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YES, there is hope and help for depression! Please read the following articles on overcoming and beating depression.

In any given 1-year period, 9.5 percent of the population, or about 18.8 million American adults, suffer from a depressive illness. The economic cost for this disorder is high, but the cost in human suffering cannot be estimated. Depressive illnesses often interfere with normal functioning and cause pain and suffering not only to those who have a disorder, but also to those who care about them. Serious depression can destroy family life as well as the life of the ill person. But much of this suffering is unnecessary.

Most people with a depressive illness do not seek treatment, although the great majority—even those whose depression is extremely severe—can be helped. Thanks to years of fruitful research, there are now medications and psychosocial therapies such as cognitive/behavioral, "talk" or interpersonal that ease the pain of depression.

Unfortunately, many people do not recognize that depression is a treatable illness. If you feel that you or someone you care about is one of the many undiagnosed depressed people in this country, the information presented here may help you take the steps that may save your own or someone else's life.

WHAT IS A DEPRESSIVE DISORDER?

A depressive disorder is an illness that involves the body, mood, and thoughts. It affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood. It is not a sign of personal weakness or a condition that can be willed or wished away. People with a depressive illness cannot merely "pull themselves together" and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people who suffer from depression.

TYPES OF DEPRESSION

Depressive disorders come in different forms, just as is the case with other illnesses such as heart disease. This pamphlet briefly describes three of the most common types of depressive disorders. However, within these types there are variations in the number of symptoms, their severity, and persistence.

Major depression is manifested by a combination of symptoms (see symptom list) that interfere with the ability to work, study, sleep, eat, and enjoy once pleasurable activities. Such a disabling episode of depression may occur only once but more commonly occurs several times in a lifetime.

A less severe type of depression, dysthymia, involves long-term, chronic symptoms that do not disable, but keep one from functioning well or from feeling good. Many people with dysthymia also experience major depressive episodes at some time in their lives.

Another type of depression is bipolar disorder, also called manic-depressive illness. Not nearly as prevalent as other forms of depressive disorders, bipolar disorder is characterized by cycling mood changes: severe highs (mania) and lows (depression). Sometimes the mood switches are dramatic and rapid, but most often they are gradual. When in the depressed cycle, an individual can have any or all of the symptoms of a depressive disorder. When in the manic cycle, the individual may be overactive, overtalkative, and have a great deal of energy. Mania often affects thinking, judgment, and social behavior in ways that cause serious problems and embarrassment. For example, the individual in a manic phase may feel elated, full of grand schemes that might range from unwise business decisions to romantic sprees. Mania, left untreated, may worsen to a psychotic state.

SYMPTOMS OF DEPRESSION AND MANIA

Not everyone who is depressed or manic experiences every symptom. Some people experience a few symptoms, some many. Severity of symptoms varies with individuals and also varies over time.

Depression

Mania

CAUSES OF DEPRESSION

Some types of depression run in families, suggesting that a biological vulnerability can be inherited. This seems to be the case with bipolar disorder. Studies of families in which members of each generation develop bipolar disorder found that those with the illness have a somewhat different genetic makeup than those who do not get ill. However, the reverse is not true: Not everybody with the genetic makeup that causes vulnerability to bipolar disorder will have the illness. Apparently additional factors, possibly stresses at home, work, or school, are involved in its onset.

In some families, major depression also seems to occur generation after generation. However, it can also occur in people who have no family history of depression. Whether inherited or not, major depressive disorder is often associated with changes in brain structures or brain function.

People who have low self-esteem, who consistently view themselves and the world with pessimism or who are readily overwhelmed by stress, are prone to depression. Whether this represents a psychological predisposition or an early form of the illness is not clear.

In recent years, researchers have shown that physical changes in the body can be accompanied by mental changes as well. Medical illnesses such as stroke, a heart attack, cancer, Parkinson's disease, and hormonal disorders can cause depressive illness, making the sick person apathetic and unwilling to care for his or her physical needs, thus prolonging the recovery period. Also, a serious loss, difficult relationship, financial problem, or any stressful (unwelcome or even desired) change in life patterns can trigger a depressive episode. Very often, a combination of genetic, psychological, and environmental factors is involved in the onset of a depressive disorder. Later episodes of illness typically are precipitated by only mild stresses, or none at all.

Depression in Women

Women experience depression about twice as often as men. Many hormonal factors may contribute to the increased rate of depression in women—particularly such factors as menstrual cycle changes, pregnancy, miscarriage, postpartum period, pre-menopause, and menopause. Many women also face additional stresses such as responsibilities both at work and home, single parenthood, and caring for children and for aging parents.

A recent NIMH study showed that in the case of severe premenstrual syndrome (PMS), women with a preexisting vulnerability to PMS experienced relief from mood and physical symptoms when their sex hormones were suppressed. Shortly after the hormones were re-introduced, they again developed symptoms of PMS. Women without a history of PMS reported no effects of the hormonal manipulation.

Many women are also particularly vulnerable after the birth of a baby. The hormonal and physical changes, as well as the added responsibility of a new life, can be factors that lead to postpartum depression in some women. While transient "blues" are common in new mothers, a full-blown depressive episode is not a normal occurrence and requires active intervention. Treatment by a sympathetic physician and the family's emotional support for the new mother are prime considerations in aiding her to recover her physical and mental well-being and her ability to care for and enjoy the infant.

Depression in Men

Although men are less likely to suffer from depression than women, 3 to 4 million men in the United States are affected by the illness. Men are less likely to admit to depression, and doctors are less likely to suspect it. The rate of suicide in men is four times that of women, though more women attempt it. In fact, after age 70, the rate of men's suicide rises, reaching a peak after age 85.

Depression can also affect the physical health in men differently from women. A new study shows that, although depression is associated with an increased risk of coronary heart disease in both men and women, only men suffer a high death rate.

Men's depression is often masked by alcohol or drugs, or by the socially acceptable habit of working excessively long hours. Depression typically shows up in men not as feeling hopeless and helpless, but as being irritable, angry, and discouraged; hence, depression may be difficult to recognize as such in men. Even if a man realizes that he is depressed, he may be less willing than a woman to seek help. Encouragement and support from concerned family members can make a difference. In the workplace, employee assistance professionals or worksite mental health programs can be of assistance in helping men understand and accept depression as a real illness that needs treatment.

Depression in the Elderly

Some people have the mistaken idea that it is normal for the elderly to feel depressed. On the contrary, most older people feel satisfied with their lives. Sometimes, though, when depression develops, it may be dismissed as a normal part of aging. Depression in the elderly, undiagnosed and untreated, causes needless suffering for the family and for the individual who could otherwise live a fruitful life. When he or she does go to the doctor, the symptoms described are usually physical, for the older person is often reluctant to discuss feelings of hopelessness, sadness, loss of interest in normally pleasurable activities, or extremely prolonged grief after a loss.

Recognizing how depressive symptoms in older people are often missed, many health care professionals are learning to identify and treat the underlying depression. They recognize that some symptoms may be side effects of medication the older person is taking for a physical problem, or they may be caused by a co-occurring illness. If a diagnosis of depression is made, treatment with medication and/or psychotherapy will help the depressed person return to a happier, more fulfilling life. Recent research suggests that brief psychotherapy (talk therapies that help a person in day-to-day relationships or in learning to counter the distorted negative thinking that commonly accompanies depression) is effective in reducing symptoms in short-term depression in older persons who are medically ill. Psychotherapy is also useful in older patients who cannot or will not take medication. Efficacy studies show that late-life depression can be treated with psychotherapy.

Improved recognition and treatment of depression in late life will make those years more enjoyable and fulfilling for the depressed elderly person, the family, and caretakers.

Depression in Children

Only in the past two decades has depression in children been taken very seriously. The depressed child may pretend to be sick, refuse to go to school, cling to a parent, or worry that the parent may die. Older children may sulk, get into trouble at school, be negative, grouchy, and feel misunderstood. Because normal behaviors vary from one childhood stage to another, it can be difficult to tell whether a child is just going through a temporary "phase" or is suffering from depression. Sometimes the parents become worried about how the child's behavior has changed, or a teacher mentions that "your child doesn't seem to be himself." In such a case, if a visit to the child's pediatrician rules out physical symptoms, the doctor will probably suggest that the child be evaluated, preferably by a psychiatrist who specializes in the treatment of children. If treatment is needed, the doctor may suggest that another therapist, usually a social worker or a psychologist, provide therapy while the psychiatrist will oversee medication if it is needed. Parents should not be afraid to ask questions: What are the therapist's qualifications? What kind of therapy will the child have? Will the family as a whole participate in therapy? Will my child's therapy include an antidepressant? If so, what might the side effects be?

The National Institute of Mental Health (NIMH) has identified the use of medications for depression in children as an important area for research. The NIMH-supported Research Units on Pediatric Psychopharmacology (RUPPs) form a network of seven research sites where clinical studies on the effects of medications for mental disorders can be conducted in children and adolescents. Among the medications being studied are antidepressants, some of which have been found to be effective in treating children with depression, if properly monitored by the child's physician.

DIAGNOSTIC EVALUATION AND TREATMENT

The first step to getting appropriate treatment for depression is a physical examination by a physician. Certain medications as well as some medical conditions such as a viral infection can cause the same symptoms as depression, and the physician should rule out these possibilities through examination, interview, and lab tests. If a physical cause for the depression is ruled out, a psychological evaluation should be done, by the physician or by referral to a psychiatrist or psychologist.

A good diagnostic evaluation will include a complete history of symptoms, i.e., when they started, how long they have lasted, how severe they are, whether the patient had them before and, if so, whether the symptoms were treated and what treatment was given. The doctor should ask about alcohol and drug use, and if the patient has thoughts about death or suicide. Further, a history should include questions about whether other family members have had a depressive illness and, if treated, what treatments they may have received and which were effective.

