--such as meditation and yoga--involve activities in which you focus on something other than your pain. You can do many at home. Listening to music, visualizing a relaxing scene, trying a new hobby or visiting a friend may also help. These techniques can alter peripheral and central pain processes and are especially effective for chronic headache and muscle tension.

Biofeedback may also help by teaching you to be aware of autonomic pain responses such as skin temperature, muscle tension, blood pressure and heart rate, and how to modify these. Ask your doctor about where to find help in learning relaxation and biofeedback techniques.

Occupational therapy--This helps you return to ordinary tasks around your home and work. Focusing on home responsibilities, work or volunteer activities--perhaps for limited hours at first--is a first step in pain rehabilitation.

Physical therapy and exercise--You may fear exercise will increase pain, but if you start gently and increase gradually, exercise usually doesn't cause injury or additional pain. A regular program should include stretching, strengthening activities and aerobic exercise, such as walking, swimming or cycling. Slow stretching can relax muscles and release tension. If you have chronic back pain, you may get enough relief from muscle-strengthening exercises alone, thereby avoiding surgery.

Family therapy--Chronic pain can change personalities and unravel relationships. The person with pain feels guilt and family members become stressed taking over additional responsibilities and new roles. The key is to maintain your normal responsibilities and roles as much as possible.

A Part of Life

Pain may be universal--perhaps even unavoidable. But it doesn't have to control your life. The keys to successful pain control are early treatment, ongoing assessment, and clear communication between you and your doctor.


Originally published in Mayo Clinic Health Letter. Last updated June 10, 1999.

As early as 6,000 years ago, Sumerian healers used opium, a drug derived from the poppy plant, to relieve pain. Today, researchers know that your brain has special receptors for morphine-like substances.

Morphine, a potent narcotic painkiller used to treat acute pain and pain associated with terminal illness, is derived from opium. Researchers also know that your brain and spinal cord make their own morphine-like pain relievers, called endorphins (en-DOR-fins) and enkephalins (en-KEF-uh-lins). When they attach to morphine receptors, these natural pain relievers help relay "stop-pain" messages back to the site of tissue damage. You can stimulate the release of endorphins through aerobic exercise. Duration of exercise appears to be more important than intensity.

Doing low-intensity aerobic exercises for 30 to 45 minutes at a time, five or six days a week, may produce an effect. Be sure to build up slowly. Even exercising three or four days a week may produce some effect. You should have a complete medical evaluation before beginning any exercise program that is more vigorous than walking if: You are age 40 or older. You have been sedentary. You have risk factors for coronary artery disease. You have chronic health problems.

Transmission of Pain Signals

Nerve endings called nociceptors transmit pain messages through peripheral nerves and your spinal cord to your thalamus. The thalamus alerts your cerebral cortex, the thinking part of your brain, and sends a message back to the injury site, telling nociceptors to stop sending pain messages.

The Potentially Beneficial and the Toxic

March 27, 1997

NOTE: Our listing of the following herbs as potentially beneficial should not be viewed as an endorsement of any of them. "In most of these cases there are prescription medications that have a stronger and more predictable effect," says Dr. Donald D. Hensrud, a preventive medicine and nutrition specialist at Mayo Clinic, Rochester, Minn. "In general, I don't recommend any of these herbal products."

As noted in the accompanying article, Herbal remedies - There's no magic, herbal preparations can vary widely, making the concentration of ingredients often inconsistent. One should be careful in using herbal products because they are largely unregulated. Toxic impurities have been found in some cases. If you take herbal supplements, inform your physician of the type and dose to determine whether there is a risk of interaction with other medications you may be taking.

Examples of potentially beneficial herbs ...

Chamomile: A member of the daisy family, German chamomile may aid indigestion and may have anti-inflammatory properties. Chamomile is usually taken as a strong tea. However, use caution with chamomile if you are allergic to ragweed, asters, chrysanthemums, or other members of the daisy (Asteraceae) family.

Heartburn update - A broader array of nonprescription medications

Heartburn treatments - A step-by-step guide

Echinacea: Also a member of the daisy family, echinacea is a hot-seller for people seeking to stave off the common cold. The plant, native to the central United States, is reported to have some properties that modestly boost immunity for battling upper respiratory infections, although more studies are needed before any conclusive statement can be made. Echinacea is usually sold in extract form either dissolved in alcohol or in capsules.Use of echinacea is discouraged during pregnancy and for people with tuberculosis or autoimmune problems.

