When a drug returns more than a billion dollars in sales, it hits blockbuster status. So, notching up over US$11 billion in 2011 antidepressants are bona fide showstoppers. But these little pills have truly arrived now, starring in their very own Hollywood thriller.

Side Effects, director Steven Soderbergh’s cinematic swan song, charts the gradual unhinging of Emily Taylor (Rooney Mara). Husband Martin (Channing Tatum) has just emerged from a four-year prison stretch for insider trading.

The reunion is joyous, but bleak clouds soon gather and Emily’s world crumbles. This is not Emily’s first taste of psychic anguish. She sought counsel from Dr Victoria Siebert (Catherine Zeta-Jones) after Martin’s initial imprisonment.

Emily is finally pushed to the wall – literally – and lands in an emergency department. Her physical injuries are trivial, but psychiatrist Dr Jonathan Banks (Jude Law) worries Emily is on the low road to nowhere. The upshot is a diagnosis of depression and, you guessed it, the ubiquitous script for antidepressants.

The plot then borrows from almost every chapter in the psychiatric ethics textbook. As the title makes plain, Emily draws the short straw in the side-effect stakes. Parasomnias – unusual behaviour while asleep – are associated with a range of medications, including antidepressants. For Emily, a bout of sleep-capsicum-slicing takes a murderous, if improbable turn, when she puts her kitchen knife to an alternative use.

Enter moral conundrum number one. Is Emily a murderess? If, as seems the case, a crime was committed while asleep, can we adduce the mens rea, or intent necessary to ascribe guilt? Or is Dr Banks culpable here? After all, he persisted with the medication, even though aware of an earlier somnambulist incident. The media gets hold of the story and Banks’ life slowly unravels.

The movie faithfully renders the entrenched role of antidepressants in the United States and, increasingly, the developed world. Emily’s boss mentions her brush with them, as does a friend who even recommends her own brand.

The milieu is one of biological materialism, or the reduction of psychological symptoms to a question of deranged biochemistry. Depression is portrayed as a “flaw in chemistry not character”. In fact, Emily has good reason to be depressed. But in shooting from the hip with drugs, and making a decidedly pedestrian effort to explore life events, Dr Banks is a plausible Dr Everyman.

The spectre of Big Pharma looms large. A lavish lunch, courtesy of a drug company rep, lands Banks a lucrative recruiting role for a new anxiety drug trial. Ministering to a patient with anxiety, the good doctor studiously declares his conflict of interest. But the lure of “free meds” to join the trial is overwhelming, and the research subject is bagged.

The pitfalls of combining therapeutic obligations with the promise of Pharma coin are well described and have been chillingly dissected by bioethicist Carl Elliot. Patients are squeezed in a pharma sandwich, pressured on one side by physicians with big money riding on drug companies, and subtly cajoled on the other by direct-to-consumer advertising of prescription drugs (DTCA).

An antidepressant commercial for Emily’s drug Ablixa delivers the stock formula. Moody music, downcast woman, then a catchy exhortation to “take back your life from depression”. Presto, the rising tones of joy as mother strokes daughter’s hair in a verdant lakeside setting thanks, of course, to Ablixa. In fact, the ad is not only a brilliant replica of DTCA but was, perhaps a little cynically, released as part of the film’s sophisticated marketing.

But the ethics of pharmaceutical advertising is no laughing matter. It’s well known that positive imagery and music can induce favourable attitudes towards a product. Our research team has recently amassed evidence that such evaluative conditioning leads to stronger beliefs about drug effectiveness in DTCA. Despite the potency of imagery and music in DTCA, this content remains largely unregulated by the US Food and Drug Administration.

Serious consideration of the ethics of antidepressant use is, inevitably, set aside by the imperatives of hard business and a crowd-pulling plotline. All is not as it seems, so much of the moral scalp scratching becomes moot.

Don’t get me wrong. Catherine Zeta-Jones is unnerving, if falling short of the bunny-boiling heights of Glenn Close in Fatal Attraction. And Jude Law is a cracking shrink, even if his slide to ignominy could have been more emphatic than a perfunctory two-day growth and faded T-shirt under his designer jacket.

But there’s a nagging dissatisfaction that the ethics of antidepressant use, including the pressures of drug advertising and doctors in the pocket of Big Pharma, are never properly explored. But that, as they say, is Hollywood.