Last, a diagnostic evaluation should include a mental status examination to determine if speech or thought patterns or memory have been affected, as sometimes happens in the case of a depressive or manic-depressive illness.

Treatment choice will depend on the outcome of the evaluation. There are a variety of antidepressant medications and psychotherapies that can be used to treat depressive disorders. Some people with milder forms may do well with psychotherapy alone. People with moderate to severe depression most often benefit from antidepressants. Most do best with combined treatment: medication to gain relatively quick symptom relief and psychotherapy to learn more effective ways to deal with life's problems, including depression. Depending on the patient's diagnosis and severity of symptoms, the therapist may prescribe medication and/or one of the several forms of psychotherapy that have proven effective for depression.

Electroconvulsive therapy (ECT) is useful, particularly for individuals whose depression is severe or life threatening or who cannot take antidepressant medication.ECT often is effective in cases where antidepressant medications do not provide sufficient relief of symptoms. In recent years, ECT has been much improved. A muscle relaxant is given before treatment, which is done under brief anesthesia. Electrodes are placed at precise locations on the head to deliver electrical impulses. The stimulation causes a brief (about 30 seconds) seizure within the brain. The person receiving ECT does not consciously experience the electrical stimulus. For full therapeutic benefit, at least several sessions of ECT, typically given at the rate of three per week, are required.

Medications

There are several types of antidepressant medications used to treat depressive disorders. These include newer medications—chiefly the selective serotonin reuptake inhibitors (SSRIs)—the tricyclics, and the monoamine oxidase inhibitors (MAOIs). The SSRIs—and other newer medications that affect neurotransmitters such as dopamine or norepinephrine—generally have fewer side effects than tricyclics. Sometimes the doctor will try a variety of antidepressants before finding the most effective medication or combination of medications. Sometimes the dosage must be increased to be effective. Although some improvements may be seen in the first few weeks, antidepressant medications must be taken regularly for 3 to 4 weeks (in some cases, as many as 8 weeks) before the full therapeutic effect occurs.

Patients often are tempted to stop medication too soon. They may feel better and think they no longer need the medication. Or they may think the medication isn't helping at all. It is important to keep taking medication until it has a chance to work, though side effects (see section on Side Effects on page 13) may appear before antidepressant activity does. Once the individual is feeling better, it is important to continue the medication for at least 4 to 9 months to prevent a recurrence of the depression. Some medications must be stopped gradually to give the body time to adjust. Never stop taking an antidepressant without consulting the doctor for instructions on how to safely discontinue the medication. For individuals with bipolar disorder or chronic major depression, medication may have to be maintained indefinitely.

Antidepressant drugs are not habit-forming. However, as is the case with any type of medication prescribed for more than a few days, antidepressants have to be carefully monitored to see if the correct dosage is being given. The doctor will check the dosage and its effectiveness regularly.

For the small number of people for whom MAO inhibitors are the best treatment, it is necessary to avoid certain foods that contain high levels of tyramine, such as many cheeses, wines, and pickles, as well as medications such as decongestants. The interaction of tyramine with MAOIs can bring on a hypertensive crisis, a sharp increase in blood pressure that can lead to a stroke. The doctor should furnish a complete list of prohibited foods that the patient should carry at all times. Other forms of antidepressants require no food restrictions.

Medications of any kind—prescribed, over-the counter, or borrowed—should never be mixed without consulting the doctor. Other health professionals who may prescribe a drug—such as a dentist or other medical specialist—should be told of the medications the patient is taking. Some drugs, although safe when taken alone can, if taken with others, cause severe and dangerous side effects. Some drugs, like alcohol or street drugs, may reduce the effectiveness of antidepressants and should be avoided. This includes wine, beer, and hard liquor. Some people who have not had a problem with alcohol use may be permitted by their doctor to use a modest amount of alcohol while taking one of the newer antidepressants.

Antianxiety drugs or sedatives are not antidepressants. They are sometimes prescribed along with antidepressants; however, they are not effective when taken alone for a depressive disorder. Stimulants, such as amphetamines, are not effective antidepressants, but they are used occasionally under close supervision in medically ill depressed patients.

Questions about any antidepressant prescribed, or problems that may be related to the medication, should be discussed with the doctor.

Lithium has for many years been the treatment of choice for bipolar disorder, as it can be effective in smoothing out the mood swings common to this disorder. Its use must be carefully monitored, as the range between an effective dose and a toxic one is small. If a person has preexisting thyroid, kidney, or heart disorders or epilepsy, lithium may not be recommended. Fortunately, other medications have been found to be of benefit in controlling mood swings. Among these are two mood-stabilizing anticonvulsants, carbamazepine (Tegretol^®) and valproate (Depakote^®). Both of these medications have gained wide acceptance in clinical practice, and valproate has been approved by the Food and Drug Administration for first-line treatment of acute mania. Other anticonvulsants that are being used now include lamotrigine (Lamictal^®) and gabapentin (Neurontin^®): their role in the treatment hierarchy of bipolar disorder remains under study.

Most people who have bipolar disorder take more than one medication including, along with lithium and/or an anticonvulsant, a medication for accompanying agitation, anxiety, depression, or insomnia. Finding the best possible combination of these medications is of utmost importance to the patient and requires close monitoring by the physician.

Side Effects

Antidepressants may cause mild and, usually, temporary side effects (sometimes referred to as adverse effects) in some people. Typically these are annoying, but not serious. However, any unusual reactions or side effects or those that interfere with functioning should be reported to the doctor immediately. The most common side effects of tricyclic antidepressants, and ways to deal with them, are:

Herbal Therapy

In the past few years, much interest has risen in the use of herbs in the treatment of both depression and anxiety. St. John's wort (Hypericum perforatum), an herb used extensively in the treatment of mild to moderate depression in Europe, has recently aroused interest in the United States. St. John's wort, an attractive bushy, low-growing plant covered with yellow flowers in summer, has been used for centuries in many folk and herbal remedies. Today in Germany, Hypericum is used in the treatment of depression more than any other antidepressant. However, the scientific studies that have been conducted on its use have been short-term and have used several different doses.

Because of the widespread interest in St. John's wort, the National Institutes of Health (NIH) conducted a 3-year study, sponsored by three NIH components—the National Institute of Mental Health, the National Center for Complementary and Alternative Medicine, and the Office of Dietary Supplements. The study was designed to include 336 patients with major depression of moderate severity, randomly assigned to an 8-week trial with one-third of patients receiving a uniform dose of St. John's wort, another third sertraline, a selective serotonin reuptake inhibitor (SSRI) commonly prescribed for depression, and the final third a placebo (a pill that looks exactly like the SSRI and the St. John's wort, but has no active ingredients). The study participants who responded positively were followed for an additional 18 weeks. At the end of the first phase of the study, participants were measured on two scales, one for depression and one for overall functioning. There was no significant difference in rate of response for depression, but the scale for overall functioning was better for the antidepressant than for either St. John's wort or placebo. While this study did not support the use of St. John's wort in the treatment of major depression, ongoing NIH-supported research is examining a possible role for St. John's wort in the treatment of milder forms of depression.

The Food and Drug Administration issued a Public Health Advisory on February 10, 2000. It stated that St. John's wort appears to affect an important metabolic pathway that is used by many drugs prescribed to treat conditions such as AIDS, heart disease, depression, seizures, certain cancers, and rejection of transplants. Therefore, health care providers should alert their patients about these potential drug interactions.

Some other herbal supplements frequently used that have not been evaluated in large-scale clinical trials are ephedra, gingko biloba, echinacea, and ginseng. Any herbal supplement should be taken only after consultation with the doctor or other health care provider.

PSYCHOTHERAPIES

Many forms of psychotherapy, including some short-term (10-20 week) therapies, can help depressed individuals. "Talking" therapies help patients gain insight into and resolve their problems through verbal exchange with the therapist, sometimes combined with "homework" assignments between sessions. "Behavioral" therapists help patients learn how to obtain more satisfaction and rewards through their own actions and how to unlearn the behavioral patterns that contribute to or result from their depression.

Two of the short-term psychotherapies that research has shown helpful for some forms of depression are interpersonal and cognitive/behavioral therapies. Interpersonal therapists focus on the patient's disturbed personal relationships that both cause and exacerbate (or increase) the depression. Cognitive/behavioral therapists help patients change the negative styles of thinking and behaving often associated with depression.

Psychodynamic therapies, which are sometimes used to treat depressed persons, focus on resolving the patient's conflicted feelings. These therapies are often reserved until the depressive symptoms are significantly improved. In general, severe depressive illnesses, particularly those that are recurrent, will require medication (or ECT under special conditions) along with, or preceding, psychotherapy for the best outcome.

HOW TO HELP YOURSELF IF YOU ARE DEPRESSED

Depressive disorders make one feel exhausted, worthless, helpless, and hopeless. Such negative thoughts and feelings make some people feel like giving up. It is important to realize that these negative views are part of the depression and typically do not accurately reflect the actual circumstances. Negative thinking fades as treatment begins to take effect. In the meantime:

How Family and Friends Can Help the Depressed Person

The most important thing anyone can do for the depressed person is to help him or her get an appropriate diagnosis and treatment. This may involve encouraging the individual to stay with treatment until symptoms begin to abate (several weeks), or to seek different treatment if no improvement occurs. On occasion, it may require making an appointment and accompanying the depressed person to the doctor. It may also mean monitoring whether the depressed person is taking medication. The depressed person should be encouraged to obey the doctor's orders about the use of alcoholic products while on medication. The second most important thing is to offer emotional support. This involves understanding, patience, affection, and encouragement. Engage the depressed person in conversation and listen carefully. Do not disparage feelings expressed, but point out realities and offer hope. Do not ignore remarks about suicide. Report them to the depressed person's therapist. Invite the depressed person for walks, outings, to the movies, and other activities. Be gently insistent if your invitation is refused. Encourage participation in some activities that once gave pleasure, such as hobbies, sports, religious or cultural activities, but do not push the depressed person to undertake too much too soon. The depressed person needs diversion and company, but too many demands can increase feelings of failure.