Feverfew: Consuming leaves of this plant in the daisy family is believed to provide relief and prevention of migraines. Its use dates almost to biblical time. However, in recent times some tablets sold as feverfew have been found to have small amounts of the active ingredients.

Headache - New way of looking at pain is leading to better control of this universal affliction

Garlic: One of the world's most-used herbs also lowers cholesterol and thins the blood when taken in large amounts. Garlic also may have antibacterial and anticarcinogenic properties. Garlic pills are most effective when coated to prevent breakdown in the stomach before they enter the small intestine. Eating enough garlic to have possible medicinal value requires at least five or more cloves a day which may lead to heartburn (not to mention fewer close friends!). Avoid large amounts of garlic if you are taking aspirin or other drugs that thin the blood.

Oasis Heart Resource Center references:

Ginger: This root appears to be effective against motion sickness when taken in powdered form. It also may help nausea.

Ginkgo biloba: Seeds and fruits of this tree have been used as medicine in China since 2800 B.C. In recent times, some studies suggest that ginkgo extract may improve circulation, memory and mental function, especially in older people. More data is needed before any conclusions can be reached.

Dementia - When you suspect a loved one's problem Alzheimer's Resource Center Hawthorn: Extracts from this plant may dilate coronary blood vessels, decreasing blood pressure, and provide a mild improvement of heart function. However, self-medication is not recommended, especially for something as vital as your heart.

Milk thistle: This prickly plant, native to Mediterranean Europe, has fruits that appear to contain properties which may protect against hepatitis and cirrhosis of the liver. It is taken by pill or injection. The active ingredients are not very effective in teas because they are poorly soluble in water.

The ABCs (and DEFGs!) of Viral Hepatitis

Saw palmetto: Berries from this fan palm grown in the southern United States are believed to contain properties that may improve urinary flow in men with benign prostate enlargement (BPH). Like milk thistle, the tea form of saw palmetto derives little or no benefit. German health officials allow saw palmetto to be sold as a drug for benign prostate enlargement. However, U.S. officials banned over-the-counter drugs to treat this condition, including saw palmetto. Therefore, the product is not classified as a drug in the United States. It is, however, sold in U.S. health-food stores as a supplement, which means its manufacturers do not have to prove safety or effectiveness.

St. John's wort: Extracts from this yellow flower may provide some benefit for people with depression, according to an analysis of 23 clinical studies published in the British Medical Journal last year. However, more information is needed, including data on the most effective dosage and long-term safety. Depression can be caused by illnesses such as heart or thyroid disorders, so we urge caution. Self-medication with herbal remedies could obscure an important and treatable underlying cause of depression.

Valerian: Widely used in Europe, valerian tea and extracts appear to be an effective (although mild) sedative.

Examples of toxic herbs ...

NOTE: The following herbs definitely can be toxic and should be avoided.

Chaparral: The chaparral shrub, which grows in the southwestern United States and Mexico, has been used for herbal teas by American Indians without toxicity. In tablet form, however, chaparral has proven to cause toxic hepatitis, including the case of a patient who required a liver transplant.

Comfrey: The toxicity of comfrey is well-established. Like chaparral, it can cause liver damage. There have been documented cases of death from intake of comfrey.

Ephedra (ma huang): Despite the claims of marketers, there is no reliable evidence that the active agent, ephedrine, is safe or effective in aiding weight loss. Ephedrine increases blood pressure. It can cause heart palpitations and can lead to stroke. It has been linked to the deaths of at least 15 people.

Lobelia: An overdose of lobelia, also called Indian tobacco, can lead to vomiting, convulsions, coma and death.

Yohimbe: Promoted as an aphrodisiac, yohimbine is the active ingredient from this West African plant. It can cause weakness, paralysis, gastrointestinal problems and even psychosis. Yohimbine is sometimes prescribed in the United States for treatment of impotence. However, self-medication is strongly discouraged because of its side effects.

Impotence - New treatments offer help

Kombucha: Kombucha "mushrooms" are actually a colony of yeast and bacteria that people have used in tea. There was a case in Iowa of a death possibly linked to kombucha.

Stephania and magnolia: Toxic to the kidneys, these have been used in a weight-loss product in Belgium. The result: kidney transplant or dialysis in 20 patients.

Jin bu huan: This herb is a sedative that has resulted in overdose in some children.


What is depression?

