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Experts say people fail to seek help for depression because they fear being stigmatized (PNI)

By Claudine Chamberlain ABCNEWS.com

With the amount of media attention Prozac gets, you might assume that just about everyone around you is popping the anti-depression pill.

But that's not the case. According to mental health experts, fully two-thirds of the 17.6 million clinically depressed people in the United States don't get any form of treatment for their illness. Of those, an estimated 15 percent commit suicide.

"Depression remains one of the most undertreated and yet easy-to-treat disorders in medicine," says Peter Kramer, clinical professor of psychiatry at Brown University and author of Listening to Prozac. "And that's so rare. Usually things that are easy to treat are treated."

Ads Aim at the Untreated

The depression-treatment gap is one reason Prozac's maker, Eli Lilly, recently launched a multimillion-dollar advertising campaign for the drug. The more people hear about the symptoms of depression, the company reasons, the more likely they'll be to seek help.

That help might come in the form of Prozac—but not necessarily. In addition to plain old talk therapy, there's a wide range of other antidepressants. Often, a combination of medication and psychotherapy turns out to be the most effective treatment for depression.

Tom Ricke, director of communications for the National Depressive and Manic-Depressive Association, says social stigma is the main reason people don't seek medical attention for their depression.

"People feel they should be able to pull themselves up by the bootstraps," he says. "They don't understand that depression is an illness of the brain, not a fault in their character."

Insidious Illness

Kramer offers another explanation: "One of the most frustrating things about depression is how insidious it is," he says. "It comes on slowly and in the end the person is quite paralyzed. It goes unrecognized because it doesn't have the drama of a broken bone."

Everyone feels sadness in reaction to life's blows—the loss of a job, the death of a loved one. But eventually the low-spirited feeling fades. For people suffering from depression, however, the sadness isn't temporary. Feelings of despair, low self-esteem, irritability and general melancholy overcome the person's life to the point that even basic everyday activities become difficult.

That's because their feelings aren't a reaction to a specific event; they're more likely the result of faulty biochemical systems in areas of the brain that control emotions.

Prozac and other antidepressant medications alter those systems in specific ways. Prozac belongs to a family of drugs that staves off depression by enhancing the function of serotonin, a brain chemical associated with feelings of well-being. These medications are often seen as the treatment of choice for mild to moderate cases of depression because they have fewer or less severe side effects than other antidepressant drugs.

Pills Could Help Many Patients

While some people have concerns about treating mental illnesses with chemistry-altering medications, medical experts say pills can provide patients with welcome relief from the constant feelings of darkness and despair. Dr. Robert Hirschfeld, a psychiatrist at the University of Texas Medical Branch in Galveston, estimates that drug treatment would help 75 percent of people who are depressed.

Hirschfeld headed up a panel of experts that studied undertreatment of depression and reported its findings in a January issue of the Journal of the American Medical Association. To joke that everyone is on Prozac these days is "cute," he says, "but it's absolutely not true. There are far too few people on medications for depression."

Like the Valium craze of the 1970s, Prozac may turn out to be this decade's "Mother's Little Helper." But despite the popularity of Prozac and other antidepressants, there's still a lot more helping to be done.

Drugs That Treat Depression

There are three main types of drugs that are used to treat depression, classified according to how they affect the chemical messengers in the brain.

Selective Serotonin Reuptake Inhibitors (SSRIs)

How they work: Enhance the function of the brain chemical serotonin. Main side effect is agitation similar to drinking too much coffee.

Drugs: fluoxetine (Prozac), paroxetine (Paxil) and sertraline (Zoloft)

Tricyclic Antidepressants (TCAs)

How they work: Enhance brain chemicals norepinephrine and serotonin. These drugs have been around longer, and more is known about them. Side effects can include weight gain, lowered blood pressure, heart problems, fatigue and constipation.

Drugs: amitriptyline (Elavil, Endep), clomipramine (Anafranil), desipramine (Norpramin, Pertofrane), doxepin (Adapin, Sinequan), imipramine (Imavate, Janimine, Presamine, Tofranil), nortriptyline (Aventyl, Pamelor), protriptyline (Vivactil) and trimipramine (Surmontil)

Monoamine Oxidase Inhibitors (MAOIs)

How they work: Fight off an enzyme called monoamine oxidase that harms certain brain chemicals. Patients who take these drugs must avoid foods like yogurt, pickles, cheese, red wine or beer.

