Author Archives: drhansdreyer

DIABETES, DEPRESSION AND STRESS

Depression is not generally listed as a complication of diabetes. However, it can be one of the most common and dangerous complications. The rate of depression in diabetics is much higher than in the general population. Diabetics with major depression have a very high rate of recurrent depressive episodes within the following five years. (Lustman et al 1977) A depressed person may not have the energy or motivation to maintain good diabetic management. Depression is frequently associated with unhealthy appetite changes. The suicidal diabetic adolescent has constant access to potentially lethal doses of insulin.

At this point in time, it is well accepted that psychological factors and psychiatric conditions can affect the course of medical illnesses. There is some suggestion that the stress of depression itself may lead to hyperglycemia in diabetics. The interaction between cardiovascular disorders (such as heart attack and high blood pressure) and depression has been extensively studied. Anxiety and depression can also affect other conditions including irritable bowel syndrome, headache and skin diseases. Treatment of anxiety and depression may lead to a better medical prognosis and well as a better quality of life.

For over three hundred years, physicians have suspected an interaction between the emotions and the course of diabetes mellitus. Studies have examined whether stressful events or psychiatric illness might precipitate either Type I (insulin-dependent) or Type II (Non-insulin dependent) diabetes. So far, study results are not conclusive.

Now that we have more accurate methods of measuring glucose control, it has become easier to measure both short-term and long-term effects of emotional factors on blood glucose level. One study found that children judged to have a “Type A” personality structure had an increased blood sugar elevation in response to stress. Children with a calmer disposition had a smaller glucose rise when stressed. (Stabler et al. 1987) A 1997 study suggested that Type I patients with a history of a psychiatric illness might be at increased risk for developing diabetic retinopathy. Those patients with a psychiatric history were found to have a higher average glycosylated hemoglobin. (a measure of long term diabetic control) (Cohen et al. 1997) Children whose relatives made more critical comments had significantly poorer glucose control. Interestingly enough, emotional overinvolvement between family members was not correlated with poor diabetic control. (Koenigsberg et al. 1993) Diabetic adolescents had a higher incidence of suicidal ideation than expected. Those with suicidal ideation took poorer care of themselves. Not living in a two-parent home was associated with poorer long-term diabetes control. (Goldston, et al. 1997)

Recent studies have suggested that effective treatment of depression can improve diabetic control. In a study by Lustman and colleagues, glucose levels were shown to improve as depression lifted. The better the improvement, the better the diabetic control. (Lustman et al. 1997a)

Being diagnosed with diabetes is a major life stress. It requires a large number of physical and mental accommodations. The individual must learn about a complex system of dietary and medical interventions. Lifestyle, work, and school schedules may have to be altered. This can consume a lot of energy for both the individual and his or her family. Just as important, are the psychological adjustments. One must adjust to a new view of oneself. For those who liked to see themselves as invincible, this may be particularly difficult.

Many newly diagnosed diabetics go through the typical stages of mourning. These are denial, anger, depression and acceptance.

Denial: This can be one of the more dangerous stages of the grief process. It may not occur only once. Many individuals cycle back to this phase several times. The honeymoon phase, associated with early Type I diabetes, may reinforce denial. Denial is a common stance for adolescent diabetics.

Anger: It really does seem unfair. The type II diabetic, trying to lose weight, may envy heavier people who seem to enjoy good health. One might erupt at someone who innocently offers a desert. Unfortunately, anger can drastically affect glucose levels.

Depression: Mild depressive feelings are a normal part of grieving and adaptation. As long as they are not pervasive or prolonged, they may not be harmful. However, when the depression lasts a long time, becomes severe or interferes with diabetic management, one should seek prompt treatment.

Acceptance: Individuals achieve different degrees of acceptance and inner peace. Some will need to experience the denial, anger and depression several times as they move through different phases of life and different stages of diabetes. Some people move through a chronic disease to a state of much greater self-knowledge. They may actually say that the diabetes was, in part, a blessing. Through their close attention to diet and exercise, and their close monitoring of stress levels, they have arrived at a deeper understanding of themselves and their relations to others. They realize that for all human beings, life is vulnerable and precious.

Often, individuals with depression do not realize that they are depressed. It is easy to attribute the symptoms of depression to the diabetes. This is particularly difficult since depressed diabetics may have poorer glucose control. Sometimes a spouse or close friend can give good feedback. However, medical professionals or mental health clinicians may be the best ones to determine what is the diabetes and what is due to depression. A psychiatrist has had medical training before specializing in mental health. He or she can sort out the diagnosis, communicate with your regular doctor and help coordinate the treatment of the depression with treatment of the diabetes.

Symptoms of Depression: These are based on the Diagnostic and Statistical Manual of the American Psychiatric Association, 4th Edition. (DSM-4)

  • Depressed mood for most of the day
  • Decreased pleasure in normal activities
  • Difficulty sleeping or significantly increased need to sleep
  • Weight loss or weight gain.
  • Feelings of guilt or worthlessness
  • Low energy level
  • Difficulty making decisions of concentrating
  • Suicidal thoughts
  • Treatment of Depression:

The most important starting point is an accurate diagnosis. There have been major advances in the treatment of depression. There are specific medications and specific psychotherapy techniques that have been shown to help depression. Often individuals do well with a combination of antidepressant treatment and psychotherapy. Be sure that your clinician is willing to take the time to communicate with your diabetes team. Ideally, the mental health clinician should be familiar with your type of diabetes.

Antidepressants: Today, we have a much wider variety of antidepressant medications than were available fifteen years ago. Because we have more medication choices, we can often minimize annoying side effects. The older tricyclic antidepressants can increase glucose levels in non-depressed diabetics. However, when depressed diabetics take them, diabetic control improves. (Lustman et al. 1996) Selective Serotonin Reuptake Inhibitors (SSRIs such as Prozac and Zoloft) are easier to administer and have fewer side effects, so they are more often used as the first line antidepressants. Sometimes they can cause decreased sexual desire. This may be a sensitive issue for some diabetics, especially those who have some sexual difficulty due to their diabetes. This is not a reason to avoid treatment. Keep an open dialogue with your psychiatrist. If the medication does affect sexual functioning, dose adjustment or a switch to another type of antidepressant can usually take care of the problem. Often, treatment of the depression can result in much better sexual functioning. Other types of antidepressants, such as Bupropion (Wellbutrin) or Venlafaxine (Effexor) add to our treatment options. Some people respond to the first medication. Other people may have to try several medications before they hit upon the right one.