Depression is an illness, not a personality flaw, characterized by negative thoughts and feelings. There are a number of different types of depression:

  • Major depression
  • Dysthymia
  • Bipolar disorder
  • Postpartum depression
  • Seasonal affective disorder (SAD)
  • Major depression occurs in disabling episodes (once, twice, or several times in a lifetime), which interfere with the ability to work, sleep, eat, and/or enjoy pleasurable activities
  • Dysthymia refers to chronic (long-term) depression which is not disabling, but which prevents an individual from feeling good and/or functioning at full capacity.
  • Major depressive episodes may occur periodically in individuals with chronic dysthymia. o In bipolar disorder, bouts of depression alternate with periods of mania (or elation).
  • Postpartum depression occurs in new mothers, shortly after childbirth
  • Seasonal affective disorder (SAD) refers to depression which occurs primarily during the winter months.

What causes depression?

Causes of depression vary from person to person. Some of the factors which can contribute to depression include:

  • Genetic predisposition (heredity)
  • Biochemical predisposition ("brain chemistry")
  • Low self-esteem
  • Losses/disappointments
  • Difficult relationships/situations
  • Life changes
  • Stress
  • Chronic illness

What are the symptoms of depression?

  • Persistent feelings of sadness, guilt, hopelessness, helplessness, or worthlessness
  • Changes in sleeping patterns (inability to sleep or excessive desire to sleep)
  • Changes in eating patterns (loss of appetite or overeating)
  • Impaired ability to concentrate, remember, or make decisions
  • Loss of interest (in work, school, hobbies, friends, family, sex)
  • Lack of energy
  • Decreased ability to experience enjoyment or pleasure
  • Restlessness or irritability
  • Thoughts of death or suicide
  • Recurring physical symptoms (headaches, digestive disorders, pain)

How is depression diagnosed?

Diagnosis of depression is made based upon:

  • Symptoms
  • Physical examination
  • Psychiatric evaluation

How is depression treated?

Treatment options include:

  • Medication
  • Psychotherapy
  • Electroconvulsive therapy (ECT)

What role does medication play in the treatment of depression?

  • A variety of different antidepressant medications are available.
  • A doctor or psychiatrist may need to prescribe a number of different medications before finding the medication, combination of medications, and/or dosage that is most effective for a particular patient.
  • Regular follow-up with a doctor or psychiatrist is necessary, for ongoing evaluation of the dosage and effectiveness of the medication
  • It can be tempting to stop medication too soon. Always consult your doctor or psychiatrist before discontinuing antidepressant medication.
  • For treatment of bipolar disorder or chronic major depression, medication may need to be taken indefinitely to help prevent disabling symptoms.
  • Different antidepressant medications have different side effects. Discuss possible side effects with your doctor.

What role does psychotherapy play in the treatment of depression?

  • Interpersonal therapy focuses on dealing with problematic personal relationships.
  • Cognitive/behavioral therapy focuses on changing negative patterns of thinking and behavior.
  • Psychodynamic therapy focuses on resolving internal psychological conflicts.
  • Most cases of severe, recurrent depressive illness require medication along with psychotherapy for most effective treatment.

What role does electroconvulsive therapy play in treatment of depression?

ECT may be used in cases of depression which:

  • Are severe
  • Are life-threatening
  • Do not respond to medication

How can a depressed person help themselves?

The feelings of fatigue, worthlessness, and hopelessness associated with depression may make a depressed person feel like giving up. Remember that these feelings are symptoms, and should improve upon effective treatment of the depression.

Until treatment begins to take effect:

  • Do not take on too much responsibility.
  • Do not set goals which are too difficult.
  • Avoid isolating yourself from other people
  • Engage in activities which make you feel better.
  • Avoid making major life decisions.
  • Do not expect to 'snap out of' depression.
  • Do not blame yourself if you do not feel better right away.
  • Remember that feeling better takes time, and that depressed people rarely just 'snap out of it.'

Antidepressant Medications

How is depression treated?

Treatment of depression often involves a combination of counseling and the use of antidepressant medications.

How do antidepressant medications work?

Antidepressants affect the levels of certain chemicals (called neurotransmitters) in the brain. By restoring the brain's chemical balance, antidepressants help relieve the symptoms of depression.

Antidepressants are not tranquilizers or "uppers." They are not addictive. Antidepressants can provide relief of symptoms within one to two months. However, treatment is often continued for six months to a year, to help avoid relapse. In some cases, more long-term use of medications may be necessary.

