Volume 21 • Issue 4 Ill> Consuming the recommended amount of calcium (1,200-1,500 mg daily) may have a benefit beyond helping to build strong bones. A large study sponsored by the National Institutes of Health and AARP found that men who consumed at least 1,500 mg of dietary calcium daily were 16% less likely to get colon or other digestive cancers than men who consumed 500 mg or less. Women who reported consuming at least 1,300 mg each day were less likely to get any type of cancer. Archives of Internal Medicine, vol. 169, p. 391. ~ Getting enough sleep can help prevent colds, reports a recent study. Investigators interviewed 153 healthy men and women on their sleeping habits and then gave them nasal drops containing a cold virus . The results? Participants who slept seven hours or less were three times more likely to develop a cold than participants who slept eight hours or more. Waking up frequently also increased suscepti· bility to the virus. Archives of Internal Medicine, vol. 169, p. 62. FREE Health Emails! Check our website for free medical info you can't afford to miss! • Heart attack prevention checklist • Preventing diabetic retinopathy • New options for treating fibromyalgia www.JohnsHopkinsHealthAlerts.com For the Health News You Need June 2009 "Shock" Therapy for Depression Survives Controversy, Offers Hope Popular scare stories have saddled electroconvulsive therapy (ECT) with a bad reputation. Perhaps most famously, the 1975 movie One Flew Over the Cuckoo's Nest portrays "shock" treatment as a violent method of psychiatric control. It is true that, decades ago, ECT practices were crude and injured some patients. But you may be surprised to learn that, today, ECT is far and away the most effective treatment available for severe depression and frequently works when medication does not. It is also safe and relatively painless. That is why each year, an estimated 100,000 patients in the United States turn to ECT for help . How IT WORKS During therapy, doctors use electric currents to provoke a seizure, which appears to rejuvenate the brain. Scientists still aren't sure why it works, but the process has been likened to rebooting a computer or even hitting a malfunctioning machine to make it work. The seizures affect a variety of nerve cells and hormones and also alter brainwave speed for weeks after treatment; ECT may derive its efficacy from a combination of these changes. psychotic depression characterized by paranoia and delusional thoughts. Moreover, it serves as an emergency measure for people contemplating suicide or who have stopped taking care of themselves, regardless of whether they have tried medication. In these circumstances, time is of the essence, and while finding the right antidepressant and tailoring its dosage can take weeks or even months, ECT usually starts relieving depression within three weeks. An extensive body of research indicates that roughly 85% of severely depressed patients go into remission after ECT (compared with 40-70% of patients who try antidepressants). This is despite the fact that patients on ECT are typically the most difficult to treat. Seniors in particular may benefit from ECT, and in fact, the majority of ECT patients at Johns Hopkins are over 60. Many older patients who have other chronic conditions opt for this therapy because they don't want to pile more medications onto their daily regimen (drug interactions may be a concern). Others try ECT after struggling with side effects from depression drugs. In a 1999 study from The Americontinued on next page C ON T ENTS WHO CAN BENEFIT When hypertension is resistant 3 Doctors typically recommend ECT for people with severe depression who have not responded to psychotherapy and several different antidepressants . ECT can also treat bipolar disorder and Surgical treatments for glaucoma 4 Recognizing thyroid disorders 6 Adhesions after colon surgery Will walking prevent dementia? 8 ~ HEALTH AFTER 50 Johns Hopkins Medicine Baltimore, Maryland MEDICAL EDITOR: Simeon Mlirgolls, M ,D " Ph.D. Professor, Medlclile &. Biological Chemistry EDITORIAL BOARD OF ADVI SORS: Michele F. Bellantoni, M.D. Associate Prof~ssor, Medicine; Medical Dnettor, Johns Hopkins Ba)'VI1IW Care Centef Susan B. Bressier, M .D. The Juha G levy, Ph_D Professor of Ophthalmology H. Ballentine Carter, M.D. Professor, Uroloyy &. Oncology; Director. DiVISion of Adult Ur ology Bllrbara de Lataur, M.D, Distinguished Service Proftl~sor. PhYSical Medicme & Rehabilitation John A. Flvnn, M,O., M.B.A. Professor. Medlcme; Director, Spondyloarthrltls Proyr am Arlene A . Forast iere. M .D . Professor, MedlClfle & Ollcol09Y. Sidney KImmel ComprehensNe Cancer Center H. Franklin Herlong, M.D. Associate Professor, M~ i Clne &. OloestlVe Disease, Johns Hopkins Bayview Medical Center Bruce Perler, M,D.. M,B.A. The Julius H. Jacobson II Prolessor of Surgery; Chlel, DIVISion of Vascula r Surgery; Director, Vascular NOninvas IVe laboratory Peter Rabln s, M,D.. M.P.H. ProfeSSO(, P~yc hiatry & Healtfl POliCY, Director, DMslOO 01 Genamc Psycll8try & Neuropsyctllstry Edward E, Wallach, M.O, The J Donald Woodruff Plole&sor of G)'f1acology, Department Ilf Gynecology & Dbstetncs James L W"lu, M.D. The M.J CudahyPlofesso r of Cardiology: Director, Ca rdiology Fellowship and Training Program, Associate Dean, Admlsslons Dalal Haldeman Vlc a President. MarutJn!! & CommunicatIOns Joann Rodgers Dlrectol, Medili Re lations & Public Affalrr. Customer Service: Subscription Dept. 