Psychotherapy: Recently, researchers have made an effort to do good psychotherapy outcome studies. It turns out that several forms of psychotherapy really do work better than simple “tincture of time.” Cognitive psychotherapy is one of the methods that has demonstrated good results for depression. In this type of therapy, the individual identifies thought patterns associated with a depressive, hopeless outlook. Frequently these thought patterns are based on erroneously assumptions about self and others. The therapist helps the patient monitor such thoughts and to replace them with more effective positive ways of thinking. Cognitive therapy can also be helpful in non-depressed individuals who are having trouble with their diabetic management.

Anxiety and stress can also cause large jumps in blood glucose levels. Panic attacks may resemble hypoglycemic episodes and vice-versa. (When in doubt, treat it as hypoglycemia.) People respond differently to stressful situations. Given the same subjective level of stress, one diabetic may have a different glucose response from another. Because of this, one should monitor blood glucose more frequently during periods of stress. On the positive side, a conscientious diabetic may have a unique barometer of stress unavailable to the general population. There are a number of specific anxiety disorders that are treated differently. As with depression, there are specific medications and therapies that have been shown to work. If anxiety is severe, it is important to identify the specific type, so that one can embark on the right treatment. We will not cover all of these treatments in this article. The following are some general suggestions for dealing with stress and mild to moderate anxiety.

Examine your lifestyle for sources of stress. Are there stressers that can be eliminated?

Learn relaxation techniques. Yoga, meditation, prayer, and hypnosis may help. Make sure that you are getting enough sleep

Exercise. The body’s primitive stress response was designed to prepare the individual to fight or to run away. In our society, we do not usually respond to stress with physical activity. Exercise helps our bodies deal with the physiological results of stress.

Make a list of the things that are worrying you. When you have a concrete list, the problems often look more manageable.

Many people do not like the idea that they may have emotional difficulties. Some find it easier to attribute everything to physical problems or life circumstances. However, good diabetic management is dependent on the development of self-knowledge. Many of the things that other people’s bodies do automatically, diabetics must do consciously. This includes closer monitoring of both one’s blood glucose and one’s emotional state. Ultimately, the years of deliberately imitating natures beautiful and complex feedback systems can lead to a greater understanding and appreciation of body and mind.

References:

1 Lustman, PJ, Griffith, LS, Freedland, KE, Clouse, RE; The course of Major Depression in Diabetics Gen Hosp Psychiatry 1997; 19(2) 138-143.

2 Stabler B, Surwit, RS, Lane JD, et al. Type A Behavior pattern and blood glucose control in diabetic children Psychosomatic Medicine 1987; 49: 313-316.

3 Cohen, ST, Welch, G, Jacobson, AM, et al The Association of Lifetime Psychiatric Illness and Increased Retinopathy in Patients with Type I Diabetes Mellitus Psychosomatics 1997; 38: 98-108.

4 Koenigsberg, HW, Klausner, E, Pelino, D et al. Expressed Emotion and Glucose Control in Insulin-Dependent Diabetes Mellitus American Journal of Psychiatry 1993.

5 Goldston, DB, Kelley, AE, Reboussin, DM Suicidal Ideation and Behavior and Noncompliance with the Medical Regimen among Diabetic Adolescents American Journal of Child and Adolescent Psychiatry 1997.

6. Lustman, PJ, Griffith, LS, Clouse, RE et al. Effects of Nortryptiline on depression and glycemic controlin diabetes: Results of a double-blind, placebo-controlled trial. Psychosomatic Medicine 1997;59(3) 241-250.
By Carol E. Watkins, MD
Northern County Psychiatric Associates

DEFINITION OF DEPRESSION

When discussing depression as a symptom, a feeling of hopelessness is the most often described sensation. Depression is a common psychiatric disorder in the modern world and a growing cause of concern for health agencies worldwide due to the high social and economic costs involved. Symptoms of depression, like the disorder itself, vary in degree of severity, and contribute to mild to severe mood disturbances. Mood disturbances may range from a sudden transitory decrease in motivation and concentration to gloomy moods and irritation, or to severe, chronic prostration.

With treatment, more than 80% of people with depression respond favorably to medications, and the feeling of hopelessness subsides. With treatment, most people are able to resume their normal work and social activities.

Depression may occur at almost any stage of life, from childhood to middle or old age, as a result of a number of different factors that lead to chemical changes in the brain. Traumatic experiences, chronic stress, emotional loss, dysfunctional interpersonal relationships, social isolation, biological changes, aging, and inherited predisposition are common triggers for the symptoms of depression. Depression is classified according to the symptoms displayed and patterns of occurrence. Types of depression include major depressive disorder, bipolar depressive disorder, psychotic depressive disorder, postpartum depression, premenstrual dysphoric disorder, and seasonal disorder. Additional types of depression are included under the label of atypical depressive disorder. Many symptoms overlap among the types of depression, and not all people with depression experience all the symptoms associated with their particular type of the disorder.

Description

Symptoms of a depressive disorder include at least five of the following changes in the individual’s previous characteristics: loss of motivation and inability to feel pleasure; deep chronic sadness or distress; changes in sleep patterns; lack of physical energy (apathy); feelings of hopelessness and worthlessness; difficulty with concentration; overeating or loss of appetite; withdrawal from interpersonal interactions or avoidance of others; death wishes, or belief in his/her own premature death. In children, the first signs of depression may be irritation and loss of concentration, apathy and distractibility during classes, and social withdrawal. Some adults initially complain of constant fatigue, even after long hours of sleep, digestive disorders, headaches, anxiety, recurrent memory lapses, and insomnia or excessive sleeping. An episode of maression may be preceded by a period of dysthymia, a mild but persistent low mood state, usually accompanied by diminished sexual drive, decreased affective response, and loss of interest in normal social activities and hobbies.

Most individuals with depression have difficulty in dealing with the challenges of daily life, and even minor obstacles or difficulties may trigger exaggerated emotional responses. Frustrating situations are frequently met with feelings of despair, dejection, resentment, and worthlessness, with people easily desisting from their goals. People with depression may try to avoid social situations and interpersonal interactions. Some people with depression overeat, while others show a sharp loss of appetite (anorexia). In some individuals, medical treatments for some other existing illness may also cause depression as an adverse reaction. For instance, antihypertensive drugs, steroids, muscle relaxants, anticancer drugs, and opioids, as well as extensive surgery such as a coronary bypass, may lead to depression. Cancer and other degenerative diseases, chronic painful conditions, metabolic diseases or hormonal changes during adolescence, or after childbirth, menopause, or old age may be potential triggers for depression. When the first onset of depression occurs after the age of 60, there is a greater possibility that the causative factor is a cerebrovascular (blood vessels in the brain) degeneration.

