Judy Foreman

Nationally Sindicated Fitness, Health, and Medicine Columnist

Alcohol’s insidious grip

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Barbara Raymond, now in her mid-50’s, started drinking hard as a 15-year-old in Abington. At the time, she had no idea why, though she later linked it to depression.

She made her first suicide attempt at 16. At 18, in the throes of alcoholic amnesia, she married a man she’d known for two weeks. He turned out to be an alcoholic and a batterer who broke her arm and gave her “a bunch of bruises” over the years. She rarely sought care, she says: “I was too ashamed.”

By 24, she’d had six kids and several more suicide attempts. After the last, she ended up “dead on arrival” at a local hospital, where doctors revived her and someone suggested Al-Anon, a program for people affected by other people’s drinking.

Nobody asked whether she had a problem herself. But she knew she did. “I detoxed at AA [Alcoholics Anonymous]. I had the DTs (delerium tremens, severe withdrawal symptoms). No one treated me. I did it by myself, at home . . .At the time I got sober, there was not as much help as there is today.”

Today, there are new medications, better understanding of male-female differences in alcohol metabolism, and research into genes that may trigger alcoholism. Most important, there’s the recognition that, as Raymond says, “you don’t have to hit bottom like I did. If you’re worried about drinking, get help. Sooner rather than later.”

This Thursday, you can get free alcohol screening at any of 2,000 sites nationwide, including 450 colleges. You just show up, fill out an anonymous questionnaire, then meet confidentially with a clinician for 10 minutes. If he or she thinks you have a problem, you’ll get a referral for help.

Modelled on the 9-year-old depression screening day (held each October), the alcohol screening is run by Dr. Shelly Greenfield, medical director of the alcohol and drug abuse outpatient program at McLean Hospital. It is sponsored by the National Institute on Alcohol Abuse and Alcoholism, a government agency, and dozens of professional organizations.

Depression screening has proved that offering a chance to drop in and talk privately with a counsellor turns up a “big, undiagnosed, untreated population who can be helped,” Greenfield says. It is hoped the same will hold for people with alcohol problems, she says. And there are many of them.

By government estimates, nearly 14 million Americans have an alcohol use disorder, which includes abuse (impairment but not physical dependence) and dependence (alcoholism), which is characterized by uncontrolled drinking, tolerance for high doses and withdrawal symptoms when drinking stops, among other things.

Granted, moderate alcohol use — one drink a day for women, two for men (with a “drink” defined as 5 ounces of wine, 1.5 oz. of spirits or 12 oz. of beer) — lowers the risk of heart disease.

This is because alcohol raises HDL, or “good cholesterol,” and lowers LDL, or “bad cholesterol.” It also makes it harder for platelets to form clots that can block arteries. And some alcohol, notably red wine, contains anti-oxidants that keep LDL from oxidizing; in oxidized form, LDL leads to arterial plaques.

Heavy drinking, on the other hand, can adversely affect not just the drinker — raising the risk for hypertension, stroke, heart disease, some cancers, violence and suicide — but family and friends as well. And half of all US adults have or have had a close relative with a drinking problem, government data show.

But researchers are getting an increasingly good grip on how alcohol problems develop and how best to treat them.

The drug Antabuse, for instance, has long been known to help people quit by making them sick if they drink, says Dr. Enoch Gordis, director of the National Institute on Alcohol Abuse and Alcoholism. But the drinker has to be motivated to take it.

A newer approach, using naltrexone (marketed as Revia or Trexan) may help more. In 1992 studies at the University of Pennsylvania and Yale, researchers found it reduced craving and increased abstinence. The drug is now FDA-approved for this use.

Yet another drug, acamprosate, also helps, perhaps by reducing craving.

In addition, anti-depressant drugs such as Zoloft have been shown to reduce drinking in people who have both depression and alcohol problems, though not in those who aren’t depressed.

Non-drug treatments work, too. The most famous is the 12-step AA model. But an NIAAA study of 1,726 alcoholics in 1997 found that several types of group therapy are also effective ways to quit and stay abstinent.