Do not accuse the depressed person of faking illness or of laziness, or expect him or her "to snap out of it." Eventually, with treatment, most people do get better. Keep that in mind, and keep reassuring the depressed person that, with time and help, he or she will feel better.

WHERE TO GET HELP

If unsure where to go for help, check the Yellow Pages under "mental health," "health," "social services," "suicide prevention," "crisis intervention services," "hotlines," "hospitals," or "physicians" for phone numbers and addresses. In times of crisis, the emergency room doctor at a hospital may be able to provide temporary help for an emotional problem, and will be able to tell you where and how to get further help.

Listed below are the types of people and places that will make a referral to, or provide, diagnostic and treatment services.

Dealing with the Depths of Depression

Imagine attending a party with these prominent guests: Abraham Lincoln, Theodore Roosevelt, Robert Schumann, Ludwig von Beethoven, Edgar Allen Poe, Mark Twain, Vincent van Gogh, and Georgia O'Keefe. Maybe Schumann and Beethoven are at the dinner table intently discussing the crescendos in their most recent scores, while Twain sits on a couch telling Poe about the plot of his latest novel. O'Keefe and Van Gogh may be talking about their art, while Roosevelt and Lincoln discuss political endeavors.

But in fact, these historical figures also had a much more personal common experience: Each of them battled the debilitating illness of depression.

It is common for people to speak of how "depressed" they are. However, the occasional sadness everyone feels due to life's disappointments is very different from the serious illness caused by a brain disorder. Depression profoundly impairs the ability to function in everyday situations by affecting moods, thoughts, behaviors, and physical well-being.

Twenty-seven-year-old Anne (not her real name) has suffered from depression for more than 10 years. "For me it's feelings of worthlessness," she explains. "Feeling like I haven't accomplished the things that I want to or feel I should have and yet I don't have the energy to do them. It's feeling disconnected from people in my life, even friends and family who care about me. It's not wanting to get out of bed some mornings and losing hope that life will ever get better."

Depression strikes about 17 million American adults each year--more than cancer, AIDS, or coronary heart disease--according to the National Institute of Mental Health (NIMH). An estimated 15 percent of chronic depression cases end in suicide. Women are twice as likely as men to be affected.

Many people simply don't know what depression is. "A lot of people still believe that depression is a character flaw or caused by bad parenting," says Mary Rappaport, a spokeswoman for the National Alliance for the Mentally Ill. She explains that depression cannot be overcome by willpower, but requires medical attention.

Fortunately, depression is treatable, says Thomas Laughren, M.D., team leader for psychiatric drug products in FDA's division of neuropharmacological drug products.

In the past 13 years, the Food and Drug Administration has approved several new antidepressants, including Wellbutrin (bupropion), Prozac (fluoxetine), Zoloft (sertraline), Paxil (paroxetine), Effexor (venlafaxine), Serzone (nefazodone), and Remeron (mirtazapine).

According to the American Psychiatric Association (APA), 80 to 90 percent of all cases can be treated effectively. However, two-thirds of the people suffering from depression don't get the help they need, according to NIMH. Many fail to identify their symptoms or attribute them to lack of sleep or a poor diet, the APA says, while others are just too fatigued or ashamed to seek help.

Left untreated, depression can result in years of needless pain for both the depressed person and his or her family. And depression costs the United States an estimated $43 billion a year, due in large part to absenteeism from work, lost productivity, and medical costs, according to the National Depressive and Manic Depressive Association.

The three main categories of depression are major depression, dysthymia, and bipolar depression (sometimes referred to as manic depression).

Major depression affects 15 percent of Americans at one point during their lives, according to the U.S. Department of Health and Human Services. Its effects can be so intense that things like eating, sleeping, or just getting out of bed become almost impossible.

Major depression "tends to be a chronic, recurring illness," Laughren explains. Although an individual episode may be treatable, "the majority of people who meet criteria for major depression end up having additional episodes in their lifetime."

Unlike major depression, dysthymia doesn't strike in episodes, but is instead characterized by milder, persistent symptoms that may last for years. Although it usually doesn't interfere with everyday tasks, victims rarely feel like they are functioning at their full capacity. According to the National Alliance for the Mentally Ill, almost 10 million Americans may experience dysthymia each year.

Finally, bipolar disorder cycles between episodes of major depression and highs known as mania. Bipolar disorder is much less common than the other types, afflicting about 1 percent of the U.S. population. Symptoms of mania include irritability, an abnormally elevated mood with a decreased need for sleep, an exaggerated belief in one's own ability, excessive talking, and impulsive and often dangerous behavior.

Study after study suggests biochemical and genetic links to depression. A considerable amount of evidence supports the view that depressed people have imbalances in the brain's neurotransmitters, the chemicals that allow communication between nerve cells. Serotonin and norepinephrine are two neurotransmitters whose low levels are thought to play an especially important role. The fact that women have naturally lower serotonin levels than men may contribute to women's greater tendency to depression.

Family histories show a recurrence of depression from generation to generation. Studies of identical twins confirm that depression and genes are related, finding that if one twin of an identical pair suffers from depression, the other has a 70 percent chance of developing the disease. For fraternal twins or siblings, the rate is just 25 percent.

Environmental factors, however, may also play a role in depression. When combined with a biochemical or genetic predisposition, life stressors (such as relationship problems, financial difficulties, death of a loved one, or medical illness) may cause the disease to manifest itself.

John (not his real name), 25, was diagnosed with depression for the first time last year when he and his girlfriend ended their three-year relationship. "I couldn't do anything because I was totally absorbed with the whole break-up issue," he says. "It was impossible for me to sleep, and I would wake up at 3 or 4 in the morning and literally shake. And when it was time to wake up, I just couldn't get out of bed."

In addition, substance abuse and side effects from prescription medication may also lead to a depressive episode. And research shows that people battling serious medical conditions are especially prone to depression. According to the U.S. Department of Health and Human Services, those who have had a heart attack, for example, have a 40 percent chance of being depressed.

Seasonal affective disorder, often called "SAD," is a striking example of an environmental factor playing a major role in depression. SAD usually starts in late fall, with the decrease in daylight hours and ends in spring when the days get longer.

The symptoms of SAD, which include energy loss, increased anxiety, oversleeping, and overeating, may result from a change in the balance of brain chemicals associated with decreased sunlight. The exact reason for the association between light and mood is unknown, but research suggests a connection with the sleep cycle. Several studies have suggested that light therapy, which involves daily exposure to bright fluorescent light, may be an effective treatment for SAD.

Medical professionals generally base a diagnosis of depressive disorder on the presence of certain symptoms listed in the American Psychiatric Association's Diagnostic and Statistical Manual. The DSM (presently in the fourth edition) lists the following symptoms for depression:

Even with this list of symptoms, diagnosing depression is not simple. According to the National Alliance for the Mentally Ill, it takes an average of eight years from the onset of depression to get a proper diagnosis.

In making a diagnosis, a health professional should also consider the patient's medical history, the findings of a complete physical exam, and laboratory tests to rule out the possibility of depressive symptoms resulting from another medical problem.

The symptoms of the depressive part of bipolar disorder are the same as those expressed in major (unipolar) depression. Because of the similarities in symptoms and the fact that manic episodes usually don't appear until the mid-20s, some people with bipolar disorder may mistakenly be diagnosed with unipolar depression. This may lead to improper treatment because antidepressants carry the risk of triggering a manic episode. (For information about treating bipolar disorder, see "Evening Out the Ups and Downs of Manic-Depressive Illness" in the June 1996 FDA Consumer.)

One major approach for treating depression is the use of antidepressant medications. The older antidepressants include tricyclic antidepressants such as Tofranil (imipramine) and monoamine oxidase inhibitors such as Nardil (phenelzine). Antidepressants approved more recently include the selective serotonin reuptake inhibitors Prozac, Paxil and Zoloft, and the other newer antidepressants Wellbutrin, Effexor, Serzone, and Remeron.

The effects of antidepressants on the brain are not fully understood, but there is substantial evidence that they somehow restore the brain's chemical balance. These medications usually can control depressive symptoms in four to eight weeks, but many patients remain on antidepressants for six months to a year following a major depressive episode to avoid relapse.

Different drugs work for different people, and it is difficult to predict which people will respond to which drug or who will experience side effects. So it may take more than one try to find the appropriate medication.

Since the mid-1950s, tricyclic antidepressants have been the standard against which other antidepressants have been measured. Monoamine oxidase inhibitors were discovered around the same time as tricyclic antidepressants, but were prescribed less because, if mixed with certain foods or medications, the drugs sometimes resulted in a fatal rise in blood pressure.

Laughren describes Prozac as the "first of a new type of more selective antidepressants." The older antidepressants had unpleasant and sometimes dangerous side effects, such as insomnia, weight gain, blurred vision, sexual impairment, heart palpitations, dry mouth, and constipation. Prozac, other selective serotonin reuptake inhibitors, and other recently approved antidepressants have had generally safer side effect profiles.

A recent study funded by NIMH suggested that Prozac may be as effective in treating children and teens as adults, but the drug is not yet approved by FDA for use in this population.

Other types of therapy, such as natural substances extracted from plants, are currently being studied. Although not approved by FDA, some people believe St. John's wort, for example, is extremely helpful in alleviating their depressive symptoms. (See "An Herbal Alternative?")