Molecular genetics research has recently shown that mutations in a gene coding for a protein that transports serotonin (a neurotransmitter) to neurons may determine how an individual will cope with stressful situations. A two-decade study involving 847 people of both sexes has shown that those who inherited two copies of the long version of the gene 5-HTT have a 17% risk of suffering a major depressive episode due to exposure to four or more identified stressful situations in their lives, whereas those with one long and one short version of the gene had the risk increased to 33%. The study has also shown that individuals with two short copies of the gene have a 43% probability of a major depressive episode when exposed to four or more stressful life events. The shorter version of the gene 5-HTT does not directly causes depression, but offers less protection against the harmful effects of traumatic or stressful situations to the brain. Studies of population genetics have also shown that about 50% of the world’s Caucasian population carry one short and one long version of 5-HTT genes.

Depressive episodes may be associated with additional psychiatric disorders. Neurotic depression is often triggered by one or more adverse life events or traumatic experiences that have historically caused anxiety in the life of the person experiencing depression. For example, loss of social or economical status, chronic failure in living up to the expectations of parents, teachers, or bosses, death of a close relation, work-related competitive pressures, and other stressful situations such as accidents, urban violence, wars, and catastrophic events may lead to a depressive episode. Conversely, anxiety disorders such as panic syndrome, phobias, generalized anxiety, and post-traumatic stress disorder may trigger a major depressive crisis. Psychotic depressive disorders are likely to be associated with other psychiatric diseases or caused by them. Eating disorders such as bulimia, anorexia nervosa, and binge-eating disorder are generally accompanied by depression or may be caused by an existing depressive state. Neurodegenerative diseases such as Alzheimer’s, Huntington’s, and Parkinson’s diseases frequently have depression among their symptoms.

Dysthymia is a mild but chronic depressed state, characterized by melancholic moods, low motivation, poor affective responsiveness, and a tendency for self isolation. A dysthymic state lasting two years or longer is a risk factor for the onset of a major depressive episode. However, many dysthymic individuals experience a chronic low mood state throughout their daily lives. Dysthymia is a frequent occurrence in individuals involved in chronic dysfunctional marriages or unsatisfying work conditions. Such chronic stressful situations alter the brain’s neurochemistry, thus the opportunity arises for symptoms of depression to develop.

Psychotic depression is a particularly serious illness and possesses biological and cognitive (thought) components. Psychotic depression involves disturbances in brain neurochemistry as a consequence of either a congenital (from birth) condition or due to prolonged exposure to stress or abuse during early childhood. Prolonged exposure to severe stress or abuse in the first decade of life induces both neurochemical and structural permanent changes in the developing brain with a direct impact on emotional aspects of personality. Normal patterns of perception and reaction give way to flawed mechanisms in order for a person to cope with chronic fear, abuse, and danger. Perception becomes fear-oriented and conditioned to constantly scan the environment for danger, with the flight-or-fight impulse underlying the individual’s reactions. Delusions, misinterpretation of interpersonal signals, and a pervading feeling of worthlessness may impair the individual’s ability to deal with even minor frustrations or obstacles, precipitating deep and prolonged episodes of depression, often with a high risk of suicide. Hallucinations may also occur, such as hearing voices or experiencing visions, as part of depression with psychosis.

A major depressive disorder (MDD) or clinical depression may consist of a single episode of severe depression requiring treatment or constitute the initial sign of a more complex disorder such as bipolar disorder. MDD may last for several months or even years if untreated and is associated with a high risk of suicide. In bipolar disorder, manic (hyper-excited and busy) periods alternate with deep depressive episodes, and are characterized by abnormal euphoria (an exaggerated feeling of happiness and well-being) and reckless behavior, followed by deep distress and prostration, often requiring hospitalization.

Major episodes of depression may last for one or more years if not treated, leading to a deep physical and emotional prostration. The person with major depression often moves very slowly and reports a sensation of heaviness in the arms and legs, with simple walking requiring an overwhelming effort. Personal hygiene is neglected and the person often desires to stay secluded or in bed for days or weeks. Suicidal thoughts may frequently occupy the mind or become recurrent patterns of thinking. Painful or unsettling memories are often recalled, and contribute to feelings of helplessness.

Atypical depression causes a cyclic behavior, alternating periods of severe and mild depressive states, punctuated by mood swings, hypersensitivity, oversleeping, overeating, with or without intermittent panic attacks. This depressive disorder is more common in women, with the onset usually occurring during adolescence.

Premenstrual dysphoric disorder (PDD) is not premenstrual stress. It is a more severe mood disorder that can cause deep depression or episodes of heightened irritation and aggressiveness, starting one or two weeks before menstruation and usually persisting during the entire period. Premenstrual dysphoric disorder is associated with abnormal changes in levels of hormones that affect brain neurochemistry.

Seasonal affective disorder (SAD) is caused by disturbances in the circadian cycle, a mechanism that controls conversion of serotonin into melatonin in the evening and mid-afternoon, and the conversion of melatonin into serotonin during daytime. Serotonin is the neurotransmitter responsible for sensations of satiety and emotional stability, which is converted at nighttime into melatonin, the hormone that regulates sleep and other functions. Some people are especially susceptible to the decreased exposure to daylight during long winter months and become depressed and irritable. Overeating and oversleeping during the winter season are common signs of seasonal affective disorder, along with irritation and depressed moods. However, as the amount of light increases during the spring and summer seasons, the symptoms disappear.

Postpartum depression is a severe and long-lasting depressive state also associated with abnormal changesmone levels affecting brain neurochemistry. If untreated, postpartum depression may last for months or even years, and is highly disruptive to family and maternal-child relations.

Without treatment, the risk of suicide as a consequence of depression should not be underestimated. Suicide accounts for approximately 15% of deaths among people with significant depression, and half of all suicide attempts in the United States are associated with depression. Persistent and recurrent depressive episodes are important contributors to other diseases alike such as myocardial infarction, hypertension, and other cardiovascular disorders.