The value of regular physical activity to a person’s well-being is unequivocal. But how much exercise do we need to maintain health, improve fitness or lose weight? And where is the line between healthy and harmful?

To maintain a healthy weight, Australia’s dietary guidelines recommend adults do at least 30 minutes of moderate intensity physical activity – such as brisk walking, social tennis or swimming – on most days. But if we want to lose weight, and don’t cut back on food and drink, we need to do more.

The American College of Sports Medicine agrees adults should get at least 150 minutes of exercise a week, though it explains this might be 20 to 60 minutes of vigorous exercise – which makes you huff and puff, such as jogging, aerobics, football and netball – three days a week.

The College guidelines also prescribe the quantity and and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal and neuromotor (or functional) fitness in healthy adults:

• For flexibility, adults should do stretching exercises at least two days a week, with each stretch being held for ten to 30 seconds, to the point of tightness or slight discomfort
• For resistance training, adults should train each major muscle group two or three days a week
• For cardiovascular fitness, people should gradually increase the time, frequency and intensity of their workout.

The adage that if a little bit of exercise is good for me, then more should be better, still pervades the fitness industry. As does the “no pain, no gain” myth, which came to prominence in the early 1980s via Jane Fonda aerobic workout videos. Fonda would also urge viewers to “feel the burn” and exercise beyond the point of reasonable physical stress. These days the “no pain, no gain” motto is used to show that physical development is the result of training hard.

We often judge the efficacy of our workouts by our level of soreness the next day. This type of pain is called delayed onset muscle soreness or DOMS and occurs a day or two after exercise. It is most frequently felt when you begin a new exercise program, change your routine, or dramatically increase the duration or intensity of your workout. DOMS is a normal response to unusual exertion and is part of the body’s adaptation process that leads to increased strength or endurance as muscle recover and hypertrophy.

But while discomfort is natural if you push yourself, pain is the body’s protective mechanism, warning us to ease the intensity or protect an injured part of the body. Resisting this warning risks damaging tissue and may cause your body to over-compensate with other movements that can aggravate the injury and lengthen healing time. It’s also likely to reduce your motivation to continue exercising.

Pain during exercise can also indicate underlying health problems and should be seen as a signal to stop exercising and seek professional advice:

• Chest pain during exercise is a red flag for potential heart problems
• Exercise-induced bronchospasm (a sudden constriction of the bronchial muscles), even in non-asthmatics, may indicate an underlying respiratory problem
• Joint pain may result from osteoarthritis or indicate meniscal (knee) injury, ligament or tendon microdamage.

If you do find yourself sore after a tough workout or competition, try some low-impact aerobic exercises to maintain your blood flow during warm-down. Other remedies such as massage, ice baths and the RICE (rest, ice, compression, elevation) combination may also ease muscle soreness.

In terms of medication, non-steroidal anti-inflammatory drugs (such as aspirin, ibuprofen) can temporarily help reduce the effects of muscle soreness, though they won’t speed-up healing.

It’s certainly not easy building up your fitness or losing weight but the “no pain, no gain” motto is based less on the science of exercise physiology than on outdated sports psychology; it’s a recipe for injury.

When you feel pain during exercise, stop what you’re doing and take stock of how you’re feeling. If you think you can, try returning to the activity you were doing, but if the pain persists, then stop for good.

There are good reasons why people may want to swap soy with dairy milk. The carbon, water and phosphate footprint of soy milk is a fraction of the latter. But the main reason for the increasing popularity of soy milk seems to be health concerns, such as inflammatory bowel disease and lactose intolerance.

First, let’s look at what these milks are. The milk from a cow (or goat, or sheep) is complete food for the growth and development of a young animal. It contains all the essential amino acids (the protein building blocks that your body is unable to make for itself) as well as a complex mixture of fats, carbohydrates, vitamins and minerals including calcium, phosphate and vitamin B12.

A soy bean is also complete food – for the growth and development of a soy plant seedling. The nutritional needs of plants are obviously quite different from those of animals, and accordingly, the nutritional profile of unadulterated soy milk is very different from that of animal milks.

Fresh soy milk, made from grinding and then straining soaked dried soy beans, has less fat and carbohydrate than animal milks, and only a small amount of calcium. And it’s missing some of the vitamins present in animal milks as well.

The protein content of soy milk is similar to cow’s milk, and all the essential amino acids are present but in smaller amounts than in cow’s milk. Because it’s plant food, soy milk contains small amounts of fibre, and twice as much folate as animal milks.