For true alcoholics, abstinence is still the only longterm solution. For alcohol abusers, cutting back may work.

Ultimately, scientists hope to find a genetic trigger — or several — for alcoholism. The idea that genes play a role is supported by indications that alcoholism, often, though not always, runs in families. If either parent is an alcoholic, you have three to five times the normal risk of becoming one yourself.

More support for the genetic hypothesis comes from the fact that half of Asians who drink experience unpleasant side effects such as flushing, almost “as if they had Antabuse built in” to their genes, says Gordis. Just like the drug, this genetic factor seems to protect against alcohol abuse.

But so far, scientists haven’t found a single gene related to any alcohol-related behavior, even in animals.

What is clear is that alcohol affects men and women differently. In men and women of equal size who consume equal amounts of alcohol, blood levels of alcohol are higher in women, because women’s bodies have less water and more fat, which means alcohol is not diluted as much as it in men. Women also produce lower amounts of a stomach enzyme called alcohol dehydrogenase, which helps digest alcohol.

Women’s livers also are more vulnerable to alcohol. Some data suggest it takes five drinks a day to cause cirrhosis, or scarring, in men, but only a glass and a half or so in women.

Breast cancer is another worry for women who drink. A study published last year of pooled data on more than 322,000 women found that the risk of invasive breast cancer is 41 percent higher for women who have two to five drinks a day than for nondrinkers. This is considered a modest increase in risk.

Women are also less likely to seek treatment for alcohol problems and more likely to say their drinking is related to depression or family problems, which means the drinking itself may not get addressed.

Whether you’re male or female, if you’re worried about your drinking, get screened and get help. Take it from Barbara Raymond, who now counsels alcoholics at McLean.

She’s been happily remarried for 12 years. She’s earned her bachelor’s degree from Bridgewater State and is about to get a master’s in social work. And she’s been sober — for 27 years.

SIDEBAR 1:

Some questions you might be asked in alcohol screening

  • How often do you have a drink containing alcohol?
  • How many alcoholic drinks do you have on a typical day when you are drinking?
  • How often do you have four or more drinks on one occasion?
  • How often during the last year have you found that you were not able to stop drinking once you started?
  • How often during the last year have you failed to do what was normally expected from you because of drinking?
  • How often during the last year have you needed a first drink in the morning after a heavy drinking session?
  • How often during the last year have you had a feeling of guilt or remorse after drinking?
  • How often during the last year have you been unable to remember what happened the night before because you had been drinking?
  • Have you or someone else been injured as a result of your drinking?
  • Has a relative or friend or doctor or other health worker been concerned about your drinking or suggested you cut down?

    • SIDEBAR 2:

    Bottom line on bottoms up, who has an Alcohol Problem?

    • Nearly 14 million Americans meet diagnostic criteria for alcohol use disorders.
    • Half of US adults have or have had a close relative with a drinking problem.
    • About 74 percent of male drinkers and 71 percent of female drinkers exceed moderate drinking guidelines at least once a year.

    Harmful Effects of Alcohol

    • Heavy drinking raises the risk for high blood pressure, stroke, heart disease, certain cancers, accidents, violence, suicides, birth defects and overall mortality.
    • Economic costs to society are $167 billion annually.
    • Harmful drinking is involved in one-third of child abuse cases and many unintentional deaths from falls, burns, and drownings.

    Drinking Among Teens and College Students

    • Young persons who begin drinking before age 15 are four times more likely to develop alcohol dependence and twice as likely to develop alcohol abuse as those who begin drinking at age 21.
    • More than one-third of high school seniors perceive no great risk in consuming four to five drinks a day.
    • Alcohol is a factor in about one-half of fatal traffic crashes among persons 18-24 years of age. Among fraternity and sorority residents, 81% report binge-drinking.
    • Two to three times as many teenagers and young adults die in alcohol-related crashes as die from illegal drug use.

    SOURCE: National Institute on Alcohol Abuse and Alcoholism and Dr. Shelly Greenfield.