Resources

BOOKS

Klein, Donald F., MD. Understanding Depression: A Complete Guide to Its Diagnosis and Treatment. New York: Oxford Press, 1995.

Solomon, Andrew. The Noonday Demon: An Atlas of Depression. New York: Scribners, 2002.

PERIODICALS

Manji, H. K., W. C. Drevets, and D. S. Charney. “The Cellular Neurobiology of Depression.” Nature Medicine (May 2001) 7: 541–546.

Teicher, Martin H. “Wounds That Won’t Heal–The Neurobiology of Child Abuse.” Scientific American (March 2002): 68–75.

OTHER

National Institute of Mental Health: Depression. February 12, 2004 (March 31, 2004).

ORGANIZATIONS

National Institute of Mental Health (NIMH). Office of Communications, 6001 Executive Boulevard, Room 8184, MSC 9663, Bethesda, MD 20892-9663. (301) 443-4513 or (800) 615-NIMH (6464); Fax: (301) 443-4279. nimhinfo@nih.gov.

Sandra Galeotti

Info Supplied by answers.com – depression

DEPRESSION

Depression has been recorded since antiquity. Everybody feels ‘blue’, ‘sad’ or ‘upset’ at times or at some stage in his or her life. Transitory feelings of sadness or discouragement are perfectly normal, especially during particularly difficult times in a person’s life. A person who cannot get over these feelings may suffer from an illness called depression. In modern medicine it is well recognized that depression is an illness caused by an imbalance of neurochemicals in the brain.

How to tell when you are depressed

You can determine whether you are depressed, and also measure the severity of the depression by completing this Questionnaire.

Depression is a serious illness (a medical condition) and should not be confused with other mood conditions such as ordinary grief, burnout or disappointment. The two major indications of a major depression are either:

  • Feeling sad, blue, down in the dumps that lasts two weeks or more;
  • Diminished interest in pleasurable activities, including sex;

If any of the above important symptoms are present, also look for:

  • Significant weight loss or gain;
  • Sleeplessness or excessive sleeping;
  • Slowed body movements or thoughts;
  • Fatigue;
  • Feelings of worthlessness or guilt;
  • Impaired concentration, indecision or forgetfulness; and / or
  • Thoughts of death or suicide.

If you have either one of the first two symptoms, coupled with any four of the last seven, it means that you probably have a major depression. When the symptoms last for at least two weeks or if they include thoughts of suicide you should consult your doctor immediately.

What Causes Depression?

With our current medical knowledge we must assume that no single cause gives rise to depression. In some cases environmental stress, personal circumstances and life events (psychosocial cause) can give rise to a depressive episode. These events may be death of a loved one, physical illness, financial hardship, retirement and retrenchment. Genetic research also supports the theory that there are family links in depression. Ultimately depression has a neurochemical cause which forms the basis of modern medical management.

Treatment for Depression

Depression is one of the most easily treated emotional disorders today. More than 80 % of depressive patients should recover within a few weeks thanks to a variety of effective treatments that have become available.

MEDICAL TREATMENT

Antidepressants are highly effective treatments. The choice of an antidepressant can be made from one of several classes of antidepressants. The most commonly used first line treatment for depression is the Selective Serotonin Reuptake Inhibitors (SSRI’s). Older classes of antidepressants are the Tricyclic Antidepressants and Monoamine Oxidase Inhibitors. Several new classes of antidepressants have been launched in recent years. Electroconvulsive or ‘shock’ therapy (ECT) is considered by many to be a very effective treatment for severe depression. It is used as a last line of treatment when all the other options were not successful.

What can you expect when treated with an antidepressant?

This is a graphic representation of the phases during treatment.

depression_treatment

  • The onset of action of all antidepressants is slow and you can expect at least two weeks of taking the antidepressant medication before you would start feeling better.
  • A full response would only be felt after 6 to 8 weeks.
  • It might be necessary for your doctor to adjust the dose of the medication upwards, or even change the medication to another class should you not have an adequate response.
  • The duration of treatment should be at least 6 months to a year. Some patients might even have to stay on a maintenance dose of medication for a longer time, in some cases even for life.
  • Never stop or change the dose of your medication without consulting your doctor. The patient must be committed to treatment and follow-up with his or her doctor at regular intervals.
  • Antidepressants do not have any addictive properties.
  • Maintenance is probably the most important facet in successful long-term treatment of depression – This can only be done by monitoring the outcome (Results) of treatment of depression on a regular basis.

PSYCHOLOGICAL TREATMENT

Even if medication is working, the value of psychotherapy is important. Therapy is useful during or after medication to repair other problems associated with depression. Psychotherapy involves the verbal interaction between a trained professional (usually a psychologist) and a patient with emotional or behavioural problems. The therapist applies techniques based on established psychological principles to help the patient gain insights about him or herself and thus change his or her maladaptive thoughts, feelings and behaviour. Several forms of this ‘talk treatment’ have proven useful in helping the depressed person. Today it is well recognized that Cognitive-Behavioural Therapy is most effective in dealing with patients with depression.

It is also important that depressed patients take responsibility for their own well being and develop a lifestyle that enhances this well being. The way you live your life, take care of yourself, and feel about yourself affects mood instability and depression. A concerted effort to alleviate stress in your life will go a long way to stabilize your mood. Making positive changes in your lifestyle and changing negative thought patterns to positive ones will also enhance overall well being. Take stock of your life, look at your lifestyle, build positive self-esteem and self-confidence, develop new ways of thinking, use relaxation techniques, change your diet, get regular exercise and join support groups.

How can family and friends help?

The willingness to listen to the negative thoughts and emotions of the depressed person is very important. Family and friends should be able to talk about and recognize feelings of such a person. (The following articles can be used as guidelines in understanding and developing these skills. Emosionele Inteligensie en Aktief Luister ). Family and friends should also be willing to find out more about depression, to learn the symptoms, and to help with treatment. Depression affects functioning, personality, attitude and perspective. People should know what to expect during the early stages of depression and over the long term. Relationships and lives will most probably be disrupted. An afrikaans article is available called ” Hoe om depressielyers te verstaan en te ondersteun “.

Depression usually means a loss of self-esteem or self-confidence. By maintaining as normal a relationship as possible, talking through unwarranted negative thinking, encouraging efforts to improve, and acknowledging that the person is suffering from an illness will improve the depressed person’s self-worth. Telling him “pull your-self together” will only worsen the situation, so do not use this, thinking it is a form of encouragement.