The contrast between the two products is significantly reduced when comparing the commonly-available commercial brands of soy and cow’s milk. Both types of milk are heat-treated as part of production, to destroy bacteria and enzymes that may be harmful to health or shorten shelf life. They’re also nutritionally similar.

Supermarket soy milk products are mostly made from soy protein isolate powder (rather than ground whole soy beans), reconstituted with water and adjusted with oil and often sugar, to bring the fat and carbohydrate content to levels comparable with full-cream cow’s milk. A similar vitamin and mineral content is achieved by adding vitamins (including B12) and calcium.

Once this is done, the main differences between the products are in the type (rather than the amount) of carbohydrate, protein and fat.

The carbohydrate in cow’s milk is lactose, the milk sugar, which is digested by the enzyme lactase. In most animals (including human ones), the amount of lactase in the intestine naturally decreases after weaning. Once this has happened, milk cannot be digested properly, causing flatulence or diarrhoea.

In humans who continue to consume lactose-rich dairy products throughout their lives, lactase enzymes are maintained in the gut. But some unlucky individuals become lactose intolerant and, for them, soy milk is a useful alternative as it contains no lactose.

For everyone else, though, lactose has some advantages over other sugars because it has a very low glycaemic index. This means that it is released slowly into the blood, avoiding abrupt spikes in blood glucose levels.

Both soy and dairy milk are good sources of protein, with different health advantages. Soy protein appears to have its own protective effect on heart health, possibly due to its content of phytochemicals (beneficial plant substances). Some of these include phytoestrogens, whose weak oestrogen-like action can help soothe hormonal swings during menopause.

Cow’s milk consists of two proteins, casein and whey, both of which are popular among body-builders as effective muscle-building proteins. In controlled diets, dairy foods appear to promote fat loss, possibly due to the effect of their calcium content in conjunction with the dairy proteins and other substances in milk. This effect is not seen when the same nutrients are consumed as supplements.

The fat content is similar in both cow and soy milk, and low fat or “light” varieties are available for both. The type of fat in full-cream cow’s milk is butterfat, high in saturated fat, while soybean oil is mostly polyunsaturated. The fats added to soy milk are usually canola or sunflower oil, again rich in polyunsaturated and monounsaturated fats. This means that soy milk is a source of “good” fats.

The Heart Foundation recommends we avoid saturated fats in order to control our cholesterol levels, but interestingly full-fat dairy foods don’t appear to increase the risk of heart disease in the same way as other sources of saturated fat. This may be due to the protective effect of other complex elements in milk (such as the proteins or minerals) or the unsaturated fats present.

Fresh, raw soy milk and fresh, raw animal milk are very different foods. But in the form usually purchased in the supermarket, there’s little difference in their nutritional profile. So rest assured that if you choose to replace some, or all, of your dairy milk intake with soy milk for environmental reasons, you will not be nutritionally disadvantaged.

9 January 2013, 6.38am AEST

Explainer: what is post-traumatic stress disorder?

People have probably always known about the psychological effects of experiencing life-threatening events such as military combat, natural disasters, or violent assault. Literature through the ages – some of it thousands of years old – provides many vivid portrayals of these internal struggles to recover from horrific experiences.

It was not until 1980, however, that these reactions were formally recognised by the international psychiatric community. The name chosen was post-traumatic stress disorder, or PTSD, and the diagnostic criteria were agreed.

Before discussing the nature and treatment of PTSD, it’s important to emphasise that human beings are generally resilient. Most people exposed to potentially traumatic events recover well with help from family and friends, and don’t develop mental health problems.

For those who don’t recover so well, PTSD is only one possibility, with depression, substance abuse, anxiety, and physical health problems also common. But PTSD is the only condition specifically tied to a traumatic experience.

Symptoms

PTSD is a serious psychiatric disorder characterised by three groups of symptoms:

• Reliving the traumatic event. People with PTSD describe vivid, painful images and terrifying nightmares of their experience.
• Avoidance. People with PTSD try to avoid reminders of what happened. They become emotionally numb and socially isolated to protect themselves from the pain.
• Being constantly tense and jumpy, always on the look-out for signs of danger. PTSD is associated with significant impairment in social and occupational functioning.

Causes and risk factors

The latest Australian National Mental Health Survey reported that over 4% of the population experienced the symptoms of PTSD in the last year.