Do antidepressant medications cause side effects?

Antidepressants can have side effects, although not all people experience all side effects. Some people experience no side effects at all. Often, side effects are most severe at first, but disappear after a few days or a few weeks of treatment. If side effects do not go away, a patient should consult his/her healthcare provider.

Is there more than one type of antidepressant?

There are four major classes of antidepressants:

  • Tricyclics (or heterocyclics)
  • Selective serotonin reuptake inhibitors (SSRIs)
  • Monoamine oxidase inhibitors (MAOIs)
  • Others

What are tricyclic antidepressants?

Tricyclics include:

  • Amitriptyline (brand name: Elavil)
  • Amoxapine (Asendin)
  • Desipramine (Norpramin)
  • Doxepin (Adapin, Sinequan)
  • Imipramine (Tofranil)
  • Maprotiline (Ludiomil)
  • Nortriptyline (Pamelor)
  • Protriptyline (Vivactil)
  • Trimipramine (Surmontil)

Potential side effects of tricyclics include:

  • Dry mouth
  • Blurred vision
  • Constipation
  • Difficulty ing
  • Impaired thinking
  • Tiredness/sleepiness
  • Hand tremors
  • Dizziness when standing up
  • Weight gain
  • Muscle twitching
  • Weakness
  • Increased heart rate

What are the SSRIs?

SSRIs include:

  • Fluvoxamine (brand name: Luvox)
  • Fluoxetine (Prozac)Paroxetine (Paxil)
  • Sertraline (Zoloft)

SSRIs tend to have fewer side effects than tricyclics. Some potential side effects include:

  • Decreased appetite
  • Nausea/vomiting
  • Nervousness/anxiety
  • Insomnia or sleepiness
  • Headache
  • Dry mouth
  • Sexual dysfunction
  • TremorInability to sit still
  • Runny stools/diarrhea

What are the MAOIs?

MAOIs include:

  • Socarboxazid (brand name: Marplan)
  • Phenelzine (Nardil)
  • Tranylcypromine (Parnate)
  • MAOIs can cause a fatal increase in blood pressure when mixed with certain foods or other medications.

Anyone taking an MAOI should consult his/her healthcare provider before taking any other medication, and must carefully follow dietary restrictions.

What are "other" antidepressants?

Others include:

  • Bupropion (brand name: Wellbutrin)
  • Mirtazapine (Remeron)
  • Nefazodone (Serzone)
  • Venlafaxine (Effexor)

Some of the potential side effects of these medications include:

  • Headache
  • Dizziness
  • Nausea
  • Constipation
  • Dry mouth
  • Drowsiness

How does a healthcare provider decide which drug to prescribe for the treatment of depression?

Because of the wide variety of drugs available, and the difficulty of predicting which drug will be most effective (with few or no side effects) in any given patient, it may be necessary to try more than one drug before finding the appropriate medication.

The following are signs that an antidepressant is working:

  • Improved sleep
  • Improved ability to meet day-to-day obligations
  • Improved self-care (grooming, dressing, eating regularly)
  • Increased energy
  • More "normal" appetite
  • Resolution of weight problems
  • Increased desire to live

What else might a patient need to know about taking antidepressants?

When taking antidepressants:

  • Consult a healthcare provider before taking any other medications (prescription or over-the-counter), as interactions may occur.
  • Do not drink alcohol.
  • For women of childbearing age, consult a healthcare provider about the safety of antidepressant medications during pregnancy and/or breastfeeding.
  • Do not stop taking an antidepressant abruptly.
  • Antidepressants should be tapered gradually, to help avoid relapse.

Medications revolutionize treatment

The development of antidepressant medications and mood-stabilizing drugs in the last 20 years has revolutionized treatment of depression. Medication can relieve symptoms in most people with depression, and its become the first line of treatment for most types of the disorder.

Treatment may also include psychotherapy, which may help you cope with ongoing problems that may trigger or contribute to depression. A combination of medications and a brief course of psychotherapy is usually effective for people with mild to moderate depression.

Psychotherapy is usually not effective in severe depression. Both medications and psychotherapy can take 4 to 8 weeks to have an effect. In severely depressed people, this delay can actually increase depression and risk of suicide as people think treatment isnt working and feel like giving up. Depression is usually treated in two stages. Acute treatment with medications helps relieve symptoms until you feel well. Once your symptoms have eased, maintenance treatment typically continues for 4 to 12 months to prevent a relapse. Its important to keep taking your medication even though you feel fine and are back to your usual activities.