When people are unresponsive to antidepressant medications or can't take them because of their age or health problems, electroconvulsive therapy (ECT), or "shock therapy," can offer a lifesaving alternative. Like antidepressants, ECT is believed to affect the chemical balance of the brain's neurotransmitters.

Before ECT, the patient is given anesthesia and a muscle relaxant to prevent injury or pain. Then electrodes are placed on the person's head, and a small amount of electricity is applied. This procedure is usually done three times a week until the patient improves. Some patients may experience a temporary loss of short-term memory.

For severe depressive episodes, medications are often the first step because of the relatively quick relief they can bring to physical symptoms. For the long term, however, psychotherapy may be needed to address certain aspects of the illness that drugs cannot. "Although the biological features of depression may respond better to drugs," Laughren says, "people may need to relearn how to interact with their environment after the biological part of the depression is controlled."

"I wanted to talk things out and get better in that way," John says. "And even after the first couple of times I saw my therapist, I could do a little bit more. Talking with her gave me some reality that how I was feeling wasn't so abnormal, so unusual, or so terrible."

Anne explains, "It's just comforting sometimes to share the little day-to-day happenings in my life with someone who doesn't get to see them first-hand."

Some find support groups to be invaluable in helping them cope with their depression. "It's through talking with others with similar experiences," says Mary Rappaport, "that you can better understand what you're going through."

Changes in lifestyle are also important in the management of depression. Exercise, even in moderate doses, seems to enhance energy and reduce tension. Some research suggests that a rush of the hormone norepinephrine following exercise helps the brain deal with stress that often leads to depression and anxiety. A similar effect may be obtained through meditation, yoga, and certain diets.

Like many others who have not had to face depression themselves, John's friends lacked knowledge about the disease. "I think the whole thing really affected my relationships with people," he says. "I was pretty much a jerk all of the time. I didn't want to talk to anybody. I just wanted them to leave me alone."

With the growing awareness of the seriousness of the disorder and the biological causes, the understanding and support of family and friends may be easier to come by. "The future looks very bright for individuals who in the past have often had to suffer alone," says Rappaport. "More and more people are coming out, which encourages people to talk about it." Among those who have "come out" recently to publicly discuss their personal bouts with depression are comedian Drew Carey and "60 Minutes" correspondent Mike Wallace.

Experts say that no one, young or old, has to accept feelings of depression as a necessary part of life. The National Depressive and Manic Depressive Association and other organizations offer medical information and referrals. By trying different options for facing their personal challenges, Anne and others have learned what treatments help them most. "All in all," Anne says, "I think my ability to weather the ups and downs of life has gotten better."

Researchers continue to make great strides in understanding and treating depression. For example, scientists are beginning to learn more about the chromosomes where affective disorder genes appear to be located. "While there is a long way to go in coming up with even more effective drugs," Laughren says, "there's much ongoing research and reason for optimism."

"An Herbal Alternative?"

St. John the Baptist's birthday is celebrated on June 24. It is also around this time that the pretty yellow flowers of St. John's wort, the plant named in his honor, bloom in Germany. The plant may be more than just beautiful. Hypericum, the concentrated extract of flowers and leaves, is thought by some to be effective in treating depression.

While the herb is the most-prescribed antidepressant in Germany, in the United States, St. John's wort is not an approved drug. Many health food stores in this country sell it as a dietary supplement, but FDA does not allow any antidepressant claims because it has not been proven to be a safe and effective drug for this use. "There's no particular reason to doubt that it might have biological effects," says Thomas Laughren, M.D., in FDA's division of neuropharmacological drug products. "Whether or not it is an effective antidepressant remains to be seen."

The National Institutes of Health is sponsoring studies to determine if St. John's wort is safe and effective as a treatment for mild to moderate cases of depression. One issue of concern is how the herb interacts with certain drugs, especially antidepressants that affect the brain chemical serotonin.

'If Someone You Know Is Depressed'

According to the National Institute of Mental Health, to help someone recover from depression:

Top Medical Diagnoses in Doctors' Visits in 1995

Diagnosis	Percentage
Hypertension	5.0
Otitis Media	2.4
Routine Child Health Exam	2.3
Acute Upper Respiratory Infection	2.1
Diabetes Mellitus	2.0
Routine Pregnancy Exam	1.7
Acute Pharyngitis	1.7
Chronic Sinusitis	1.6
Bronchitis	1.6
Surgery follow-up	1.3
Depressive Disorder	1.1
Asthma	1.1
Depression is one of the most common medical problems in the United States. (Source: Scott-Levin, Newtown, Pa.)

The Lowdown on Depression

Thirty-three-year-old Saritza Velilla of Frisco, Tex., was just 7 years old when she first started feeling worthless. As the years went by, these feelings intensified and she became more withdrawn from social activities. But it wasn't until 1996 that Velilla was diagnosed with clinical depression, and only recently that she found relief from her ongoing symptoms.

"I always felt outside the mainstream," she remembers. "I could feel alone in a roomful of people." Velilla grew up for the most part with a great void in what she calls "that important emotional need" for parental care, affection, or attention. "Without those bonds in place," she says, "I did not develop emotionally and had trouble relating to others."

Velilla is not alone in grappling with the consequences of mental illness. An estimated 22 percent of Americans 18 and older--about 1 in 5 adults--have a diagnosable mental disorder in any given year, according to the National Institute of Mental Health (NIMH). To complicate matters, many people struggle with more than one mental disorder at a time. The pain and suffering that goes along with these illnesses is felt not only by those who have a disorder, but also by the people who care about them.

Family members often watch their loved ones cycle in and out of treatment, on and off medications, and, in some cases, in and out of jail. Pete Earley of Fairfax, Va., says that if medical experts had responded to his son's mental condition as quickly as law enforcement reacted to his criminal behavior, his son would be receiving therapy instead of facing a possible prison term.

Earley's son has bipolar disorder--also called manic-depressive illness--a form of mental illness different from Velilla's that can cause extreme shifts in mood, energy and functioning. Earley says his son is frequently delusional, paranoid, and psychotic. If he discontinues his medications, he exhibits bizarre, irrational behavior.

According to the NIMH, most people with a depressive illness do not get the help they need, although the great majority--even those whose depression is severe--can be helped. Without treatment, the symptoms of depression can last for weeks, months, or even years. With treatment, many people can find relief from their symptoms and lead a normal, healthy life.

More Than a Mood Swing

Clinical depression, one of the more common categories of mental illnesses, is a serious brain disorder that affects the way nearly 19 million American adults feel, think, and interact. In contrast to the normal emotional experiences of sadness, loss, or passing mood states, clinical depression is extreme and persistent and can interfere significantly with a person's ability to function. People with depression cannot merely "pull themselves together" and get better. Depression cannot be willed or wished away.

There are three main types of clinical depression: major depressive disorder; dysthymic disorder; and bipolar depression, the depressed phase of bipolar disorder. Within these types are variations in the number of associated mental symptoms, and their severity and persistence.

A person experiencing major depressive disorder suffers from, among other symptoms, a depressed mood or loss of interest in normal activities that lasts most of the day, nearly every day, for at least two weeks. Such episodes may occur only once, but more commonly occur several times in a lifetime.

Unlike major depressive disorder, dysthymic disorder--a chronic but less severe type--doesn't strike in episodes, but is instead characterized by milder, persistent symptoms that may last for years. Although it usually doesn't interfere with everyday tasks, people with this milder form of depression rarely feel like they are functioning at their full capacities.

Bipolar disorder cycles between episodes of major depression, similar to those seen in major depressive disorder, and highs known as mania. In a manic phase, a person might act on delusional grand schemes that could range from unwise business decisions to romantic sprees. Mania left untreated may deteriorate into a psychotic state.

For Earley, one of his son's recent psychotic episodes played out in a burglary charge. The pair was headed home from a local hospital where doctors had refused to treat him involuntarily. Earley's son suddenly leapt from their moving car, ran away, and broke into a stranger's house. After throwing a potted plant through a glass door and smashing some furniture, he then ran upstairs and drew himself a bubble bath. Earley says his son has never been in trouble with the law before and that he did not take anything from the house.

It's Not 'All In The Head'

Because the symptoms, course of illness, and response to treatment vary so much among people with depression, doctors believe that depression may have a number of complex and interacting causes.

Some factors include another medical illness, losing a loved one, stressful life events, and drug or alcohol abuse. Any of these factors also may contribute to recurrent major depressive episodes.

Modern brain imaging technologies are revealing that neural circuits responsible for the regulation of moods, thinking, sleep, appetite, and behavior fail to function properly in people with depression. Imaging studies also indicate that critical neurotransmitters--chemicals used by nerve cells to communicate--are out of balance.

Moreover, genetics research suggests that vulnerability to depression results from the influence of multiple genes acting together with environmental factors. The hormonal system that regulates the body's response to stress also is overactive in many depressed people.

Research conducted in the fields of psychiatry, behavioral science, neuroscience, biology, and genetics, including studies of twins, lead scientists to believe that the risk of developing mental illness increases if another family member is similarly affected, suggesting a hereditary component.

This was the case for 34-year-old Susan Poage of Thornton, Colo. She recently was diagnosed with clinical depression, like her mother before her. Poage recalls a dismal childhood.

"There was a lot of silent crying, promiscuity, alcohol and drugs," she says, "and I don't remember having any good times." With the help of her doctor and a five-year struggle with drug therapy, Poage today is managing her symptoms of depression, including thoughts of suicide.

Despite strong evidence for genetic susceptibility, scientists still don't know the number of genes that might be involved in making someone more likely to develop a mental disorder. Identification of these genes has proved to be extremely difficult.

Similarly, the role of environmental effects in the development of mental illness remains largely unknown.

