So, I get asked this question all the time.  If I start an anti-depressant pill, will I have to take it forever?  Is it addicting? Anti-depressants have helped millions of people with the debilitating symptoms of depression.  However, long term use of anti-depressants has been increasing significantly.  Overall 35 million people in the U.S. are on antidepressants.  15.5 million of Americans have been taking these medications for depression for at least five years.  This number has tripled since 2000. 

Some people have no problem stopping the medications without any issues.  However, a large percentage of patients (about 75%) have significant withdrawal symptoms.  These symptoms consist of dizziness, confusion and fatigue.  Anti-depressants were never considered an addictive medication like opiates.  Because they are so effective at treating the symptoms of depression, withdrawal symptoms and the inability to discontinue were not well studied.  Most studies really explored use for a couple of months, not years.  However, today there are millions of patients that have been on these medications for years and we have very little data about the effects of taking these medications for so long. 

So, who cares and why is this an issue?  If it makes you feel better, you should just stay on it right?  Anti-depressants are not harmless and have lots of side effects.  They can cause increased appetite, weight gain, erectile dysfunction, loss of sexual desire, insomnia, dry mouth, fatigue, drowsiness, constipation just to name a few.  There is also concern that instead of developing good coping skills for common life issues like death in the family, financial hardship, relationship issues, we are resorting to popping pills.  While there are lots of patients that have legitimate psychiatric issues that require them to be on medication to prevent them from harming themselves, milder forms of depression, such as life circumstances like a death in the family, can often be solved with counseling and developing better coping mechanisms. 

So, what can be done to help patients transition off anti-depressants better?  First, we need more studies that explore long term effects of different classes of anti-depressants.  This will allow us to counsel patients more carefully about withdrawal symptoms prior to starting the medication.   Second, as providers we need to be more careful about prescribing antidepressants and encouraging our patients with milder symptoms to seek other options first.  Third, for patient that have had bad experiences with withdrawal symptoms, there are certain antidepressants with a longer half-life that have fewer symptoms.  It may be prudent to switch them to one of those medications or start them on one of those it they need to reinitiate antidepressants.  Fourth, encouraging micro tapering over 9 months to a year rather than quicker tapering may help prevent the severity of withdrawal symptoms for some. 

Hopefully, you won't find yourself in a position to need these medications, but if you do, be sure to discuss all possible options with you doctor.  Also, and even more importantly, be sure to speak with your doctor before stopping your current medications or changing your own dose.  Everyone goes through challenging circumstances in his or her life, but only you know if your current situation is beyond your abilities to get through.  In those cases, seeking help isn't a sign of weakness; it's a sign that you're strong enough to do whatever it takes to get through your challenges.

​Dr. Pam

I’ve often heard people joke about “being addicted” to sugar, but as it turns out, sugar addiction may not be a laughing matter.  Believe it or not, the same reward pathways in the brain the reinforce drug and nicotine use also reinforce sugar use.  Dopamine (essentially a chemical in the brain the makes you feel good) causes us to feel both withdrawal from and cravings for sugar.  The bottom line is withdrawal+craving=addiction.

As Americans, we consume roughly the equivalent of 65 lbs of sugar per year.  That’s a lot, right?  To put it in perspective, even the suggested amount of no more than 9 teaspoons of added sugar per day for men and only 6 per day for women add up to 29 lbs and 19 lbs, respectively.  Instead we consume nearly 20 teaspoons per day, more than double the recommended daily amount!

So, what’s the problem with some sugar?  Obviously, most people are aware of the negative effects on heart health, blood pressure, cholesterol, and rotten teeth, not to mention risk of diabetes and obesity, but that’s really only the tip of the iceberg.  Cancer cells thrive on sugar, and there’s probably also a link between asthma and sugar intake.  Also, excess sugar intake can inhibit the ability to get a good night’s sleep and even predispose to depression and dementia.  Lastly, if the above reasons aren’t good enough to limit sugar intake, excess sugar consumption makes you look older faster, aging you nearly 5 years faster per 20 oz soda per day.  You might as well be smoking for all of the harm it does to your face.