Episodes of depression recur in 80 percent to 90 percent of people who have one episode. Doctors now understand depression as a chronic condition, which often requires ongoing medication, much like people with diabetes who need to take insulin indefinitely. If you have recurrent episodes, your doctor may recommend that you continue taking medication longer perhaps for years. The longer you stay on medication, the less likely depression will recur.

Here's more about the types of treatments for depression:


Drugs are the first-line treatment for depression. Medications for depression arent habit-forming (addictive), and theyre usually less costly than lengthy counseling. In addition, adequate treatment with medications is more likely to prevent a recurrence.

Side effects from antidepressant medications are usually mild and temporary. The most common are dry mouth, changes in sleep patterns, restlessness, nausea, constipation, bladder problems, sexual dysfunction, dizziness and drowsiness.

As with all medications, there are some cautions, especially for older people. Drugs are cleared from their bodies more slowly, so they may need lower doses. In addition, older people often take more drugs for other conditions. These drugs may interact with antidepressants. And antidepressants that cause sedation may make older people more prone to falls.

Medication choice depends on your symptoms and your personal or family history of depression. Here are some types of antidepressants:

Selective serotonin reuptake inhibitors (SSRIs)

Selective serotonin reuptake inhibitors, such as fluoxetine (Prozac), paroxetine (Paxil) and sertraline (Zoloft), have become the first-line treatment for depression because they have fewer serious side effects. They seem to work by increasing the availability of the neurotransmitter serotonin in your brain. Other new drugs similar to SSRIs include serotonin and norepinephrine reuptake inhibitors (SNRIs), such as nefazodone (Serzone), trazodone (Desyrel) and venlafaxine (Effexor), and dopamine reuptake inhibitors, such as bupropion (Wellbutrin).

Tricyclic and tetracyclic antidepressants

These medications also affect neurotransmitters, but by a different mechanism than SSRIs. They are often used to treat moderate to severe depression. Among tricyclic antidepressants are amitriptyline (Elavil, Endep), desipramine (Norpramin) and nortriptyline (Aventyl, Pamelor). The newer tetracyclics include maprotiline (Ludiomil) and mirtazapine (Remeron). Tricyclic medications are also used to treat chronic pain, headache syndromes, fibromyalgia and irritable bowel syndrome.

In general, they shouldn't be used if you have glaucoma, benign prostatic hyperplasia (enlarged prostate) or certain types of heart disease.

Monoamine oxidase inhibitors (MAO inhibitors)

These drugs, which include phenelzine (Nardil) and tranylcypromine (Parnate), prevent the breakdown of neurotransmitters. The drugs have potentially serious side effects and are rarely used. They're typically prescribed for chronically depressed people who eat or sleep excessively.

Lithium and mood-stabilizing medications

Lithium (Eskalith, Lithobid), valproate (Depakene, Depakote) and carbamazepine (Epitol, Tegretol) are used to treat bipolar depression. They provide relief 50 percent to 80 percent of the time.

Can St. John's wort relieve depression?


Psychotherapy, when combined with drugs, may be helpful for people who have a psychological or social component to their depression. Such components could include stress, previous abuse, bereavement, marital discord or financial worries.

There are several types of psychotherapy. In general, none has proven more effective than another in treating depression. However, within each type, a short-term, goal-oriented approach aimed at helping you deal with a specific issue is most effective.

Prolonged psychotherapy is seldom necessary. The success of therapy is highly dependent on first finding a physician you're comfortable with. Its the relationship that's important, not the particular type of psychotherapy. Physicians may also enlist the aid of other professionals.

For mild to moderate depression, regular contact with your primary-care physician, who can prescribe medications, monitor other medical conditions and offer support and encouragement, may be all that's needed.

For people with severe depression, its generally better to begin treatment with medications, followed by psychotherapy. Specialized and supervised group therapy, such as bereavement groups, stress management classes, marital counseling and family therapy, may also be beneficial.

Electroconvulsive therapy

Despite the images conjured up in most people's minds, electroconvulsive therapy is generally safe and effective. In fact, it's the "gold standard" for treatment of severe depression. In this therapy, you're given a light general anesthesia. A small electrical current is passed through your brain for 1 to 2 seconds. The stimulus causes a controlled seizure. You wake up in 5 to 10 minutes and rest for about half an hour. Most people require 6 to 10 treatments. Experts aren't certain how this therapy relieves symptoms of depression. The seizure may affect levels of neurotransmitters in your brain. The most common side effect is confusion that lasts a few minutes to several hours.