Diagnosing Depression

Medical professionals generally base a diagnosis of mental illness on the presence of certain symptoms listed in the 4th edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). The symptoms listed for a major depressive episode include:

A person is clinically depressed if he or she has five or more of these symptoms and has not been functioning normally for most days during the same two-week period.

Dysthymic disorder is diagnosed when depressed mood persists for at least two years (one year in children) and is accompanied by at least two other symptoms of depression.

The episodes of depression that occur in people with bipolar disorder alternate with mania, which is characterized by abnormally and persistently elevated mood or irritability. Symptoms of mania include overly inflated self-esteem, decreased need for sleep, increased talkativeness, racing thoughts, distractibility, physical agitation, and excessive risk-taking. Because bipolar disorder requires different treatment than major depression or dysthymia, obtaining an accurate diagnosis is extremely important.

Treating Depression

Finding the right treatment for depression can be as difficult as convincing someone that they need help. However, according to the NIMH, clinical depression is one of the most treatable of all medical illnesses.

Because it is currently against the law in Virginia, where the Earleys live, to force someone into medical treatment, Earley must rely on his son's willingness to take his medicines. Typically, bipolar patients periodically stop taking their medications.

"Part of my son's illness," Earley explains, "is believing he is perfectly fine when he goes off his medicines.

"Even though it was obvious that my son was clearly out of his mind, the law still insisted that he was capable of deciding whether or not he needed treatment," says Earley. "In these cases, you are asking an irrational person to make a rational decision. It's like expecting a person with a broken leg to run a marathon."

Today, most people with depression can be treated successfully with antidepressant medications, "talk" therapy (psychotherapy), or a combination of the two. (See "Classification of Antidepressants".) Experts agree that successful treatment also hinges on early intervention. And early treatment increases the likelihood of preventing serious recurrences.

Drug Treatment

Existing antidepressant drugs are known to influence the functioning primarily of either or both of two neurotransmitters in the brain--serotonin and norepinephrine. Older medications--tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs)--affect the activity of both of these neurotransmitters simultaneously. Their disadvantage is that they can be difficult to tolerate due to significant side effects, or, in the case of MAOIs, dietary and medication restrictions.

Newer medications, such as the selective serotonin reuptake inhibitors (SSRIs), have fewer side effects than the older drugs, making it easier for people, including older adults, to adhere to treatment. Both generations of medications are effective in relieving depression, although some people will respond to one type of drug, but not another.

"Clinicians tell us that different drugs seem to work for different people," says Thomas Laughren, M.D., team leader for the review of psychiatric drugs in the Food and Drug Administration's Division of Neuropharmacological Drug Products. "And it's difficult to predict which people will respond to which drug or who will experience what side effects." So, Laughren says, it may take more than one try to find the appropriate medication. "Now that we've made a distinction between different depression subtypes, this seems to have stimulated additional drug research. Drug companies are also conducting more longer-term studies in depression, and this is important since depression tends to be a chronic illness."

Although some improvement may be seen in the first few weeks, antidepressants usually must be taken regularly for three to four weeks (and sometimes longer) before full therapeutic benefits occur. "If we had a better understanding of the biological basis for depression, it would help in the discovery of newer antidepressants that hopefully would work faster and better," says Laughren. "Unfortunately we do not really understand the mechanism for the antidepressant drugs."

The medication most often used to treat bipolar disorder is lithium (Eskalith, Lithane, Lithobid, Cibalith-S). Lithium evens out mood swings in both directions--from mania to depression, and depression to mania. It is used not just for manic attacks or flare-ups of the illness, but also as an ongoing maintenance treatment for bipolar disorder.

Non-Drug Treatments

In psychotherapy, also called "talk therapy," a person discusses with a mental health professional the feelings, thoughts and behaviors that seem to cause difficulty. The goal of psychotherapy is to help people understand and manage their problems so that they can function better.

"Finding a therapist who believes in recovery is the first step," says Velilla. "Someone who can teach you to think differently and learn new behaviors." She believes that her feelings of neglect, coupled with the eventual divorce of her parents, ultimately triggered many of her bouts with depression. Her own divorce some years later, she says, only heightened her feelings of worthlessness. "My therapist finally put a name to what I'd been feeling since I was 7 years old."

Psychotherapy can help people with bipolar disorder, and their families, identify early warning signs and manage emotional stress, which may help prevent a bipolar episode.

Richard O'Connor, Ph.D., a psychotherapist in Canaan, Conn., and the author of several books on depression, believes that people need to help themselves "break the bad habits in their lives that set them up for depression." Waking up and going to sleep at the same time each day, for example, might help those people prone to bouts of insomnia due to irregular sleep patterns.

A depression sufferer himself, O'Connor came to this belief after many of the people he was treating "thought it was too late for them to help themselves, and they wanted us to pick up the pieces," he says. "People are responsible for their own recovery. They must learn to take care of themselves and structure their lives so that they're less likely to trigger an episode."

When people are unresponsive to psychotherapy and medications, or the combination of the two works too slowly to relieve severe symptoms, such as psychosis or recurring thoughts of suicide, electroconvulsive therapy (ECT) may be considered. Electrodes are placed at precise locations on the head to deliver electrical impulses. The stimulation causes a 30-second seizure within the brain; however, the person does not consciously feel the stimulus. Three sessions per week typically are given for full therapeutic benefit. Like antidepressants, ECT is believed to affect the chemical balance of the brain's neurotransmitters.

Interest is rapidly growing as well in the use of herbs for treating depression. But, according to a study published in the April 10, 2002, issue of the Journal of the American Medical Association, an extract of the popular herb St. John's wort was no more effective for treating major depression of moderate severity than an inactive pill (placebo). The multi-site trial, involving 340 people, also compared the FDA-approved antidepressant drug Zoloft (sertraline) to a placebo as a way to measure how sensitive the trial was to detecting antidepressant effects. Since Zoloft was also found to be no different than the placebo in that study, Laughren says it can best be thought of as a "failed study" that isn't informative about the antidepressant effectiveness of St. John's wort.

The NIMH cautions people who think they may be depressed not to use dietary supplements without first being evaluated by a psychiatrist or examined by a physician. The risks, according to the institute, can outweigh any potential benefits.

Following Prescribed Treatment

Antidepressant drugs are not considered to be candidates for abuse. However, as is the case with any type of medication, use of antidepressants must be carefully monitored to make sure the correct dosage is being given. Care also is needed when antidepressants are discontinued.

As is often seen with antibiotics, people may be tempted to stop antidepressants too soon. They may feel better and think they no longer need the medication, or they may believe the medication isn't working. But quickly stopping certain antidepressants is linked to side effects ranging from flu-like symptoms to sensory disturbances. As a result, new labeling, as specified by the FDA, recommends that patients taper off these medications slowly. If a person encounters problems going off a drug, he or she is advised to consult a physician rather than reduce dosage without supervision.

After spending 11 days in the hospital following the burglary, Earley's son was released to his parents. He is currently awaiting trial on two counts of felony breaking and entering and destruction of property. He is attending a 15-week treatment program that includes routine medications, and he now has a job and hopes to return to college to finish his education.

"He doesn't want to be delusional," says Earley. "He's embarrassed and ashamed about what happened. But now he's got no choice but to admit that he is sick and always will be. The question is, will that be enough to keep him taking his medications?"

When a patient and the health-care provider think that medication can be discontinued or scaled back, they will discuss how best to ease off the medication gradually.

The NIMH says it is important to keep taking prescribed medication until it has had a chance to work, even though side effects may appear before antidepressant activity does.

As for Velilla, "I'm still not taking any medication," she says, "but I think I may not need it after all. I continue to read books that will inspire and give me tools to deal with life. I feel like I am making progress in counseling and in all areas of my life and that makes me feel pretty good and optimistic about recovering."

Where to Get More Information:

National Institute of Mental Health (NIMH)
Public Inquiries
6001 Executive Blvd.,
Rm. 8184, MSC 9663
Bethesda, MD 20892-9663
301-443-4513
www.nimh.nih.gov

National Foundation for Depressive Illness, Inc.
PO Box 2257
New York, NY 10116
1-800-239-1265
www.depression.org

National Mental Health Association (NMHA)
2001 N. Beauregard St., 12th Floor
Alexandria, VA 22311
1-800-969-NMHA (1-800-969-6642)
TTY: 1-800-443-5959
www.nmha.org

According to the late health and nutrition researcher, Dr. Linus Pauling, “you can trace every ailment, every sickness and every disease to an Organic Trace Mineral deficiency.” Dr. Pauling was a much-acclaimed and heralded leader in researching disease and received 2 Nobel Prizes in his lifetime.

Organic Trace Minerals are needed by the human body for optimum health. Organic Trace Minerals help the body create “balance” - also known as "homeostasis."

Because of the way we grow most of our food, and with all the fertilizers, pesticides, and non-organic farming methods, soil depletion has caused a loss of the organic trace minerals that used to be in our foods that were grown on the farm. All of the non-organic chemical fertilizers applied on the crops being grown in today's "factory farms" kill the microorganisms in the soil that used to produce Organic Trace Minerals. When our farmer's soils are destroyed by the chemical fertilizers that are so widely used in the production of our crops that are grown on the "factory farms," the "natural" organic humus soils are destroyed, and the plants/crops grown in that soil are missing the "natural" organic trace minerals. This was the finding over 70 years ago by Dr. Northern in 1936, and as documented in the U.S. Senate Document 264.

Without Organic Trace Minerals, the body cannot utilize amino acids, fats and vitamins properly. Organic Trace Minerals are absolutely necessary and required by every cell, organ, gland, muscle and vital life functions in the human body. Without Organic Trace Minerals, optimum health cannot be achieved, and diseases and accelerated oxidation occurs in the body.

Organic Trace Minerals are “the gift of life” and cellular nutrition and function becomes impossible without all of the essential Organic Trace Minerals.

