Beyond Blue

Beyond Blue


Do Antidepressants Dull Emotions?An Interview with Ron Pies, M.D.

posted by Beyond Blue

Ron Pies photo 2.jpg
On Fridays I will address a question related to depression and find the answer from an expert. If you have a question you want answered, please ask it on the combox of this post, and I’ll try my best to do some research and feature it in an upcoming Friday post.

Today I have the pleasure of interviewing one of my favorite psychiatrists, Dr. Ron Pies. Dr. Pies is Professor of Psychiatry and Lecturer on Bioethics and Humanities at SUNY Upstate Medical University, Syracuse NY; and Clinical Professor of Psychiatry at Tufts University School of Medicine, Boston. He is the author of “Everything Has Two Handles: The Stoic’s Guide to the Art of Living.”

Question: You’ve written a lot of the topic of grief and depression. How does a person know when grief becomes depression or another mood disorder?

Dr. Pies: I think it’s important to understand that grief is often a component of clinical depression, so the two are by no means mutually exclusive. For example, a mother may be experiencing intense grief over her recently deceased child, which would be an expectable and quite understandable reaction to such a devastating loss. As I try to explain in my essay on this topic, grief may take one of several “paths”, over longer periods of time. Through a process of mourning; receiving comfort from loved ones; and “working through” the meaning of the loss, most grieving persons are able eventually to move on with their lives. Indeed, many are able to find meaning and spiritual growth in the admittedly painful experience of grieving and mourning. Most such individuals, however, are not crippled or incapacitated by their grief, even when it is very intense.

In contrast, some inviduals who experience what I have called “corrosive” or “unproductive” grief are, in a sense, devoured by their grief, and begin to develop signs and symptoms of a major depressive episode. These individuals may be consumed by guilt or self-loathing–for example, blaming themselves for the death of a loved one, even when there is no logical basis for doing so. They may come to believe that life is not worth living any longer, and contemplate or even attempt suicide. In addition, they may develop bodily signs of a major depression, such as severe weight loss, persistent early morning awakening, and what psychiatrists call “psychomotor slowing”, in which their mental and physical processes become extremely sluggish. Some have likened this to feeling like a “zombie” or like “the living dead.”

Clearly, folks with this kind of picture are no longer in the realm of ordinary or “productive” grief–they are clinically depressed and need professional help. But I would resist the notion that there is always a “bright line” between grief and depression–Nature doesn’t usually provide us with such clear demarcations.

Question: I very much enjoyed your piece on Psych Central, “Having Problems Means Being Alive.” Early in my recovery, I was so afraid to take medication because I thought that it would numb my feelings, keep me from experiencing life’s highs and lows. What would you say to a person who is clinically depressed but afraid to take medication for that very reason?

Dr. Pies: People who are told by a physician that they would benefit from antidepressant medication, or a mood stabilizer, are understandably anxious about possible side effects from these medications. Before addressing the question you raise, though, I think it is important to note–as you may know from your own experience–that depression itself often leads to a blunting of emotional reactivity and an inability to feel the ordinary pleasures and sorrows of life. Many people with severe depression tell their doctors that they feel “nothing”, that they feel “dead” inside, etc. Probably the best description I’ve seen of severe depression is William Styron’s account of his own depression, in his book, “Darkness Visible”:

Death was now a daily presence, blowing over me in cold gusts. Mysteriously and in ways that are totally remote from normal experience, the gray drizzle of horror induced by depression takes on the quality of physical pain…. [the] despair, owing to some evil trick played upon the sick brain by the inhabiting psyche, comes to resemble the diabolical discomfort of being imprisoned in a fiercely overheated room. And because no breeze stirs this caldron, because there is no escape from the smothering confinement, it is entirely natural that the victim begins to think ceaselessly of oblivion… In depression the faith in deliverance, in ultimate restoration, is absent…

I present this description to place the question of antidepressant side effects in perspective: how bad could the side effects be, in comparison with severe depression itself?