A few people have some memory loss for several weeks. This therapy is usually used for people who haven't responded to medications and for those at high risk for suicide. It may be the only treatment available for severely depressed older people who can't take medications because of heart disease.

Therapy for seasonal affective disorder

People with seasonal affective disorder (SAD) have periods of depression that recur at the same time each year, usually when days are shorter in the fall and winter. Scientists think fewer hours of sunlight may increase levels of melatonin, a brain hormone thought to induce sleep and depress mood. Treatment with a specialized type of bright light, which suppresses production of melatonin, seems to help some people with this disorder.

Lifting the curtain of despair

You don't need to shoulder the heavy weight of depression alone. New medications are generally safe and effective, even for people with severe depression. With proper treatment, youll usually begin to feel better and get back to your normal activities within a few weeks. And continued therapy can help prevent recurring bouts of depression.

Components of Pain

People living with chronic conditions usually experience a cluster of symptoms -- pain and fatigue often lead the list. Pain is perceived differently by different people, and it occurs in several forms.

Organic Pain is the physical pain that is part of your condition, a protective mechanism that tells you something is wrong and alerts you to seek medical intervention. Pain can be acute, with a beginning and an end, or it can be chronic which means that it has no set time limits.

Chronic pain has a never-ending quality that requires special skills and perseverance to transcend. Organic, or physical pain, is affected by all of the other kinds of pain -- mental, emotional, social, and spiritual. Mental Pain reflects your attitude and other thoughts.

Perceptions of mental pain vary greatly among people, depending upon how they learned about pain and suffering when they were young. Jeanne Nasp, who developed juvenile rheumatoid arthritis as an infant, before she could understand pain, describes it this way: My mother knew how to take the pain away. She acknowledged it, she nurtured me, she diverted my attention by telling me stories, she worked me through it. Her loving care countered any bitterness I might have developed.

Now at 37, Jeanne has this attitude: I respect pain, and I have learned discipline and courage. When the pain is gone, I am a free woman, and there isn't anything I can't do! Your mental attitude is a strong component in how your pain affects you. It is reflected in the degree to which you suffer. Consider whether a change in your perception of pain can be a tool for change in your life.

Emotional pain is inextricably related to physical pain. Emotional pain, particularly fear and rage, causes bodily changes that in turn can cause stress. Conversely, emotions such as hope and laughter create an environment for healing.

Social pain is significant too; fatigue and loss of bodily functions can lead to loss of relationships, the loss of affiliation. This, in turn, can bring the suffering of alienation and loneliness.

Spiritual pain is the anguish you feel when life temporarily loses its meaning. It exaggerates your physical pain. It may be helpful to you in your pain management plan to think about the many components of pain and suffering.

The antidote to each is different. The hoped for outcome is comfort, or the release from suffering. Excerpted from "Living Creatively with Chronic Illness" by Eugenie G. Wheeler and Joyce Dace-Lombard; as published by Pathfinder Publishing of California.

Six Simple Steps to Coping with Pain Consider whether your pain is more physical, mental, emotional, social, or spiritual, and nurture accordingly.

Review the Pain-Depression Cycle (pain to fatigue, to loss of function, to loss of self-esteem, to isolation, to depression, to stress, to fear, and back to pain again) and identify where you tend to get stuck.

Assess where and how you can intervene to improve the quality of your life.

Begin to develop a library of articles and books that you can tap for a plan of action. Attend classes and workshops.

Incorporate humor and the release of laughter into your life. Rent videos, attend comedies, follow your favorite cartoonist.

Be ever ready to laugh at yourself. Learn more about a coping strategy that appeals to you: imagery, music, bio-feedback, or meditation.

Develop a plan for applying it. Incorporate both medical treatment and mental strategies into your total pain management plan, thereby giving yourself (and your doctor) the power and responsibility to make effective therapeutic interventions.

Excerpted from "Living Creatively with Chronic Illness" by Eugenie G. Wheeler and Joyce Dace-Lombard; as published by Pathfinder Publishing of California.

Alternative Responses to Suffering

In seeking a way out of suffering, some people use pills, alcohol, or tranquilizers. Others become increasingly passive. None of these attempts provides lasting relief, and they all keep you a victim of your condition.