Verbatim Unabridged extracts from the 74th Congress 2nd Session in 1936 about the Importance of Organic Trace Minerals:

"Our physical well-being is more directly dependent upon the minerals we take into our systems than upon calories or vitamins, or upon the precise proportions of starch, protein or carbohydrates we consume."

"Do you know that most of us today are suffering from certain dangerous diet deficiencies which cannot be remedied until depleted soils from which our food comes are brought into proper mineral balance?"

"The alarming fact is that foods (fruits, vegetables and grains) now being raised on millions of acres of land that no longer contain enough of certain minerals are starving us - no matter how much of them we eat. No man of today can eat enough fruits and vegetables to supply his system with the minerals he requires for perfect health because his stomach isn't big enough to hold them."

"The truth is that our foods vary enormously in value, and some of them aren't worth eating as food. Our physical well-being is more directly dependent upon the minerals we take into our systems than upon calories or vitamins or upon the precise proportions of starch, protein or carbohydrates we consume."

"This talk about minerals is novel and quite startling. In fact, a realization of the importance of minerals in food is so new that the textbooks on nutritional dietetics contain very little about it. Nevertheless, it is something that concerns all of us, and the further we delve into it the more startling it becomes."

"You'd think, wouldn't you, that a carrot is a carrot - that one is about as good as another as far as nourishment is concerned? But it isn't; one carrot may look and taste like another and yet be lacking in the particular mineral element which our system requires and which carrots are supposed to contain."

"Laboratory tests prove that the fruits, the vegetables, the grains, the eggs, and even the milk and the meats of today are not what they were a few generations ago (which doubtless explains why our forefathers thrived on a selection of foods that would starve us!)"

"No man today can eat enough fruits and vegetables to supply his stomach with the mineral salts he requires for perfect health, because his stomach isn't big enough to hold them! And we are turning into big stomachs."

"No longer does a balanced and fully nourishing diet consist merely of so many calories or certain vitamins or fixed proportion of starches, proteins and carbohydrates. We know that our diets must contain in addition something like a score of minerals salts."

"It is bad news to learn from our leading authorities that 99% of the American people are deficient in these minerals, and that a marked deficiency in any one of the more important minerals actually results in disease. Any upset of the balance, any considerable lack or one or another element, however microscopic the body requirement may be, and we sicken, suffer, shorten our lives."

"We know that vitamins are complex chemical substances which are indispensable to nutrition, and that each of them is of importance for normal function of some special structure in the body. Disorder and disease result from any vitamin deficiency. It is not commonly realized, however, that vitamins control the body's appropriation of minerals, and in the absence of minerals they have no function to perform. Lacking vitamins, the system can make some use of minerals, but lacking minerals, vitamins are useless."

"Certainly our physical well-being is more directly dependent upon the minerals we take into our systems than upon calories or vitamins or upon the precise proportions of starch, protein of carbohydrates we consume."

"This discovery is one of the latest and most important contributions of science to the problem of human health."

What is "Organic For Life™"

"Organic for Life™" is our company's name for our new line of organic products.

The National Organic Program is a set of legal standards and regulations developed and enforced by the United States Department of Agriculture (USDA) that define farming, production and certification practices for foods bearing the organic label and sold in the United States.

What are the National Organic Standards and National Organic Standards Board (NOSB)?

The National Organic Standards are the standards for the organic industry as promulgated and set forth by the National Organic Standards Board (NOSB).

The National Organic Standards Board is a 15-member, non-governmental, federal advisory committee created by the Secretary of Agriculture under the Organic Food Production Act ("OFPA") and the Federal Advisory Committee Act ("FACA"). By law the NOSB's makeup is a diverse constituency representing organic farming operations (4 people), organic handling operations (2), retail establishments with significant trade in organic product (1), experts in environmental protection and resource conservation
(3), public interest or consumer interest groups (3), scientific experts in toxicology, ecology or biochemistry (1) and an organic certifying agent (1).

The USDA appoints all National Organic Standards Board members, although the public is allowed to make recommendations for appointments. National Organic Standards Board members serve staggered five-year terms.

In general, the National Organic Standards Board is designed to be a public voice concerning the regulation of organic food. It is responsible for advising the Secretary of Agriculture on implementing our national organic food laws. Board is responsible for evaluating substances for inclusion on the National List of allowed
(or prohibited) synthetic substances.

Unfortunately, in the first proposed national organic rule the USDA ignored most of the National Organic Standards Board's recommendations. For example, the proposed rule allowed for genetically engineered foods even though the National Organic Standards Board specifically stated that they should not be allowed in organic.

The National Organic Standards Board meets between two to four times a year to develop recommendations on a number of issues concerning organic food. The meetings are open to the public and the Board often publishes working papers that are available for public comment. Please review the National Organic Standards Board's website at:

http://www.ams.usda.gov/nop/nosbinfo.htm for more information.

About 70% of the 73 million women are of menstruating age in the U.S. use tampons.

In the U.S., women between 11 and 60 years of age reported 216 cases of menstrual TSS reported in 1993; 244 cases in 1994

The risk of TSS is higher for women under 30 years old; 60% of patients are between 15 and 24 years of age

The fatality rate of TSS is 3% to 5%, but it is estimated that only 10% of cases of TSS are reported, as many women suffer only flu-like symptoms

Absorbency enhancers in tampons can cause peeling of the mucous membrane, vaginal dryness, ulcers, and lesions

Perfumes and fragrances in some tampons are reported to cause vaginal irritation, allergic reactions, and disruptions of a woman's microbial balance

"Tampon users were demonstrated to be 18 times more likely to develop menstrual TSS as non-users", Infectious Diseases in Obstetrics & Gynaecology, 1993, Gilles R.G. Monif

"of [Toxic Shock] cases occurring in menstruating women, up to 99% were using vaginal tampons", Obstetrics and Gynaecologic Infectious Disease, 1994, James McGregor and James Todd, (Chapter 21 - Toxic Shock Syndrome)

"Vaginal inflammation can result from rayon fibres from tampons becoming embedded in vaginal walls", Journal of Obstetrics and Gynaecology, 1980

"Rayon tampons amplify the growth of the Toxic Shock Syndrome bacteria TSST-1" American Society for Microbiology Journal, May 1994, Dr. Philip Tierno of NYU Medical Center

Dioxin levels once thought acceptable are now reported to adversely affect the reproductive and immune systems, "A Health Assessment Document for Dioxin", published by the Environmental Protection Agency, 1996

"Cotton tampons offer no protective advantage over cotton/rayon tampons with regard to protection from TSS" Journal of Infectious Diseases, October 1995 (study by Dept. of Microbiology, University of Minnesota.

Swedish studies have shown a link between tampons containing dioxin, and other chlorine by-products, and an increased risk of cancers of the female reproductive tract (especially the uterus, ovaries and bladder).

Rayon itself poses another risk. Unknown to most women, rayon and rayon-cotton blend fibers are widely used in commercial feminine hygiene products. Rayon used to make tampons is usually treated with chemicals to increase the absorption capability.

These super absorbent fibers then absorb not only the menstrual blood, but normal vaginal secretions as well, causing drying, and ulceration of vaginal tissues. The fibers can also become imbedded in the vaginal walls. Rayon fibers have been scientifically proven to amplify the production of Toxic Shock Syndrome Toxin TSST1.

Toxic Shock Syndrome is a rare bacterial illness that caused over 50 deaths between 1979 and 1980. Unlike medical grade cotton, upon which the TSS toxin will not grow, the rayon acts like a petri dish encouraging bacterial growth. What makes these toxic residues even more disturbing, is that they come in direct contact with some of the most absorbent tissue in a woman's body.

According to a doctor at New York University Medical Center, almost anything placed on this tissue, including Dioxin, gets absorbed into the body.

Why is it acceptable to have toxic substances in our feminine hygiene products? The tampon industry is convinced that women need bleached white products. They seem to think that we view this as "pure" and "clean." The fact is, if Dioxin puts women at risk for cancer and Dioxin is stored in fatty tissue (just like that found in the vagina), and a woman uses as many as 11,000 tampons in her lifetime, could the long term use of tampons increase cancer risk?

An FDA report said that "the most effective risk-management strategy would be to assure that tampons, and menstrual pads, contain no Dioxin." Although the FDA currently requires tampon manufacturers to monitor Dioxin levels, the results are not available to the public. The dioxin tests, are done by the manufacturers themselves, who insist their products are safe. Tampon manufacturers are not required to disclose ingredients to consumers, although many will do so voluntarily.

How much Dioxin exposure is considered safe for humans? Why has there been more research done on the possible health effects of chlorine-bleached coffee filters than on chlorine bleached tampons and related products? Women need to demand that more research be done on these issues. We have a right to know about any potential hazards associated with tampons and related products. It is only when women fully understand the consequences that we can make informed decisions regarding our health and well being.

Writer's note: Currently there are only a few non-chlorine bleached all cotton tampons available in the US. Ask about them at your local store, if they are not available, ask them to special order!

The Pros And Cons Of Tampons
The type of tampon you choose may affect your health By Laurel Kallenbach

Today's average woman uses an estimated 12,000 tampons in her lifetime, a convenience that allows an unprecedented freedom to be active and confident in avoiding embarrassing leaks. We've come a long way since rags pinned into undergarments or belted-on bulky pads were the norm, but with our freedom comes risk. There are potential problems attached to tampon use that every consumer should know about: Chlorine-bleached products, as some tampons are, contain traces of carcinogenic dioxins. Highly absorbent tampons may still cause toxic shock syndrome, a potentially fatal bacterial infection that occurs when tampons are worn for too long. There are even environmental ramifications, including pesticides sprayed on cotton crops and pollution created when tampon ingredients are bleached.