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The Johns Hopkins Medical Letter: H88lth After 50 IISSN 1042-1882) Is pu blished monthly by Un iversity Health Publishing, a division of MedlZme LlC, Stuart J ordan Publisher & Managing Dll'Gc\or Thoma s Dickey Editor Tim Jeffs Art Dlreclor Michael Brady Semor Wme r Kate Brackney As<:;oclate Editor Nicole Falcone Ed ltollal ASSistant Ll:!slie Maltese· McGili Cop;, Editor Wilma Garcia AsSOCiate Consumer Marketing DlreClor Founding Publisher & Edrtor,I989-2!Xli. RGdneyM Fnedmarr MediZine llC Traver Hutchins Chie f Exec utIve Offi cer Michael Cu nn lon Pre sident Ingrid Swan Vice Pre Sident & Gene ral Mana ge r Usa Cohen Chief FInanCial Officer Ci 2009 Med iZine LlC All righ ts reserved. j This newsletter Is not intended to provide advice on personal medical matters or to substitute for consultation with a physician. 2 June 2009 continued from previous page can Journal of Psychiatry, researchers evaluated the effects of ECT on 268 patients with major depression; 73% of participants ages 60- 74 responded to treatment, compared with 67% of participants age 75 and older and 54% of participants under age 60. In a more recent study of 253 people with major depression, researchers from the Mayo Clinic found that 90% of patients ages 46-85 went into remission after ECT, compared with 70% of patients ages 18-45. In this study, older patients were more likely to have psychotic depression, which seemed to respond particularly well to ECT. WHAT TO EXPECT If you opt for ECT, your psychiatrist will probably recommend a toral of six to 12 treatments, at a rate of three each week. The cost (about $800-1,000 per session) is covered by Medicare in most circumstances. According to guidelines from the American Psychiatric Association, ECT must be voluntary, and a doctor, anesthesiologist, and nurse must be present for each session. Your doctor w ill pass a carefully controlled electrical current through your brain to induce a 30- to 60-second seizure. Anesthesia keeps you unconscious, and muscle relaxants prevent your body from shaking. Patients usually awaken about five minutes afterward. Many feel confused for up to 45 minutes, and some people experience headaches or muscle stiffness. If you are treated at an outpatient center, a companio n must drive you home and stay until you fall asleep to help prevent confusion-related accidents, like falls. ECT may provoke dramatic initial improvements but does not permanently cure depression. The disord er can return within months (particularly if ECT sessions are stopped early, before symptoms lift completely). Thus, an antidepressant is almost always recommended afterward to head off rel apse. If a medication has not wo rked for you in the past or caused side effects, YOut psychiatrist may prescribe a different one. Keep in mind tha t even if no antidepressant could help you before, after ECT improves your depression, you may respond to antid epressants. Some people also cho ose once -a-month maintenance ECT, which can complement or substitute for depression medication. continued on page 7 Special Considerations for Chronic Conditions A s with any medical procedure, to get the safest and most effective ECl, find a center that ro utinely administers the therapy. A physician must make sure you're healthy enough for anesthesia; if you are, request an experienced anesthesiologi st. Certain chronic conditions require extra precautions: • Since it's necessary to fast for 12 hours before treatment, people w ith diabetes may have to adjust their i nsulin doses. • Eel is generally safer than depression drugs for people with cardiovascular disease, but because blood pressure rises for up to 20 m i nutes during treatment sessions, patients with hypertension r other cardiovascular conditions, or glaucoma (which can be caused by elevated pressure in the eye) should consult their doctor before starting Eel to make sure these conditions are well controlled~ __ L • Before treatment, suspend use of sleeping medications, which compound delirium . Your doctor may also recommend tapering off depression drugs temporarily . • Temporary memory side effects are a particular risk for people who have dementia, so before treatment, it is essential to make sure that severe emotional symptoms in elderly patients are not due to Alzheimer's disease, which ca n mimic depression. People with dementia