Good thing I really don’t add sugar to my food, right?  Unfortunately, roughly ¾ of packaged food contains added sugar, and the companies don’t have to let you know until 2020.  Not only that, but many packaged foods marketed as “healthy” are actually some of the biggest culprits.  Gluten-free foods typically have more sugar, salt, fat and saturated fat as well as less protein and fiber than their gluten-containing counterparts.  Not to mention, these products are typically much more expensive.  Other “healthy” products that often contain high amounts of added sugar include smoothies, trail mix, flavored yogurts, oatmeal and salad dressing.  Even juices labeled 100% juice often have very high sugar concentrations.
Trading in soda for energy drinks?  On average, energy drinks contain about 30 grams of sugar.  Sports drinks can have as many as 40 grams, and flavored coffee drinks can clock in at nearly 50 grams.  Just one of these per day can push you well past the recommended 24-36 grams per day.

Ready to make a change?  Often the first, and simplest, step is limiting sugary drinks.  Focus on increasing water, unsweetened tea, unsweetened coffee, and did I mention water intake?  Not only will this reduce your intake of added sugar, but being well-hydrated also increases satiety (fullness) thereby decreasing cravings.  Next, be sure to check out nutrition labels.  In addition to sugar levels, scan ingredients for other sweeteners like honey, anything named syrup, and anything ending in -ose (dextrose, glucose, maltose, fructose, etc.)  Finally, use whole fresh ingredients whenever possible so that you get to be in charge of the flavoring/seasoning process.

Good luck kicking that nasty sugar habit!

Dr. Nick

So, can laughing gas or nitrous oxide be used for labor pain?  Is it better than an epidural?  Does It work?  I get asked these questions all the time.  For most of us, our only experience with nitrous oxide is in the dentist’s chair.  If it works so well for dental procedures, can it work for labor?

Most expectant moms want some form of pain relief during labor.  However, some are really concerned about the lack of control and ability to move that comes with an epidural.  This is a valid concern.  Before epidurals, nitrous was used in the US and is still used in the UK, Australia, and Canada. 

So how does nitrous oxide work?  Nitrous oxide is a clear colorless gas.  It enters the blood by diffusion and is not metabolized by the body.  It is then eliminated by diffusion out of the lungs and therefore has its effect for roughly two minutes for on and offset.  This means when you inhale it, you will only feel the effects for about two minutes!  Nitrous oxide provides some pain relief but is mostly an anxiolytic (helps relieve anxiety).  It makes people feel euphoric and relaxed (You want to drill on my teeth, go for it, because I don’t care!).  This happy feeling is why it is called “laughing gas”.  It is usually administered with oxygen because there is a risk of death from lack of oxygen when used alone.   Side effects of nitrous include nausea, vomiting, headache, increased sleepiness and/or excessive sweating or shivering. 

So, what are the advantages of using nitrous to help control labor pain?  As the patient, you have a lot of control over when to use it (mask on, mask off).  It’s a lot cheaper than an epidural because it does not require the expertise of an anesthesiologist or a nurse anesthetist.  Anyone can show you how to breathe through the mask.  This may be why it is used so routinely in countries with socialized medicine.  It has a rapid onset of action and is easily reversible.   Lastly, (and possibly most importantly) it might make your doctor's jokes funny :)

So, what are the disadvantages of using nitrous to help control labor pain?

First of all, the effects of nitrous only last 2 minutes!  Can you imagine being in labor for 20 + hours and having to replace that mask every 2 minutes.  In addition, your caretakers would continuously be worried about your oxygen saturation.

Second, nitrous readily crosses the placenta and can have anesthetic effects on the fetus.  One of the main reasons so few labor and delivery wards offer nitrous as an option is because they need to have special equipment that can mix nitrous and oxygen.   The percent of nitrous you would receive at a dentist’s office is much higher than the nitrous you would receive in labor, hence it would be less effective.  If you received the same amount of nitrous in labor as you did in the dentist office this could easily cause hypoxia (oxygen level is too low for safety) in mom.  This could then easily cause fetal and newborn hypoxia, which is one of the most common causes of operative vaginal delivery or cesarean section. 

Nitrous is more sedating than an epidural.  It can also cause altered consciousness and impaired memory.  So, while you can move while inhaling nitrous, that may not be the safest option (kind of like we wouldn’t suggest driving drunk as it could cause a crash, walking while receiving nitrous gas could also lead to a crash for mom and baby).  That being said, it may make for some pretty incredible (and YouTube ready) labor and delivery videos!

Lastly, there are no great studies that look into the safety and efficacy of nitrous.  Most of the studies were not performed in the US, and of the ones that were, they did not include enough women or use standardized methods to provide reliable results.  One day nitrous may be a good option for pain control in labor.  However, first we need some better studies, especially ones that look into long term effects on the fetus, before offering it as a safe option for pain control.   

Dr. Pam