The incidence of PTSD varies considerably depending on the type of trauma, with sexual assault consistently the highest (around hald of rape victims will develop PTSD). Accidents and natural disasters – events that do not involve human malevolence – tend to be the lowest at around 10%.

About half the people who develop PTSD recover over the first six to twelve months. Unfortunately, in the absence of treatment, the other half are likely to experience chronic problems that may persist for decades.

So why do some people develop these problems and not others? The answer is a combination of what the person was like before the trauma, their experiences at the time, and what has happened since.

In terms of pre-trauma factors, genetic vulnerability plays a part, along with a history of trauma, particularly in childhood, as well as tendencies towards anxiety and depression. Not surprisingly, the more severe the traumatic experience (the higher the life threat or exposure to the suffering of others) the more likely the person will develop PTSD.

The final group of risk factors appear after the event, with the most important being social support: people who have a strong network of friends and family to support them after the experience are less likely to develop PTSD. Other life stressors during this period (such as financial, legal, health, or relationship problems) can also interfere with recovery.

Treatment

We have come a long way in improving treatments for PTSD and now have a large body of research evidence to guide our decisions.

The most effective treatment is trauma-focused psychological therapy. There are a few different forms, including cognitive behavioural therapies (CBT), as well as something called eye movement desensitisation and reprocessing (EMDR). The thing they share in common is providing the survivor with an opportunity to confront the painful memories, and to “work through” the experience in a safe and controlled environment. This therapy is not easy for either the patient or the therapist, but it is very effective in most cases.

Pharmacological treatment can also be useful in PTSD, especially in more complex cases and as an adjunct to trauma-focused psychological therapy. The most effective drugs for PTSD are the new generation anti-depressants – the selective serotonin re-uptake inhibitors or SSRIs. Other drugs can also be useful, depending on the clinical presentation.

The bottom line is that effective treatment is available if the PTSD sufferer can find their way to an experienced clinician.

We’ve come a long way in our understanding of mental health response to trauma in the last couple of decades, but many challenges lie ahead: Can we prevent the development of these problems? How should we respond with whole communities following widespread disaster such as bushfires, floods or terrorism? And can we improve the quality and availability of treatment?

As we address these challenges, we must strive to make sure the best possible care is available to those whose lives have been devastated by the experience of severe trauma.

February 2, 2013

Two ways to stay mentally sharp

Regular physical activity helps keep your heart, lungs, and muscles in shape and can stave off the effects of aging. In much the same way, exercising your brain can help keep your mind sharp and your memory intact. Here are two ways to activate your brain.

Keep busy and engaged

The MacArthur Foundation Study on Successful Aging, a long-term study of aging in America, found that education level was the strongest predictor of mental capacity as people aged. The more education, the more likely an individual was to maintain his or her memory and thinking skills. Other research has shown that people who held jobs that involved complex work, such as speaking to, instructing, or negotiating with others, had a lower risk of memory loss (dementia) than people whose jobs were less intellectually demanding.

It probably isn’t the years of formal education or the type of occupation that benefits memory. Instead, these are likely stand-ins for a lifelong habit of learning and engaging in mentally challenging activities.

Intellectual enrichment and learning stimulate the brain to make more connections. The more connections, the more resilient the brain. That’s how a lifelong habit of learning and engaging in mentally challenging activities—like learning a new language or craft—can help keep the brain in shape.

Stay connected

Establishing and maintaining close ties with others is another way to maintain mental skills and memory. There are several ways that social engagement may do this. Social interaction and mentally engaging activities often go hand in hand (think volunteering or tutoring school kids). Social relationships can also provide support during stressful times, reducing the damaging effects that stress can have on the brain.

Social support can come from relationships with family members, friends, relatives, or caregivers, as well as from a religious community or other organized group.

Meaningful, socially engaging activities may prove especially helpful. In a study conducted with the Baltimore Experience Corps, volunteers were assigned to either a waitlist (control group) or a group that helped elementary school children during class and library time. Early results suggested that participants who remained engaged in the program for many months improved their executive function and memory.

For more on boosting your memory and diagnosing memory problems, buy Improving Memory: Understanding age-related memory loss, a Special Health Report from Harvard Medical School.

Testosterone therapy in women: Myths and misconceptions.

PMID:

23380529

[PubMed – as supplied by publisher]