Understanding, care and respect will go a long way in giving the depressed person hope that his condition will eventually improve and his life return to normal.

Never ignore remarks about suicide or death. Report them to the treating doctor.

Self-help books can also be a valuable source of information. Consult your local bookstore or ask for “The Depression Workbook” by Mary Copeland (New Harbinger Publications).

If you have any more questions regarding Depression consult your Doctor.

Support Groups

The Depression and Anxiety Support Group, Johannesburg branch can be reached at Depression and Anxiety Group. Trained counsellors will be able to provide you with counselling and further information and booklets on Depression and Anxiety. They can also put you in touch with a branch in your area.

ANXIETY DISORDERS

Anxiety is a feeling of uneasiness, uncertainty or fear, in response to a real or imagined danger. The body responds to anxiety by releasing a number of “stress” hormones, like adrenaline and cortisol, which have an effect on almost every organ in the body.

What are Anxiety Disorders?

Mild forms of anxiety caused by emotional conflict or life stress are common and unproblematic. Anxiety disorders are a group of conditions in which the feelings of anxiety are not associated with a real or appropriate threat, or are much more intense and long lasting than they should be. People feel frightened and distressed for no apparent reason. This condition can paralyze the individual into inactivity or withdrawal, and can dramatically reduce productivity and significantly diminish a person’s quality of life.

Anxiety disorders are common – nearly 25% of people will experience anxiety disorders at some time in their lives.

Symptoms of Anxiety Disorders

Physical symptoms of anxiety disorders are due to released stress hormones. These may increase blood pressure, cause heart palpitations, chest pain, rapid breathing or breathlessness, sweating, increased muscle tension or irritability. Intestinal blood flow decreases, resulting in nausea or diarrhoea. There is often a decreased sex drive. Children may also have a fear of being away from the family, a refusal to go to school, a fear of strangers, a fear of falling asleep or have recurrent nightmares.

Anxiety disorders

Specific anxiety disorders each have their own particular pattern of symptoms and additional behavioural characteristics.

Depression and Anxiety

The simultaneous occurrence of depression and anxiety is very common. Figures show that between 60% and 90% of people with depression also have symptoms of anxiety. The combination is well recognized and can significantly increase the disability and disruption of normal function suffered by the patient. The anxiety associated with depression can take many forms including panic attacks, obsessive compulsive disorder, post-traumatic stress disorder, social anxiety disorder or a generalized anxiety disorder. Fortunately medication is available which can effectively relieve both depression and anxiety. If symptoms of depression and anxiety are a problem to you, you should discuss them with your doctor. Appropriate treatment can then be prescribed.

Types of Anxiety Disorders

A number of anxiety disorders have been classified. It is common for one anxiety disorder to accompany another anxiety disorder, depression, eating disorders orsubstance abuse.

Panic Disorder

People with panic disorder experience recurrent, unexpected attacks of intense anxiety or terror usually lasting 15 to 30 minutes. These attacks reach peak intensity within seconds and then subside over 5 to 20 minutes. Episodes of terror are accompanied by shortness of breath, rapid heart beat (palpitations), chest pain, hot flushes or chills, nausea, dizziness, abdominal cramps, sweating, shakiness, a choking feeling, feelings of unreality, and fears of dying or going insane. Frequency of attacks can vary widely, and may occur spontaneously or in response to a particular situation.

Phobias

Phobias are persistent, irrational fears of certain objects or situations. These people are so overwhelmed by anxiety that they avoid the feared objects or situations.

Social Phobia/Social Anxiety Disorder is an extreme fear of embarrassment or humiliation in social situations. Social phobias disrupt normal life, interfering with work, social relationships and career choices, especially when they develop during adolescence which they commonly do. People give up many pleasurable and meaningful activities due to these fears.

Agoraphobia is a paralyzing fear of being in places or situations from which a person feels there is no escape or help in case of an attack. These people confine themselves to places in which they feel safe, usually at home, which may have very damaging effects on work and social interaction. It occurs typically together with panic disorder.

Post-Traumatic Stress Disorder (PTSD)

PTSD is an extremely debilitating condition that occurs after exposure to intensely frightening events or experiences in which severe physical harm was threatened or occurred. These events include violent personal assaults such as rape, mugging, disasters, car accidents or military combat. These people repeatedly re-live the ordeal in the form of mental flash backs, nightmares or disturbing thoughts or memories, especially when reminded of the trauma. Symptoms can occur weeks, months or even years after the traumatic event. Symptoms of PTSD include emotional numbness or withdrawal, hopelessness, mood swings, sleep disturbances, depression, irritability, outbursts of anger, feelings of intense guilt, inability to concentrate and an excessive startle response to noise.

Obsessive-Compulsive Disorder (OCD)

People with OCD suffer from repeated, unwanted thoughts or mental images (obsessions) which may result in compulsive behaviour – repetitive, uncontrollable routines performed in the hope of preventing the obsessive thoughts or making them go away. Rituals such as hand washing, counting or checking are common. These rituals, however, provide only temporary relief, and not performing them markedly increases anxiety. OCD is time-consuming, distressing, and can disrupt normal functioning. Read more on OCD…

Generalised Anxiety Disorder (GAD)

People with GAD suffer from an almost constant state of tension and anxiety lasting more than 6 months, without an obvious cause for the anxiety. They usually expect the worst, worrying uncontrollably about money, health, family or work. They are constantly on edge, have difficulty concentrating and typically have physical symptoms such as fatigue, sleep disturbances, trembling, muscle tension, headaches, irritability or hot flushes. They may interpret other people’s intentions or events in a negative way, and therefore feel unsafe in the world. These symptoms cause much distress and impair normal functioning.

What Causes Anxiety Disorders?

Genetic factors, environmental influences, family and childhood experiences and biochemical disorders make certain people more susceptible to stress stimuli than the normal population. Alcohol or substance abuse, other psychological problems like depression and medical conditions like thyroid disease may also play a role.

How are Anxiety Disorders Treated?

Most anxiety disorders respond well to treatment even if two or more anxiety disorders exist simultaneously. An effective approach is a combination of cognitive-behaviour therapy (CBT) and medication.

Drug Therapy will most likely be required for prolonged periods. Anti-anxiety drugs, antidepressants like the selective serotonin-reuptake inhibitors (SSRI’s), tricyclic antidepressants (TCA’s) or Monoamine Oxidase Inhibitors (MAOI’s) may be used. Drug interactions and side effects must always be monitored.