Nevertheless, you raise a good question. There is, in fact, some clinical evidence that a number of antidepressants that boost the brain chemical serotonin (sometimes referred to as “SSRIs”) may leave some individuals feeling somewhat “flat” emotionally. They may also complain that their sexual energy or drive is reduced, or that their thinking seems a little “fuzzy” or slowed down. These are probably side effects of too much serotonin–perhaps overshooting what would be optimal in the brain. (By the way, in pointing this out, I am not taking the position–sometimes promoted by pharmaceutical companies–that depression is simply a “chemical imbalance”, that can be treated merely by taking a pill! Depression is, of course, much more complicated than that, and has psychological, social, and spiritual dimensions to it).

The sort of emotional “flattening” I have described with SSRIs may occur, in my experience, in perhaps 10-20% of patients who take these medications. Often, they will say something like, “Doctor, I no longer feel that deep, dark gloom I used to feel–but I just feel kind of ‘blah’…like I’m not really reacting much to anything.” When I see this picture, I will sometimes reduce the dose of the SSRI, or change to a different type of antidepressant that affects different brain chemicals–for example, the antidepressant bupropion rarely causes this side effect (though it has other side effects). Occasionally, I may add a medication to compensate for the SSRI’s “blunting” effect.

Incidentally, for individuals with bipolar disorder, antidepressants may sometimes do more harm than good, and a “mood stabilizer” such as lithium is the preferred treatment. Careful diagnosis is needed to make the correct “call”, as my colleague Dr. Nassir Ghaemi has shown [see, for example, Ghaemi et al, J Psychiatr Pract. 2001 Sep;7(5):287-97].

Studies of patients with bipolar disorder who have taken lithium generally suggest that it does not interfere with normal, everyday “ups and downs”, nor does it appear to reduce artistic creativity. On the contrary, many such individuals will affirm that they were able to become more productive and creative after their severe mood swings were brought under control.

I do want to emphasize that most patients who take antidepressant medication under careful medical supervision do not wind up feeling “flat” or unable to experience life’s normal ups and downs. Rather, they find that–in contrast to their periods of severe depression–they are able to enjoy life again, with all its joys and sorrows. (Some good descriptions of this may be found in my colleague, Dr. Richard Berlin’s book, “Poets on Prozac”).

Of course, we have not dealt with the importance of having a strong “therapeutic alliance” with a mental health professional, or the benefits of “talk therapy”, pastoral counseling, and other non-pharmacological approaches. I virtually never recommend that a depressed patient simply take an antidepressant–that is often a recipe for disaster, since it assumes that the person will not require counseling, support, guidance, and wisdom, all of which ought to be part of the recovery process. As I often say, “Medication is just a bridge between feeling awful and feeling better. You still need to move your legs and walk across that bridge!”

To read more Beyond Blue, go to http://blog.beliefnet.com/beyondblue, and to get to Group Beyond Blue, a support group at Beliefnet Community, click here.