A better way to start is to ask questions like the ones Leo Buscaglia poses in his book, Personhood. "What is this hurt about?" he asks. "What is there for me to learn from it? What are my alternative responses, besides suffering?"


One alternative response is the use of imagery, which can be extremely effective in helping you live with chronic pain. Imaging gives a sense of mastery as you use fantasy to trigger relaxation. Through relaxation, endorphins, the body's natural tranquilizers, are released. Three people who have developed this skill imaginatively to cope with pain are Marsha, Ken, and Barbara.

Marsha, who suffers from chronic muscle pain, uses a form of imagery called disassociation. Once, while in a grocery checkout line, she was in unbearable pain and felt trapped. She chose a creative and unconventional response. She mentally sent her body outside the store, floating on a puffy white cloud in a blue sky. There she could mentally relax and float, far from pain.

This approach got her through her shopping and home again. Ken, who suffers from rheumatoid arthritis, chooses imagery as a diversion to "take a vacation" from his pain. He sits in his chair, surrounded by the comfort items of a vast music center and many books.

If he's reading, which is a way of diverting his attention, he may stop at some point and fantasize about the next portion of the story. Ken has also created a "Fantasy Farm" in his head, where he is the master technician of all that grows in special temperature-controlled buildings. Ken fantasizes about growing perfect apricots in the winter and other delicacies in this magical place. Ken copes with pain by diverting his attention. He creates a mental environment of perfection.

Barbara, who also suffers from chronic muscle pain, uses imagery as one of many skills to cope with it. Over time, she has developed pain reduction skills that she uses during long work days and while she travels cross-country on her job. As she moved from the acute phase of her condition into a chronic one, Barbara also learned the skills of bio-feedback, deep relaxation, meditation, and imagery.

She allots one hour in the middle of the day to do these exercises even if it means lying on the floor of a plane flying across the Midwest, or closing the door of her office to practice her pain reducing skills. She isn't secretive or embarrassed about her health needs. Rather than locking herself in isolation, she chooses to share her strategies, and finds affiliation with colleagues who have discovered their own ways to meditate. Intervening early in the cycle of fear-pain-isolation-depression, she takes control by having a plan.

Pain Investigation

An approach that works especially well when pain is intense involves investigating it. This means opening yourself to the pain, leaning into it, softening around it, and allowing yourself to move beyond the anticipated fearful experience. This approach, too, involves using your imagination.

Sense of Humor

A sense of humor can also serve as an antidote to suffering. Arthur Schopenhaur, the German philosopher, describes humor as the only divine quality of man. The word humor derives from the Latin "umor," meaning fluid, liquid -- something that flows. Laughter, that spontaneous, irrepressible response to humor, does flow.

Laughter can shatter pretensions, bestow humility, restore a sense of balance, strengthen compassion, and bring you to an inner "comfort zone." In addition, when you can laugh at yourself, you are reflecting your sense of transcendence. You are saying, "I -- my identity -- is separate from this event."


People seem to know intuitively that music heals.

This wisdom was incorporated in the ancient healing art of the Egyptians, Greeks, and during the Renaissance, when a knowledge of music was required of doctors. You can activate your own inner healer by either matching your present mood to a piece of music, or by countering that mood.

Ken's wife, Maggie, says she can tell what his pain level is by what music he is listening to. Somber tones tell her he is depressed and wants to be left alone; jazzy ones that he feels better. Music has become a non-verbal way for this couple to communicate. If music is of particular interest to you, develop a plan or consult a music therapist who can devise an individualized program that will help you counter pain.


Discover what works for you. Become part of your treatment team. Resources can be found in the spiritual teachings of Judaism, Christianity, and Eastern philosophies. New Age approaches and scientific investigation are other sources of ideas. You can learn from contemporaries such as Norman Cousins, who emphasized the importance of humor in his chronicle of his experience with ankylosing spondylitis in Anatomy of an Illness. While ill, he watched old movie comedies and felt better as a result.

Whatever your chronic condition, there is pain and fatigue to contend with. When you can take charge of managing your pain, whether it is more physical or mental, social or emotional, you will perceive yourself as less a victim, and more a survivor. You will identify less with your disease, and more with the positive aspects of your life.

Excerpted from "Living Creatively with Chronic Illness" by Eugenie G. Wheeler and Joyce Dace-Lombard; as published by Pathfinder Publishing of California.


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