Cognitive-Behavioural Therapy teaches a patient to control their reactions to stress and stimuli, thus reducing the feeling of anxiety. Some therapies teach patients to understand their thinking patterns so they can react differently to the situations that cause them anxiety.

Other

Therapies may use techniques which either gradually or rapidly expose the patient to the anxiety- producing stimulus. Breathing exercises to prevent hyperventilation may also help.

Healthy Lifestyle. Regular exercise, adequate rest, and good nutrition can help reduce the impact of anxiety attacks. Rhythmic aerobic programs may also help to reduce the effects of anxiety.

It is important to remember that these conditions are treatable. Your length of therapy will be based on your personal needs. It is important to continue taking your medication for as long as your doctor advises, even if you are feeling better.

Helping someone with Anxiety Disorder
  • Don’t make assumptions about what the affected person needs – ask him or her.
  • Be predictable – don’t surprise them.
  • Let the person with the disorder set the pace for recovery. Be patient, but don’t allow self-pity to develop.
  • Never criticise or trivialise the condition.
  • Find something positive in every experience. Don’t allow the patient to avoid the anxiety.
  • Encourage the patient to take even a small step forward.

Courtesy of Medical Essentials, Health Information

ANTIDEPRESSANTS & PREGNANCY

October 5, 1999 — A group of U.S. researchers, led by University Hospitals of Cleveland and Case Western Reserve University psychiatrist Katherine L. Wisner, M.D., has compiled a review of new studies on antidepressant use among pregnant women. The review is designed to guide general physicians and obstetricians who treat pregnant women.

The article appears in the October 6,1999 issue of the Journal of the American Medical Association.

The risk for depression among all women of childbearing age is as high as 25 percent for women 25- through 44-years-old. Physicians traditionally have been reluctant to treat major depression with drug therapy in pregnant women because of safety concerns. Therefore, many pregnant women have been forced to choose between the debilitating effects of untreated depression and the unknown effects of antidepressant drug therapy on their pregnancy.

Dr. Wisner and her group (from the American Psychiatric Association’s Committee on Research on Psychiatric Treatments) compiled and evaluated data from four drug-specific studies that were published since 1993. They organized data into five categories of reproductive toxicity: intrauterine fetal death, physical malformations, growth impairment, behavioural abnormalities and neonatal toxicity.

They found that tricyclic antidepressants, fluoxetine (Prozac), and newer selective serotonin reuptake inhibitors (SSRI) did not increase the risk for intrauterine fetal death or major birth defects.

They also found that exposure to tricyclic antidepressants and newer SSRI’s did not increase the risk for growth impairment. However, there were no solid conclusions on the risk that fluoxetine posed on prenatal growth and birth weights of infants. Dr. Wisner explains, “We know that major depression commonly causes women to lose weight anyway. So it is possible that an under treated mood disorder, and not the drug itself, could affect the weight of both mom and baby. We recommend that doctors monitor the weight gain carefully in pregnant women being treated with antidepressants.” Dr. Wisner and her group found reassuring news in that children who were prenatally exposed to tricyclic antidepressants and fluoxetine showed no differences in cognitive function, temperament and general behaviour compared with children who were not exposed. No information about newer SSRI’s and behaviour was available. With this knowledge, Dr. Wisner says physicians should become more comfortable prescribing antidepressants during pregnancy. And that will help women like Rose Kreidler. Two weeks after conceiving her first child, Mrs. Kreidler, of Brook Park, began undergoing a drastic personality change; anxiety attacks, uncontrolled fits of crying and depression, and the inability to sleep and eat to the point of losing weight. After several doctors recommended therapies which didn’t work, and refusing to prescribe antidepressants without a signed waiver, Mrs. Kreidler turned to Dr. Wisner, who prescribed Nortriptyline. “I was concerned about any kind of effect on the fetus and whether it would prohibit breastfeeding, but I was in a terrible emotional state,” says Mrs. Kreidler. “I was concerned that the extreme stress I was under would be more harmful than a drug. If I couldn’t eat, I couldn’t nurture my child. I wanted to carry my child safely, but I couldn’t do anything for her if I couldn’t care for myself.” Mrs. Kreidler’s daughter, Shannon Gabrielle, was born March 26, 1997, perfectly healthy.

The one area of concern, cited by Wisner in her JAMA review, involves withdrawal symptoms in some newborns whose mothers were treated with antidepressants near the end of the pregnancy. The symptoms included transient jerky movements and seizures, rapid heart beat, irritability, feeding difficulties and profuse sweating. The Wisner group recommends that physicians consider tapering to a lower dosage or discontinuing the antidepressants 10 to 14 days before the due date. “When women and their physicians are weighing the benefits versus the risks of drug therapy, they need to look at just how severe the depressive symptoms are,” says Dr. Wisner. “Being suicidal, not eating properly or enough can do more harm to a pregnancy or fetus than an antidepressant. We share the hope that our paper will be a catalyst for improvements in the care of pregnant women with depression.” Note: There’s another class of antidepressants, these are called MAOIs. MAOInhibitors are effective antidepressants but are not safe to use during pregnancy. They may cause birth defects.

HealthyPlace.com Depression

An Overview of The Five Love Languages

By Natalie Nyquist

Can’t you picture it? You return after a few days away from home, and little siblings rush to meet you. One smothers you in hugs and kisses, another jumping up and down asking if you brought her anything. Your father takes your coat and bag upstairs, while mom tells you she missed you and is so glad you are home.

Demonstrated in this common scene are four very different ways of showing love. Understanding your friends’ and family’s love languages can be very helpful as you seek to serve and love them. For me, it has been encouraging to see that, while I have a different love language than everyone else in my family, because I understand what they need, I can serve my dad and spend time with my brothers, therefore showing them love in a way they can easily understand.

If you’ve ever felt “unloved”, it may be because your loved ones are not showing love in a way you easily see, but recognizing the various ways of expressing love is a tremendous help. Christ alone perfectly loves each of us and fulfills every need we have for acceptance and understanding. May our goal be to love as He has.