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BARBARA MARTIN

posted May 22, 2009 at 10:27 am


ALL I CAN SAY ABOUT ANTIDEPRESSANTS IS I AM BRAIN DAMAGED FROM A CAR ACCIDENT FROM 2001. I AM ON WEELBUTRIN, 150MG, NOW, BUT WAS ON MAX DOSAGE WITH I KNEW TO BE A REACTION BECAUSE I NEEDED A SUPPLEMENT. I FOUND MYSELF IN THAT “DARK PLACE” OF DEPRESSION. I WENT TO AN 8 WEEK OUTPATIENT PROGRAM AND TO LIFT ME OUT TOOK CERTAIN POINTS I HAD TO HEAR. THE SUPPLEMENTAL MED I WAS GIVEN IS EFFEXER, 225MG. THAT ACTUALLY IS VEY GOOD. I KNOW MY BODY WELL AND IT FITS. I HAVE SEEN PEOPLE DEPENDENT ON MEDS. I HAVE A PRN FOR ATIVAN IN TIMES OF GREAT STRESS, BUT I TAKE THAT MINIMALLY. SOME PEOPLE USE IT AS A CRUTCH. AN ESCAPE FROM LIFE. THAT IS THE PROBLEM WITH MEDICATION TODAY THOUGH. IT IS EASIER TO TAKE A PILL THAN FACE YOUR FEARS HEAD ON OR SAY, “YES, I HAVE A PROBLEM” nOW ,LUCKY ME, MY BRAIN DAMAGE IS MOSTLY IN MY LEFT FRONTAL LOBE AND THE LIMBIC SYSTEM, IN THAT CENTRAL PLACE, SO WHEN I GET STRESSED, I EXPERIENCE, LIKE NOW, WHAT LOOK LIKE GRAND MAL SEIZURES, I FALL DOWN AND MY BLOOD PRESSURE DROPS, MY TACHYCARDIA ACTS UP AND I GET HORRIBLE MIGRAINES, ALL FROM STRESS. I AM STILL IN THERAPY, BUT I HAVE COME A LONG WAY, BUT UNFORTUNATELY, DID NOT SAVE MY MARRIAGE. GOD HAS SAVED MY LIFE WITH THE ACCIDENT, WHICH HE HAS GIVEN ME MORE BACK THAN I COULD EVER ASK. I HAVE 2 BEAUTIFUL KIDS I WHO WILL VISIT ME AND I WILL HAVE A NEW BEGINNING. ANYONE DEPRESSED HAS TO LOOK AT THE SUNSHINE AGAIN, THE RAINBOWS. I FOUND A WHOLESALE PLACE ON THE INTERNET FOR BONSAI TREES. SOMETHING TO START WITH AND BUILD SLOWLY AGAIN.



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Larry Parker

posted May 23, 2009 at 9:04 am


Therese:
I cannot tell you what an important post this is.
You will find dozens, probably hundreds of blogs out there of people who say they were harmed by psychiatric medications and therefore they should be banned because they are unsafe.
In my own (non-scientific) research, there are some medications that should be banned, or at least made last-line instead of first-line, because by their very chemical nature they can cause diseases such as diabetes type II.
There are, of course, other drugs that if not monitored closely can cause toxic side effects (lithium) or rare but potentially fatal diseases (Lamictal, Clozaril). And some simply cause random, allergic reactions in people. Some of the voices on the Web document such harm and deserve to be heard — after all, I take two of the three drugs I just listed, and have suffered several psych med allergies. So I am not a Big Pharma rep by any means.
Yet and still, no one throughout the blogosphere has answered the central question you and Dr. Pies have raised — what side effect to one’s MOOD could possibly be worse than the crippling nature of mental illness? (Without meaning to denigrate the phenomenon that SSRI’s sometimes cause — where someone’s ability to act is spurred before their mood is — resulting sometimes in a temporarily increased suicide risk.)
Scratch the surface of these arguments, and most of the time you find people who think depression is good, not bad, and that it is a secular “dark night of the soul” that makes one a stronger person and therefore must be suffered through. With your background in Catholic theology, you have demolished this argument throughout your Beyond Blue columns — identifying the differences between deep religious and horrible medical experiences — and this is to be applauded.
I’m sorry, but in my opinion, happiness and being alive are not “negative side effects,” even if I do (as noted) have very real side effects from some of my medications. Overall, though some psych med side effects are documented and highly dangerous (and worse, in some cases, unnecessary, I don’t see where the risk/reward ratio from treating depression medically (along with therapy, prayer/meditation, diet, exercise, self-talk, etc.) is any worse than it is for other potentially fatal diseases. And depression of all sorts is potentially fatal, make no mistake.
Or would we ban chemotherapy because the terrible side effects it causes (far worse than almost any from psychiatric medications) are worse than death from cancer?