Drugs: isocarboxazid (Marplan), phenelzine (Nardil), tranylcypromine (Parnate)

Homocysteine is an Emerging Risk Factor: Folic Acid for a Healthy Heart?

Some heart specialists recommend that their high-risk patients take folic acid supplements to lower their homocysteine levels, but others are waiting to see conclusive proof that supplements work (ABCNEWS.com)

By Claudine Chamberlain, ABCNEWS.com

As study after study confirms the link between heart disease and high levels of an amino acid known as homocysteine, doctors are looking at ways to combat this emerging risk factor.

Nutritionists already know that folic acid, which is in the family of B vitamins, helps rein in homocysteine. But no study has ever demonstrated that taking folic acid to lower homocysteine does, in fact, prevent heart disease.

Researchers aren't sure how homocysteine—which is formed in the blood as the body digests protein—might contribute to heart disease, but they suspect that it damages the layer of cells that line artery walls. It may also cause blood to clot more easily.

Dr. William Castelli of the Framingham Cardiovascular Institute in Massachusetts is among the doctors already recommending folic acid supplements to patients.

"I think it's time to realize that (homocysteine) is a big player and it's easy to treat," Castelli says. By waiting for more research, he believes, "people are dragging their feet."

Who Lives, Who Dies : Evidence from a Norwegian study published in this week's New England Journal of Medicine may bring the debate about folic acid to the fore again among heart specialists.

The researchers found that among patients already suffering from heart disease, homocysteine levels served as a strong indicator of which patients would later die from the disease.

Of the nearly 600 patients studied, only 3.8 percent of those with homocysteine levels lower than nine died within four years. Of those with levels higher than 15, 24.7 percent died.

The wide-ranging Physicians Health Study had already found that a homocysteine level of 15 more than tripled a man's risk of having a heart attack. Other research has shown similar results.

Folic Acid to the Rescue : But just because there seems to be a link between homocysteine and heart disease doesn't mean experts know what to do about it. Some, like Castelli, already put high-risk patients on folic acid supplements until their homocysteine numbers fall below 10. Others are waiting to see conclusive proof that supplements work.

Nutritionists say that for most people with high homocysteine levels, the problem is not enough folic acid rather than too much protein. Folic acid and other B vitamins help break down homocysteine.

Federal nutrition guidelines recommend that people take in at least 200 micrograms of folic acid a day. But 400 micrograms a day—the quantity contained in a typical multivitamin—seems to be the amount needed to lower homocysteine levels. For patients already identified as having high levels, some doctors suggest taking as much as one milligram of folic acid per day.

Natural sources of folic acid include whole-grain breads and cereals, orange juice, lentils, beans and green leafy vegetables like spinach, kale and broccoli. Conveniently, the kind of diet you might follow to lower your cholesterol to a heart-healthy level is also likely to be high in folic acid.

Of course, this is America, and most people don't eat a healthy diet. High homocysteine levels are yet another symptom of "this great fast-food society where we have refined the grains and taken all the veggies out of the diet," Castelli says.

Good For Babies : Starting in January next year, the Food and Drug Administration will require that flour and baked goods be fortified with folic acid. But the motivation for that isn't to lower rates of heart disease—it's to prevent birth defects. Pregnant women who take folic acid help lower the risk that their babies will be born with spinal cord defects.

The American Heart Association does not recommend taking folic acid supplements to prevent heart disease, chiefly because they shouldn't be necessary if a person is eating a healthy, well-balanced diet.

Ronald Krauss, chairman of the heart association's nutrition committee and senior scientist at Lawrence Berkeley Laboratory at the University of California at Berkeley, compares current discussion of homocysteine to the early days of studying cholesterol's effect on the heart.

"The body of evidence is strong enough now that if you have heart disease or a family history of heart disease," he says, "measuring homocysteine is a good way to identify people who are at higher risk."

For now, homocysteine levels are not regularly tested, except in rare cases where someone develops heart disease without having one of the other known risk factors: smoking, high blood pressure or high cholesterol.

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