But, there are safe and ecological alternatives that enable women to still benefit from tampons. Here, natural is the rule of thumb. "Plainer is just better when it comes to tampons," says Pam Chandler, a family nurse practitioner and certified nurse midwife who practices at the holistic clinic Wellspring for Women in Boulder , Colo. Chandler encourages patients to use nonchlorine-bleached, 100 percent-organic cotton tampons and pads. "We're lucky to have healthier choices," she says.

Dioxin Dilemma

The most urgent tampon health concern is that chlorine-bleached and rayon-containing products carry trace amounts of dioxin, an extremely toxic chemical that is associated with cancer of the stomach, sinus lining, liver and lymph system. Many people are familiar with the danger of dioxins from publicity about Agent Orange and the Love Canal catastrophe. Tampons are linked to carcinogenic dioxin formed during the bleaching process that manufacturers use to purify and whiten both raw cotton and the wood pulp that goes into synthetic fibers such as rayon, a common fiber in tampons. "You find trace amounts of dioxin in some tampons, which have maximal contact with the vagina's mucous membrane, which absorbs substances directly into the bloodstream," explains Philip Tierno, MD, director of clinical microbiology and immunology at New York University Medical Center . To ensure that your tampon is free of dioxin, switch to a brand that's nonchlorine-bleached, rayon-free, and made of 100 percent-organic cotton. Though cotton is a natural fiber, the majority of cotton crops are heavily treated with insecticides, pesticides and herbicides. Organically grown cotton is not.

Check your tampon box for a list of ingredients. Whereas natural brands state that they're nonchlorine bleached, some conventional brands mention little on the subject, because along with the Food and Drug Administration (FDA) and the Environmental Protection Agency (EPA), they believe chlorine-dioxide bleaching is safe.

Tierno disagrees: While trace quantities of dioxin aren't in and of themselves a problem, tampons aren't your only exposure. "The problem is that measurable amounts of dioxins are everywhere, including food and water. Some portion of the dioxin that enters your bloodstream lodges in the body's fat cells and stays there a long time," he says. "This residual effect becomes progressively larger as you're exposed to even more dioxins."

The only way to avoid vaginally absorbed dioxin, Tierno says, is to eliminate chlorine-bleached and rayon-containing tampons and switch to peroxide-bleached products instead. Tierno also says if the label on your tampon box doesn't say "nonchlorine-bleached," it's possible that it contains chlorine. Most manufacturers proudly promote the fact that their product doesn't contain chlorine.

The cumulative risks of dioxin are unknown. While a single tampon may contain only 0.1 parts per trillion of dioxin, the fact that most women use between 10,000 and 15,000 tampons in a lifetime increases the exposure. "A trace quantity of dioxin is not acceptable in a tampon, because a woman does not expose herself to a single tampon," Tierno says. "It's trace quantity upon trace quantity upon trace quantity, multiplied by the number of tampons per month, multiplied by the number of months in a year, multiplied by 40 years of menstruation. Then add in all the dioxins you get from your diet, plus all the ones occurring in the environment."

Earth-friendly Options

The environmental impact of the manufacturing of feminine products is another reason to use organic tampons. While cotton tampons may seem better than synthetic, most cotton undergoes industrial bleaching in a polluting process that dumps dioxins, along with other hazardous organochlorines, into the water supply. Organic cotton tampons and pads are treated with hydrogen peroxide instead of bleach, making them a safer alternative. If the label states that the product is third-party certified organic, that means the cotton has been grown without pesticides on land where no pesticides have been applied for at least three years.

In response to concerns over dioxin in tampons and their impact on the environment, the EPA and some manufacturers have worked to find a better way of purifying wood pulp and cotton without creating dioxins. The result is chlorine-dioxide bleaching, a process that has replaced the elemental chlorine-gas method of the past but still generates low trace levels of dioxins.

The packaging of tampons is another troublesome environmental issue. Most are encased in a paper or cellophane wrapper, contain a cardboard or plastic applicator, and are packed in boxes. Though you can't recycle cotton tampons, there are waste-saving alternatives to dealing with menstruation, such as washable natural sponge tampons and cloth pads, and reusable, but awkward, vaginally inserted menstrual cups that collect flow.

Toxic Shock: Still A Risk

In the '70s and '80s, toxic shock syndrome ( TSS ) struck thousands of women. The crisis peaked in 1980 with 814 cases of TSS , of which 38 women died, most due to extended use of the high-absorbency Rely tampon. Today, women still get TSS , though cases are rarely publicized. Yet tampon safety is once again a national issue, in part due to the efforts of Rep. Carolyn Maloney, D-N.Y., who introduced a bill to address the health problems associated with tampon use. The Robin Danielson Act (HR 360) is named after a 44-year-old woman who died in 1998 from TSS because she didn't recognize her symptoms. The bill directs the National Institutes of Health to conduct reliable, independent research to determine the health risks posed by the presence of synthetic fibers, dioxin and other additives in tampons.

TSS is caused when staph or strep bacteria grow in the vagina, usually encouraged by the presence of a higher absorbency tampon or one that has been inserted more than eight hours. The bacteria produce toxins that are absorbed into the bloodstream, which can cause a severe drop in blood pressure (shock) and/or organ failure, especially of the liver and kidneys. In some cases, TSS is fatal. Its symptoms are similar to the flu, including a high fever, vomiting and diarrhea, muscle aches, dizziness or fainting, a red rash, headaches, bloodshot eyes and sore throat.

"Highly absorbent tampons, especially those containing synthetic fibers, increase the amounts of toxin present in the vagina," says Tierno.

In the mid-'70s, synthetic fibers were used in tampons because manufacturers wanted to produce more absorbent, leak-resistant products. Since then, three of the four problematic synthetics have been eliminated from tampons. "The only one left is viscose rayon," Tierno says.

To minimize your risk of contracting TSS , choose a tampon made of 100 percent cotton, preferably organic. "You're at the lowest risk possible with cotton," says Tierno. "In my research, every synthetic fiber amplified toxin development, whereas cotton did not."

Most precautions for guarding against TSS are simple, says holistic nurse practitioner Pam Chandler, a specialist in women's health care. Wear a tampon for a maximum of six to eight hours to avoid bacterial growth. However, she recommends leaving it in for at least two hours. "If you remove a tampon too soon, it won't be saturated," she says. "Then you risk scraping the dry, fragmented cotton across the vaginal mucosa, irritating it and setting the scenario for infection." Also, using a tampon overnight, when planning to sleep longer than eight hours, is risky. At night, consider wearing a pad instead, she advises.

Choosing a tampon with proper absorbency is crucial to preventing TSS . "At the beginning of your period, if your flow is heavy, you may need Super Absorbency so you don't have to change tampons too often," says Chandler . When the flow slows, however, don't be tempted to continue with a Super because it's more convenient. Switch to a lower absorbency tampon instead. Also, use tampons only during menstruation.

Careful Liberation

Within the last couple of years, a rash of e-mails warned women that tampon manufacturers put asbestos in their tampons to make women bleed more in hopes of selling more product. Tierno says the rumor was false. "I have been privy to every manufacturer's records over the last 21 years, and I have never seen anything related to asbestos in tampons," he says.

Though the asbestos scare amounted to nothing but an urban myth, true additives to be concerned about are fragrances and deodorants. Perfumes may mask odors, but some women suffer allergic reactions to them. "Without question, a deodorized tampon is dangerous," asserts Tierno, adding that deodorants encourage overgrowth of certain bacteria, upset the vagina's normal flora and irritate the mucous membrane.

The main point, when it comes to tampon use, is to stay informed and weigh the options. "Over the years, tampons have allowed women to be more active and fuss less during their periods," says Chandler , who points out that while this is liberating, it also makes it easy to take their use for granted.

Toxic shock syndrome is a rare infection that can happen during a woman's period. The symptoms include a sudden fever of over 101 degrees or more, diarrhea (the runs), vomiting (throwing up), muscle aches and a sunburn-like rash. If you have these symptoms during you period, see a doctor right away.

3. Change your tampon at least every 4-6 hours (read the tampon manufacturers information inside the box).

5. Do not use a birth control sponge or diaphragm during your period. During your period it is preferable to use other methods such as condoms and/or foam.

There are allegations that tampons made from rayon, or cotton with rayon, may cause or be a contributing factor to Toxic Shock Syndrome, as well as vaginal dryness or ulcerations of vaginal tissues.

Toxic Shock Syndrome is a rare but potentially fatal disease caused by a bacterial toxin. (Different bacterial toxins may cause Toxic Shock Syndrome, depending on the situation, but most often streptococci and staphylococci are responsible.) The number of reported Toxic Shock Syndrome cases has decreased significantly in recent years. Approximately half the cases of Toxic Shock Syndrome reported today are associated with tampon use during menstruation, usually in young women. Toxic Shock Syndrome also occurs in children, men, and non-menstruating women. In 1997, only five confirmed menstrual-related Toxic Shock Syndrome cases were reported, compared with 814 cases in 1980 [according to data from the Centers for Disease Control and Prevention (CDC)]. Although scientists have recognized an association between Toxic Shock Syndrome and tampon use, the exact connection remains unclear. Research conducted by the CDC suggested that use of some high absorbency tampons increased the risk of Toxic Shock Syndrome in menstruating women. A few specific tampon designs and high absorbency tampon materials were also found to have some association with increased risk of Toxic Shock Syndrome. These products and materials are no longer used in tampons sold in the U.S. Tampons made with rayon do not appear to have a higher risk of Toxic Shock Syndrome than cotton tampons of similar absorbency.

Vaginal dryness and ulcerations may occur when women use tampons more absorbent than needed for the amount of their menstrual flow. Ulcerations have also been reported in women using tampons between menstrual periods to try to control excessive vaginal discharge or abnormal bleeding. Women may avoid problems by choosing a tampon with the minimum absorbency needed to control menstrual flow and using tampons only during active menstruation.