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Ronald Pies MD

posted May 24, 2009 at 9:02 pm


Many thanks to Therese Borchard, not only for her willingness to interview me, but also for the fine work she does on this website!
Thanks also to Barbara Martin and Larry Parker for their perspectives on depression. I think Mr. Parker makes very good points re: the net benefits (for many people, not all) of antidepressants, when properly prescribed and carefully monitored. Those qualifications are very important–these are not “set and forget” medications! The patient’s response and possible side effects need to be carefully assessed. For a more detailed perspective on why antidepressants should neither be deified nor demonized, readers may want to see my essay on the Psychcentral website, entitled “Devil or Angel?”
http://psychcentral.com/blog/archives/2008/03/02/devil-or-angel-the-role-of-psychotropics-put-in-perspective/
Best regards,
Ron Pies MD



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katbird_27

posted May 25, 2009 at 12:08 pm


I like how it was mentioned that medication shouldn’t be the only answer. the one time i told a practitioner i felt depressed her first response was do you want medication for that. i am proud to say no. not because i feel i didn’t need it, but because pills shouldn’t be offered for depression without some form of testing/assessment.



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Your Name

posted May 25, 2009 at 12:49 pm


my husband was in a motorcycle accident 2 yrs. ago and before that he
was on a antidepressent drug called paxill now he has been changed to
lexapro. He had swelling in the brain and he had to have almost 19
different surgeries but he is always unhappy and gets mad at the least
of anything what do you know about the drug lexapro.



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rosafreeman

posted May 25, 2009 at 1:31 pm


plzzzzzz,help, start community places for the vet’s that are coming home, i’am married, to a vet’ from the vietnam, desertstorm, war, and it is CLEAR, these people need, psy, meds, and continued, follow-up. i, feel, that we will only hear, about war veterans, thinking, freinds and family, members are the enemy, and KILLING, inocent people. my question IS, what are dotors planing, to do to help,those coming, home from the war, to get and stay on their meds.? and yes, antidepressant do dull the emotions.



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Your Name

posted May 25, 2009 at 2:38 pm


This is a very good discussion. I have taken psychotropic medications from doctors since I was 21. I am now over 60. Lithium made me very fat, and forced me to take 9 potassium pills a day plus magnesium because the lithium washed it away. All under doctor’s instructions.
After 11 years on lithium, they started me on Tegretol as my main meds, and I have been on that since ’86. I have always taken my meds as prescribed.
Now one time I talked my family doc into decreasing the lithium, and had a little manic episode, but went right to the shrink, and got straightned out very quickly. I have always been compliant, always taken what was prescribed. Now, indeed, my last shrink, who btw does no talking therapy, increased Abilify from 7 1/2 to 30 in less than a month, and I couldn’t walk straight, and felt it very dangerous. But I ran it by him and he agreed to the 15 mg. until I see him next week.
What must be remembered in this discussion is electronic records. Only a dull, average IQ person would not recognize 24/7 monitoring.
Last year, as soon as I saw it was happening, I complained and got sent to shrink, who changed my meds. That was OK, got off that heavy dose of Seroquel at night. However, when I recognized it this time, though I tried to not annnounce I knew I was being monitored, still, it drove me nuts so to speak, and family insisted I was ‘sick’ again. Poor guy. And up went the Abilify.
Yes, something needs to be done about health care. This doctor was the only one I could find that was on my provider list in this area.
I went for about three years after my shrink of 20 years retired, without a regular shrink. This is when I nearly became unglued. Because the most important element in treating bipolar or its ugly cousin diseaes is continuity and a place to call if you are in trouble. I had not been in hospital for three decades.
This current medical intervention, though it has so far saved my life, actually threw me into mania and sleeplessness. For, I have never had such crime and punishment issues thrown at me, and still don’t know the details. Plus, can you tell the difference in Mania and being in love??????



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Clarice Baker

posted May 25, 2009 at 2:47 pm


Hi
For the past year I have been feeling very depress. Sometimes I cry other times I am just sad. I know the reason why I am feeling this way is because I suffered with Breast Cancer twice and now I am suffering with Lymophedia and COPD. I also need a need replacement and now arthistis is settling in my right hand and my left arm stays swollening all of the times from the fluid running down into my left arm and hands. What really making me feel depress even more is that I applied for my social security disability and I am being turn down. Shoould I seek professional help?