Words of Affirmation
We all like to hear an encouraging word now and then, but some people need that “I love you” on a daily basis. This doesn’t necessarily mean that they have a low self-esteem, though that is a common misconception. Quite simply, words of endearment and praise are as vital to some people as water and bread. I know that for me, having someone tell me “I love you”, is just about the best thing in the world. 🙂 This is definitely my love language. Hearing encouragement, promises of loyalty, love, and, as the title suggests, affirmation of your character, talents etc. is essential. For those of you who are the “Words of Love” type, you probably give this love more than you receive it. Perhaps you like to talk things through thoroughly and analyze conflicts down to the bone, much to the dismay of the other types, who would just as soon put the situation behind them without spending an hour discussing it. 🙂 Remember if you are feeling unloved, that all the affirmation you can ever need is found in the Bible. There should be more than enough passages of love and loyalty to lift you up. 🙂 The key to showing love to this type of person is to say the assumed, even if you think it is a given. The people who long to hear “I love you,” and “I’m proud of you”, will be amazingly encouraged by those simple words.

Physical Touch
Know an adorable little girl who thrives on cuddles and hugs? Or perhaps you are the type of person who needs that goodnight hug and kiss from your parents. My brothers have learned to endure my hugs, my ruffling their hair. Just by their allowing it they demonstrate their love for me, even as I show them my love. For the people in your life who enjoy that hug or hand squeeze, make a special effort to show them you love them in the way they can most easily recognize. Whether its the three-year-old you teach in Sunday School or an older sibling, physical touch is one of the best ways to show Christ’s love. Remember 1 Cor. 13 and keep your heart and motives pure.

Acts of Service
I need not expound to you the significance and necessity of serving the Body of Christ. This love language is an intense form of that need to serve. I have a friend who is constantly cleaning, writing sweet notes, taking time to teach someone something, reading to a sick child, being a peacemaker, or helping someone with something.

However, to love someone in this way, you must die to you personal wants and selfish ambitions. That is the hard part. But those whose language is acts of service need you to serve them. Doing a chore for someone unasked may be a wonderful opportunity to love.

Gift-Giving
This language could easily be seen as a more fleshly desire. It may seem selfish. But let’s look at it from God’s point of view. He too gives gifts to His children. Why? Out of His amazing love for us. I do not see anything wrong with the occasional thoughtful gift given as a sign of love, in hopes of encouraging another and aiding their spiritual growth. Some people are gifted to show love in this way. Learning to give as God gave – out of love.

Quality Time
All of us enjoy spending time with loved ones, and who doesn’t feel treasured when you have an in-depth discussion, or fun game with your family? For some people this is their primary way of receiving and expressing love. For some it is the hardest to give, as it requires, in some ways, more of yourself than others. It is perhaps easier to hug someone than spend an hour with them, but true Christ-like love is willing to love in all ways.

As nice as it is to know what your language is, more importantly, strive to learn other’s languages, and earnestly love them. Jesus perfectly loved everyone by healing, teaching, touching, caring, but most of all, by that act which we can never truly appreciate; His death is our life, and because of His love we can and must love others.

FIVE LOVE LANGUAGES

by Gary Chapman

Over the years, I’ve counselled thousands of married couples who are seeking to restore the mutual and affirming love they once knew. If you’re here today, then you also must be searching for the way back to love. It’s easier than you think.

Throughout all my counselling, I found that truly connecting with a loved one came down to one simple fact: you need to know and speak his or her love language. A love language is the way we express our devotion and commitment, and it can be learned or changed to touch the hearts of our partners.

Whether you’re a spouse, a parent, or a single, the five love languages are the same:

  • Words of Affirmation
  • Receiving Gifts
  • Quality Time
  • Acts of Service
  • Physical Touch

The books on this web site – five love languages will teach you how to speak the Five Love Languages. You’ll find the one that special person is waiting to hear. I truly hope for your success in renewing your relationship. To love and be loved, what could be more important?

Take the assessment to find out more about your own love languges…

Your friend and helper,
Dr. Gary Chapman

MAINTENANCE THERAPY

Maintenance therapy is important and needed for people suffering from Stress and Stress Related Illnesses:

  • Patients with 3 or more Episodes
  • Patients with 2 or more of the following risk factors:
    • Family history of affective disorders
    • History of frequent episodes
    • Long duration of individual episodes
    • Poor symptom control during continuation of prescription
    • Onset after age 60
    • Double Depression
    • Comorbid anxiety disorders or substance abuse

HIGHLY EFFECTIVE DEPRESSION THERAPY:

    • Maintain a high index of suspicion for the presence of depression
    • Make remission (the absence of residual symptoms) the goal of treatment
    • A combination of treatments with different mechanisms of action may be prescribed when single therapy fails to produce remission
    • After remission is obtained, continue treatment for 4 to 9 months for all patients, and even longer for high risk patients (with 4 or more of the risk factors mentioned above)

Look at the graphical representation of the phases of treatment for major depression.
depression_treatment

WHY SEEK ASSISTANCE

Many people suffer unnecessarily, when help is just a few clicks away. Since you are already visiting our web site, why not make full use of the opportunity. Your disorder does not mean that your life will never be the same again. In fact, in a way it may never be the same again – you could just find that the current situation can be remedied using proper treatment without suffering from adverse effects.

At the end of the day however, you have to make a decision to feel better. Remember that it is not only you who will suffer. Any mental or psycho-physiological disorder affects many people around you, most critically those closest to you – your family. It is vital that they understand how you feel and why you don’t respond in the loving manner you may have done before. Anyone with depression can testify to the following scenario: You desperately try to get attention from your wife / husband / closest companion, but your aggressive or non-responsive actions drive away the very person you want to be in contact with! This is a no-win situation.

What does this mean? Simply that in order for treatment to work, not just the patient, but also preferably the one closest to him / her should be part of the solution. Dr Hans will very likely ask you to bring along your husband / wife / partner / friend for the second consultation. This companion will have to understand what you are going through and as there are very little outward signs that something is wrong, will have to learn to notice seemingly insignificant changes in behaviour that indicate a downward slide towards the bottom.

There are thus three partners involved in the process towards recovery:

  • You, the patient, who will have to cooperate and be positive;
  • Dr Hans, the pastoral counsellor, who has to provide pastoral direction will also direct and refer you for medical assistance; and
  • Your support system : wife / husband / partner / friend, who wants to see you recover.

This will ensure that the no-win described above changes to a win-win situation.

STRESS MANAGEMENT

What is Stress?

As a condition, which affects you, stress is the reaction of the mind and body to a stressor. A stressor is any event or force, which is powerful enough to affect the way you normally function, from a dead- line at work to a dose of flu to the death of a friend. Stressors like these can shake you, both mentally and physically, and the result is the condition known as stress.