To help women compare absorbency from brand to brand, FDA requires that manufacturers measure absorbency using a standard method and describe absorbency on the package using standardized terms. Thus, the terms "junior," "regular," "super," and "super plus," always describe a specific range of tampon absorbency regardless of the brand.

Historical Perspectives Reduced Incidence of Menstrual Toxic-Shock Syndrome -- United States, 1980-1990

In May 1980, investigators reported to CDC 55 cases of toxic-shock syndrome (TSS) (1), a newly recognized illness characterized by high fever, sunburn-like rash, desquamation, hypotension, and abnormalities in multiple organ systems (2). Fifty-two (95%) of the reported cases occurred in women; onset of illness occurred during menstruation in 38 (95%) of the 40 women from whom menstrual history was obtained. National and state-based studies were initiated to determine risk factors for this disease. In addition, CDC established national surveillance to assess the magnitude of illness and follow trends in disease occurrence; 3295 definite cases have been reported since surveillance was established (Figure 1).

In June 1980, a follow-up report described three studies which detected an association between Toxic Shock Syndrome and the use of tampons (3). Case-control studies in Wisconsin and Utah and a national study by CDC indicated that women with Toxic Shock Syndrome were more likely to have used tampons than were controls. The CDC study also found that continuous use of tampons was associated with a higher risk of Toxic Shock Syndrome than was alternating use of tampons and other menstrual products. Subsequent studies established that risk of Toxic Shock Syndrome was substantially greater in women who used Rely brand tampons than in users of other brands and that risk increased with increased tampon absorbency (4-6). In September 1980, Rely tampons were voluntarily withdrawn from the market by the manufacturer.

In 1980, 890 cases of Toxic Shock Syndrome were reported, 812 (91%) of which were associated with menstruation. In 1989, 61 cases of Toxic Shock Syndrome were reported, 45 (74%) of which were menstrual. In 1980, 38 (5%) of 772 women with menstrual Toxic Shock Syndrome died; in 1988 and 1989, there were no deaths among women with menstrual Toxic Shock Syndrome. Reported by: Meningitis and Special Pathogens Br, Div of Bacterial Diseases, Center for Infectious Diseases, CDC.

Clostridium sordellii Toxic Shock Syndrome After Medical Abortion with Mifepristone and Intravaginal Misoprostol --- United States and Canada, 2001--2005

On July 22, this notice was posted as an MMWR Dispatch on the MMWR website (http://www.cdc.gov/mmwr).

On July 19, 2005, the Food and Drug Administration (FDA) issued a public health advisory regarding the deaths of four women in the United States after medical abortions with Mifeprex^® (mifepristone, formerly RU-486; Danco Laboratories, New York, New York) and intravaginal misoprostol (1). Two of these deaths occurred in 2003, one in 2004, and one in 2005. Two of these U.S. cases had clinical illness consistent with toxic shock and had evidence of endometrial infection with Clostridium sordellii, a gram-positive, toxin-forming anaerobic bacteria. In addition, a fatal case of C. sordellii toxic shock syndrome after medical abortion with mifepristone and misoprostol was reported in 2001, in Canada (2). All three cases of C. sordellii infection were notable for lack of fever, and all had refractory hypotension, multiple effusions, hemoconcentration, and a profound leukocytosis. C. sordellii previously has been described as a cause of pregnancy-associated toxic shock syndrome (3).

Investigation by FDA, CDC, and state and local health departments into the two most recently identified U.S. deaths after medical abortion is ongoing. Empiric therapy for patients suspected of having postpartum or postabortion toxic shock syndrome should include antimicrobials with anaerobic activity against Clostridium species. Health-care providers are encouraged to report any cases of postpartum or postabortion toxic shock syndrome to their state or local health department and to CDC at telephone 800-893-0485. Cases potentially associated with use of mifepristone or misoprostol should also be reported through the FDA MedWatch system available at http://www.fda.gov/medwatch/index.html or telephone 800-FDA-1088.

References

Editorial Note

Editorial Note: The number of Toxic Shock Syndrome cases reported annually to CDC has decreased substantially in the 10-year period since menstrual Toxic Shock Syndrome was first recognized. Changes in public awareness and diminished attention to Toxic Shock Syndrome in the medical literature might have resulted in reduced diagnosis and reporting. However, reporting of non-menstrual Toxic Shock Syndrome has remained constant during this time while menstrual Toxic Shock Syndrome reporting has decreased.

A multistate active surveillance study in 1986-1987 confirmed the trends detected by national passive surveillance (7). Through active case-finding efforts in an aggregate population of 34 million persons, the rate for menstrual Toxic Shock Syndrome was determined to be 1.0 per 100,000 women 15-44 years of age (7). This rate represented a substantial reduction from rates reported in similar studies in 1980 (6.2 per 100,000 women 12-49 years of age in Wisconsin (8), 9.0 per 100,000 women 12-45 years of age in Minnesota (9), and 12.3 per 100,000 women 12-49 years of age in Utah (10)). Active surveillance also confirmed that the proportion of Toxic Shock Syndrome associated with menstruation had decreased considerably: in 1988, menstrual Toxic Shock Syndrome accounted for 55% of cases detected both by active surveillance (7) and by the passive surveillance system.

A principle reason for the decreased incidence of menstrual Toxic Shock Syndrome may be decreases in the absorbency of tampons. In 1980, when tampon absorbency (in vitro) ranged from 10.3-20.5 g (4), very high absorbency products ( greater than 15.4 g) were used by 42% of tampon users (9). After the association between Toxic Shock Syndrome and absorbency was recognized, manufacturers lowered the absorbency of tampons. In 1982, the Food and Drug Administration (FDA) issued a regulation requiring that tampon package labels advise women to use the lowest absorbency tampons compatible with their needs. By 1983, tampon absorbency ranged from 6.3-17.2 g (6), and the proportion of tampon users using very high absorbency tampons had declined to 18%. By 1986, very high absorbency products were used by only 1% of women who used tampons. Effective March 1990, the FDA instituted standardized absorbency labeling of tampons, which currently range from 6-15 g.

Tampon composition has also changed since 1980. Rely tampons consisted of polyester foam and cross-linked carboxymethylcellulose, a combination that is no longer used in tampons. Polyacrylate-containing tampons were withdrawn from the market in 1985. Current tampons are manufactured from cotton and/or rayon. The unique composition of Rely tampons may have been responsible for the increased risk associated with those products (11); however, the role of current tampon composition as an independent risk factor for Toxic Shock Syndrome is unclear since composition may vary even for a particular brand and style of tampon marketed at a given time.

Other factors may have contributed to decreased reports of menstrual-related Toxic Shock Syndrome. For example, public awareness of the syndrome may cause women to seek medical care earlier in their illness; milder disease may not meet the surveillance case definition of severe multisystem illness. Increased variety in menstrual products and concern related to Toxic Shock Syndrome may have resulted in fewer women using tampons or fewer using tampons continuously.

Current public health efforts to prevent menstrual-related Toxic Shock Syndrome include tampon package labels and package inserts which describe early signs and symptoms of Toxic Shock Syndrome and warn the consumer about the risk associated with tampons. Tampon users are encouraged to select lower absorbency products to further decrease risk of Toxic Shock Syndrome. Standardized absorbency labeling permits consumers to compare absorbency between brands.

The precise mechanism by which Rely tampons increased the risk of Toxic Shock Syndrome is unknown. The increased risk associated with high absorbency tampons is also poorly understood; high absorbency may be a surrogate for another effect. However, the withdrawal of Rely tampons and the subsequent decrease in use of high absorbency tampons correlate with a marked decrease in incidence of menstrual-related Toxic Shock Syndrome. The rapid demonstration of the risk of Rely and high absorbency tampons resulted in prompt public health interventions and substantial reduction in menstrual Toxic Shock Syndrome.

References

2. Todd J, Fishaut M, Kapral F, Welch T. Toxic-shock syndrome associated with phage-group-1 staphylococci. Lancet 1978;2:1116-8.

4. Osterholm MT, Davis JP, Gibson RW, et al. Tri-state toxic-shock syndrome study: I. Epidemiologic findings. J Infect Dis 1982;145:431-40.

5. Schlech WF, Shands KN, Reingold AL, et al. Risk factors for development of toxic shock syndrome: association with a tampon brand. JAMA 1982;248:835-9.

6. Berkley SF, Hightower AW, Broome CV, Reingold AL. The relationship of tampon characteristics to menstrual toxic shock syndrome. JAMA 1987;258:917-20.

7. Gaventa S, Reingold AL, Hightower AW, et al. Active surveillance for toxic shock syndrome in the United States, 1986. Rev Infect Dis 1989;2(suppl S1):S35-42.

8. Davis JP, Chesney PJ, Wand PJ, LaVenture M, the Investigation and Laboratory Team. Toxic-shock syndrome: epidemiologic features, recurrence, risk factors, and prevention. N Engl J Med 1980;303:1429-35.

9. Osterholm MT, Forfang JC. Toxic-shock syndrome in Minnesota: results of an active-passive surveillance system. J Infect Dis 1982;145:458-64. 10. Latham RH, Kehrberg MW, Jacobson JA, Smith CB. Toxic shock syndrome in Utah: a case-control and surveillance study. Ann Intern Med 1982;96:906-8. 11. Broome CV. Epidemiology of TSS in the United States: overview. Rev Infect Dis 1989;2 (suppl S1):S14-21.

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Clostridium sordellii Toxic Shock Syndrome After Medical Abortion with Mifepristone and Intravaginal Misoprostol --- United States and Canada, 2001--2005

References

Editorial Note

References