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Your Name

posted May 25, 2009 at 2:57 pm


My second husband started becoming abusive shortly after my daughter was born..I realized he had many childhood issues & that he needed help and I could not help him..but I loved this man. He was literally two people, but resisted marriage counselling, and shortly after started drinking and drugging again, went into a Rehab,and started therapy with a great therapist..I did not realize the damage it was doing to me, by staying with him. I had spent 10 years in therapy after my first abusive marriage and swore I would never put up with an abusive man again..well I wound up staying way too long and this started my Depression. I can see this all now..that I should have left sooner..I am taking Cymbalta which keeps my head above water, but I believe I am suffering from PTSD more than the Depression. I believe I am working through the grief of what this man has caused me(he was vindictive if I would not take him back,caused me such pain by playing custody games, getting child support..it’s been awful)..I’m a nurse(40+yrs),and always worked..I was diagnosed with Fibromyalgia 3 yrs ago..and have such terrible physical pain..I find it hard keeping a job..Finding this website and the comments of Dr. Pies is helping me alot..So many Psychiatrists and Therapists want to dictate to you, and fail to listen to what you need and what you are saying..Thank you for your information and advice..



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Your Name

posted May 25, 2009 at 9:10 pm


You know I am eternally grateful that someone is finally taking a look at what is wrong with me. I am glad I am not like that woman who has COPD. If I did, noone would tell me, because they all think I am “Superwoman” when a job needs to be done….but sick when a secret or a subject needs to be discussed. Old Dr. House can’t check me out. Ha. Because now my TV is not working…or I should say the satillete channels. Really wanted to see the ballgame. Buttttt…I guess I am isolated. If someone would tell me the rules of the game, I would certainly comply. I am so tired of running the race, when I don’t know the rules or the game plan. I could have rehabilitated in 1/2 the time if someone family or friends, had told me the rules of the game. It has been heart breaking to have to find them out, everytime too late. Oh, well. Still, feel the need for human touch, and talk later.



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Your Name

posted May 26, 2009 at 12:26 am


I KNOW HOW TO COMPLY WITH THE RULES.WHEN MY DOCTOR SAY TAKE THIS MED.
3 TIMES A DAY,VERY 4 HRS.,ETC.AND I KNOW HOW TO READ INSTRUCTION TO TAKE ALL THE MEDICATIONS OTHERWISE,A HARDHEADED PATIENT WILL NEVER
GET BETTER FOR FAILURE TO COMPLY.SOMETIMES THERE WERE DOCTORS THAT
ARE VERY TLC TO PATIENTS,ESPECIALLY IF THE DOCTOR IS AN IMMEDIATE FAMILY SO HE HIS MONITORING IS TOO MUCH AND RESULTED TO WORRY.
SOMETIMES TRUST BETWEEN DOCTOR AND PATIENT IS IMPORTANT BUT OF COURSE
UNDER AN APPROVED CONFIDENCE ON THE PART OF THE DOCTOR TO THE PATIENT
THAT ALL IS WELL.THIS IS JUST MY SUGGESTION.



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Your Name

posted May 26, 2009 at 10:17 am


Hi!
I have a question regarding menopause and depression. I just turned 50 last August and my doctor told me that I was perimenopausal, but my question is: when does menopause go away because my doctor told me that I will not have it forever? Thanks!