What effect does stress have on you?

It’s known as the “fight or flight” syndrome. Back in pre-history, when humans lived much simpler lives, a stressor would probably be something like an encounter with a lion. The body would immediately react by preparing you to either fight the animal or run away as fast as possible. Hormones like adrenaline flood the body, giving the muscles higher tone so they are ready to react quickly. The heart beats faster, filling the muscles with blood from which they can draw energy, you breathe faster to get more oxygen and think faster to help you think your way out of trouble. There are a whole lot of other, similar effects, all of them intended to make as many resources as possible available in a crisis. When the stress response is prolonged, it can have serious consequences, on both your body and your mind.

Stress disorders may be classified as follows:
  • Acute stress disorders occur when a person is exposed to a severe stressor causing intense fear, helplessness or horror and experiences recurrent thoughts or flashback episodes, associated with symptoms of anxiety lasting for up to 1 month after the traumatic event.
  • Post traumatic stress disorder is diagnosed when such exposure to a severe stressor is associated with distressing recollections of the event and severe anxiety, lasting for more than 1 month.
  • Intermittent stress is when a person regularly experiences stressors, leading to episodes of anxiety, and begins to feel that their life is “spinning out of control”.
  • Chronic stress develops when ongoing exposure to anxiety causing stressors over a sustained period of time leads to feelings of hopelessness or worthlessness, and even thoughts of suicide.
How does stress affect the body?
  • Heart and circulation: while your pulse rate gets faster, your blood pressure rises. The blood gets stickier, so that if you are injured, it will clot more easily.
  • Mouth, throat and digestive system: the mouth and throat become dry as fluids are diverted away from places where they’re not essential. The digestive system shuts down – you don’t need to spend energy on digesting food when faced with a lion!
  • The skin: as the blood flow is diverted away from the skin, it becomes cool, clammy and sweaty. Your hair often feels as though it’s standing on end, because the skin tightens.
  • The immune system: the white blood cells are the immune system’s soldiers which fight off infection, so they are sent to parts where you might be injured, like the skin and bone marrow.
  • All of these reactions would not be dangerous if they were only taking place briefly and occasionally. But long-lasting stress can have serious implications:
  • Raised blood pressure over the long-term can lead to heart disease, strokes or kidney failure if it is left untreated. Stickier blood increases the likelihood of a blood clot, which may block arteries and cause a heart attack.
  • Prolonged disruptions of the digestive system can cause unpleasant symptoms like diarrhoea or constipation. Stress is linked to irritable bowel syndrome or spastic colon, which causes bouts of severe pain, and can also lead to episodes of extreme diarrhoea, followed by constipation.
  • Skin conditions like psoriasis, exzcema and acne may be made worse by stress.
  • Chronic stress affects the immune system, making you more vulnerable to developing infections like colds and flu, and even certain cancers.
  • Stress can also disturb your hormonal system. Women may produce smaller amounts of oestrogen – which makes them more vulnerable to heart disease, they can even stop menstruating. Stress is linked to a reduced desire for sex, and men may experience erectile dysfunction (impotence).
  • Since stress tightens up the muscles in preparation for action, it’s obvious that prolonged stress could cause stiffness and spasms.
  • All these physical disturbances may cause a disruption in sleeping patterns.
How does stress affect the mind?

One of the most common problems that stressed people experience is an inability to concentrate and to remember. You may suffer from feelings of panic or fear, you may be more irritable and get angry more often and more easily, you may even suffer from depression, feeling that you are worthless and that life is not worth living.

Good stress and bad stress

Not all stress is bad stress. A certain amount of stress is normal and keeps body and mind functioning. Your feelings about the source of the stress contribute to how well you handle it, so good stress is less likely to have bad consequences. None of us would be very healthy if our lives contained no surprise, delight, shock or demands of any kind!

How do you cope with stress?

For most of us, the most common answer is, very badly. We tend to do all the wrong things under stress: we eat badly, reaching for fast foods loaded with sugar and fat, and forget to take our multi vitamins or chronic medications. We drink too much alcohol in an effort to relax, we smoke and we feel we don’t have the time to exercise. To avoid the dangers of stress, we really need to adopt a strategy that addresses the whole of our lives.

Stress management techniques

Exercise makes the body better able to cope with the physiological effects of stress. It improves circulation, loosens up muscles stiffened by tension and has a profound impact on your mental health – there’s strong evidence that exercise helps to fight off one of the most unpleasant mental effects of stress – depression.

Good nutrition: Your body and mind can’t cope with stress if you aren’t getting the nutrients they need to operate. Try to eat five portions a day of fruit and vegetables. You need a mix of vegetables to get the best nutrition – dark green leafy vegetables, orange-coloured vegetables, which contain lots of anti-oxidants, cruciform vegetables like cauliflower and broccoli, which contain cancer-fighters. It’s actually quite hard to get the nutrition you need from your food these days.

Nutritional supplements

Food loses nutrients as it is harvested, handled and processed. So nutritional supplements will help to keep you well nourished. Choose a good multi-vitamin, and if you are under special stress, top up with extra B-complex vitamins, and a mix of calcium and magnesium. Calcium and magnesium also have a good effect on mental functioning.

Support from others. Devote some of your precious time to nurturing your personal relationships. Spend time with family and friends, and don’t hesitate to get help from a counsellor if you feel the need. Very often, all we need to release a build-up of pressure is a listening ear.

Reduce stress at work. Take a long, hard look at how you operate at work, and change it if necessary. Effective time management is essential. Organise and prioritise! Learn to delegate. Resolve to say ‘No’ if you feel that you are being overburdened. Communication is vital.

Relaxation techniques: As mentioned, stress management embraces a wide range of strategies and actions which address every aspect of our lives and it can be very helpful to incorporate one or more of the following relaxation techniques into your regular activities:

  • Deep breathing
  • Muscle relaxation
  • Massage therapy
Conquer stress – a lifetime commitment

Sometimes it feels as though it’s just too much effort to put into place any of the stress-beating tactics outlined here. But that’s the stress talking! It will be hard to discipline yourself to exercise, to eat properly, to meditate every day or practise one of the other relaxation techniques mentioned, but once you get into a routine, you will find that the effort is more than repaid by the results!

Recommended Reading: “Proverbial Stress Management Busters” by Prof. L. Schlebusch. (Publisher: Human & Rosseau).

Courtesy of Medical Essentials, Health Information