usually undergo Eel only when th eir depressi ve symptom s are life threatening. - - -- - - - The Johns Hopkins Medical Letter continued from previous page to chest pain or even a heart attack." If you have a healthy heart and perform well on an exercise stress test, a higher starting dosage may be app ropriate, he adds. It is important to be sure the dosage is correct. To do this, your doctor will measure blood levels of T4 and TSH for about six weeks after you have started the medication. Too high a dosage can cause heart problems and can cause or worsen osteoporosis in older women. Be consistent with the version of thyroxine you ta ke; different formulations vary enough to affect treatment results. Ask your pharmacist to give you the same brand-name or generic product each time your prescription is filled. Also, some medications and supplements, like calcium or iron pills, interfere with the absorption of thyroxine from the GI tract. If you use these supplements, be sure to take them at least four hours apart from yo ur thyroid medication. ECT (continued from page 2) THE IMPACT ON MEMORY ECT is safe enough to be used by people who h ave pacemakers, the very elderly, and even pregnant women. During treatment, the most common s id e effects are temporary learning problems and short-term memory loss, but these u sually resolve within weeks of treatment. Some patients, particularly seniors, permanently forget events that occurred around and during the period of treatment, but whether ECT is entirely responsible is hotly debated. Memory loss may be due in some part to depression itself, which harms cognition. (Also, patients who are on the lookout for side effects may worry about forgetfulness that is actually just a natural byproduct of aging.) Rest assured ECT does not damage t h e brain. And memory loss directly linked to treatment has been curtailed Hyperthyroidism: Thyroid On Overdrive Hyperthyroidism is much less common than hypothy roidism but also can lead to osteoporosis and heart problems. The condition may be mista ken for some- thing else, so if you have symptoms, it's a good idea to get your thyroid hormone levels checked. Symptoms • Weight loss • Anxiety • Hand tremors • Muscle weakness • Trouble sleeping • Irregular heartbeat Treatments • Radioactive iodine, the most common treatment destroys the thyroid gland. • Beta-blockers (blood pressure drugs) may serve as a short-term solution to control symptoms; they stop the bod y from reacting to the overpro- duction of thyroid hormones. SHOULD YOU BE TESTED? Medical opinions vary with regard to how often people should be tested for thyroid disorders, says Dr. Margolis. But as you grow older, it is important to be aware of any changes or emerging symptoms that may signal a problem in recent years by applying electrodes unilaterally (to just one side of the head) as opposed to bilaterally and by using brief pu lses of electricity instead of a continuous current, In many treatment centers , bilateral ECT is now reserved for people who do not respond to unilateral treatment. (Some doctors still question these innovations, but a growing body of research has converted most.) For people who experience confusion that persists fo r more than a day, spreadin g o ut sessions to just two a week can h elp. Once therapy starts, your doctor should regularly monitor your memory and cognitive function, • Antithyroid drugs, which include methimazole (TapalOle) or propylthiouracil (PTU), slow production of thyroid hormones. They may take a few months to kick in and are typi- cally prescribed for up to two years. • Partial surgical removal aft he thyroid gland is a final option. with your thyroid. Talk to your doctor about whether to have your th yroid levels checked, especially if you have a family history of thyroid disorders. Some doctors routinely screen their patients fo r thyroid disease every year, D A Brief History of ECT 1930s: After doctors notice that seizures caused by injected insulin improve mental illness, Italian psychiatrist Ugo Carletti uses electrodes to induce a seizure in a mechanic whose schizophrenia subsequently resolves. 19405: Docto rs experiment with ECT for a variety of illnesses; it appears most effective for depression, but some seizures are violent enough to break bones. 1950s: Anesthesia and muscle relaxants reduce these effects, 1975: The movie One Flew Over the Cuckoo's Nest depicts actor Jack Nicholson grimacing during involuntary shock therapy. This is one of many books and movies that decry ECT and fuel an antiTHE BOITOM LINE ECT has survived tremendous controversy oyer the years because it works, For people battling severe depression who have run out of other options, this treatment has been proven to help. fJ psychiatry movement. 1980s: As evidence-based medicine expands, experts reexamine data on ECT and affirm that it is highly effective for several severe psychiatric conditions, June 2009 7