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Ronald Pies MD

posted May 26, 2009 at 8:46 pm


I would like to thank each of the individuals who have commented above for their observations and comments. I know that behind each story, there is much more to be said. I can’t offer specific medical advice; however, I will comment very briefly on a few points raised in these messages:
1. I absolutely agree that “…pills shouldn’t be offered for depression without some form of testing/assessment…”! Although many professionals can provide such an assessment, the time and thoroughness can vary greatly. Whether it is your family doctor, a nurse practitioner, a psychiatrist, or other mental health
professional, enough time should be allowed to discuss medical, family, social, and psychological factors that may be involved in your depression. Ordinarily, this can’t be done in less than a half-hour of careful assessment, and an hour is even better!
2. Paxil and Lexapro are both antidepressants in the so-called SSRI family, and have very similar actions in the brain. Brain injury can lead to significant changes in mood and behavior. Sometimes, antidepressants may be helpful, but other types of medication can also be used, as can behavioral forms of therapy, and a
specialist in head injury is a good source for a “second opinion”.
3. I completely agree that much more needs to be done to help our returning soldiers! At present, the over-loaded mental health system is probably not equipped to deal with the many psychologically-wounded individuals who are returning from Iraq and Afghanistan. Within the military itself, there is great reluctance to seek professional help on the part of many soldiers with emotional
problems, for fear it will damage chances for further service and promotion. Unfortunately, there isn’t a lot the average doctor can do by him-or herself to improve the situation. But– by putting pressure on our elected representatives, and working in concert with appropriate veterans’ rights organizations, we can all do more, in my view.
4. Medical illnesses, including cancer and breathing disorders, are often associated with depressive symptoms. But having “a reason” for being depressed does not mean the condition shouldn’t be treated professionally, if it is severe, prolonged, and incapacitating. Treatment by a mental health professional may involve supportive “talk therapy”, or, in carefully-selected cases, antidepressant medication–and often, both. More general information on signs and symptoms of major depression are available on the Mayo Clinic website:
http://www.mayoclinic.com/health/depression/DS00175.
5. Perimenopause usually refers to the 2-8 years leading up to menopause. As the Mayo site notes, “Menopause, or the permanent end of menstruation and fertility, is a natural biological process, not a medical illness. Even so, the physical and emotional symptoms of menopause can disrupt your sleep, sap your energy and — at least indirectly — trigger feelings of sadness and loss.”
For many women, menopause is “no big deal”–for some, it can be a time in which feelings of loss or sadness can evolve into a clinical depression [see above website for major depression]. Depression is also seen in the perimenopausal years, and, if severe, also warrants clinical attention. Each woman’s experience with these periods of life is unique, and the approach needs to be tailored accordingly. For some, emotional support is helpful; for others, hormonal
treatments may be appropriate; for others, an antidepressant may be worth considering. And probably most menopausal women will need no professional help at all! More information on perimenopause and menopause are also available on the Mayo Clinic website, at: http://www.mayoclinic.com/health/perimenopause/DS00554. Talking with your family doctor is always a good place to start, too!
Sincerely, Ronald Pies MD



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Brian Hildebrandt

posted August 5, 2009 at 11:24 pm


For myself I’ve found the SSRI’s like Prozac have definitely numbed my emotions. It felt like I wasn’t alive and couldn’t have normal reactions to events.
I’ve faired better on Wellbutrin and low dose Abilify which tends to lift my depression but doesn’t dampen my emotions. This means I still may have some lows but I’m able to feel the highs now as well… which I am truly grateful.



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menozac

posted July 28, 2010 at 12:01 am


Recently I was supposed to go get a prescription of anti-depressants but I’m pretty nervous to go through with it. Depression runs in my family though, my mom has it, her mom has it, my aunt has it. We are just plagued by it. This just gives me all the more reason to not want to use anti depressants. Thanks for the post!



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susan

posted July 28, 2010 at 12:03 am


Recently I was supposed to go get a prescription of anti-depressants but I’m pretty nervous to go through with it. Depression runs in my family though, my mom has it, her mom has it, my aunt has it. We are just plagued by it. This just gives me all the more reason to not want to use anti depressants. Thanks for the post!
menozac review



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Treadmill Belts

posted September 13, 2010 at 2:07 pm


I’ve heard that some symptoms of depression are normal, and you shouldn’t rush and get your child medication, but that they will grow out of it eventually? what do you think?



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Best Treadmill

posted September 14, 2010 at 12:54 pm


From what I’ve seen, children that take antidepressants are full of emotion! thanks for the article!



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Dr. Tom Gibson, D.C.

posted October 29, 2010 at 5:07 pm


Antidepressants are also used in the medical treatment of migraines. Although they help patients find relief, they do not address the underlying cause of migraines, nervous system disorder. http://www.themigrainedoctor.com



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