    Anxiety over antidepressants

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    Modern anti-depressants, for which Americans spent more than $5.6 billion last year, have been a huge boon, partly because they have few disastrous side effects, even in overdose.

    With older, “tricyclic” anti-depressants like Elavil, for instance, “a 10-day supply could kill you,” says Dr. Michael Jenike, associate chief of psychiatry at Massachusetts General Hospital. The newer drugs, called SSRIs, or selective serotonin reuptake inhibitors, are rarely fatal.

    The leading SSRIs — Prozac, Zoloft and Paxil — also sidestep a hazard of older anti-depressants: MAO inhibitors like Nardil and Parnate can cause a fatal rise in blood pressure when taken with red wine, aged cheese and other foods.

    But for all their magic against both depression and anxiety, the SSRIs do have drawbacks. Like the older drugs, they can take weeks to kick in. They can also cause sexual dysfunction (lack of orgasm) and, initially, agitation. (A fourth SSRI, Luvox, which combats depression but is approved for obessessive compulsive disorder, may be somewhat less likely to cause sexual dysfunction.)

    Worse yet, the SSRIs don’t work for nearly a third of the people who try them.

    This is frustrating for the 18 million Americans who are depressed and 23 million more who are anxious, but it’s strong motivation for drug companies racing to find better drugs.

    And they are, including new classes of anti-depressants designed to act through entirely different pathways in the brain — drugs that block a brain chemical called substance P and others that block CRH, corticotropin releasing hormone.

    Spurring this effort is an explosion of basic knowledge about the brain, some of which will be presented this week in Washington by the Dana Alliance for Brain Initiatives, a nonprofit organization involving more than 185 neuroscientists.

    “For four decades, we have been increasingly perfecting anti-depressant drugs,” says Dr. Steven Hyman, director of the National Institute of Mental Health. “Now, for the first time. . .we are beginning to see the possibility of real alternatives.”

    Much of the excitement comes from the growing recognition that an almond-sized brain structure called the amygdala plays a central role in the processing of fear and almost certainly in depression and chronic anxiety as well.

    The amygdala is rich in receptors for substance P, a brain chemical originally thought to transmit pain signals but now believed to be more important for depression and anxiety. The amygdala is also rich in receptors for CRH, the stress hormone.

    At the same time that drug makers are scrambling to find drugs to block CRH and substance P, they are scurrying to improve the current SSRIs, which combat depression and anxiety by increasing levels of a brain chemical called serotonin in the synapse, or space, between nerve cells.

    Scientists have never proven that depression is caused by a deficiency of serotonin, but they have found low serotonin levels in studies of people who are aggressive or suicidal, says Dr. Peter Whybrow, director of the neuropsychiatric institute at UCLA. Increasing serotonin, he adds, is a “fulcrum where one can intervene,” but there may be even deeper root causes of depression yet to be found.

    In recent years, scientists have discovered that there are at least 15 subtypes of serotonin receptors on brain cells, as well as subtypes for two other neurotranmitters, norepinephrine and dopamine, that are also involved in depression.

    This is crucial information: It means scientists should be able to tailor a drug so it acts on some receptors and not others, keeping anti-depressant activity high while minimizing side effects like time lag to efficacy and sexual dysfunction.

    Here’s how it works: An electrical signal travels down one brain cell, telling it to release serotonin into the synapse. The serotonin lands on “post-synaptic” receptors across the synapse in the next cell, triggering new signals in that cell.

    Serotonin then floats back toward the first, or presynaptic, cell, which sucks some of it in through a “re-uptake pump” to be recycled for further use. It is this re-uptake system that the current SSRI drugs block.

    But brain cells also have “autoreceptors” that interact with serotonin in another way — by telling the cell when there’s enough serotonin in the synapse that no more needs to be made, in essence, a negative feedback loop.

    Scientists now think that one reason it takes so long for SSRIs to kick in is that it takes weeks for the cell to learn to “ignore” this feedback and start making more serotonin, says Dr. Scott Ewing, director of the depression and anxiety service at McLean Hospital in Belmont. By tinkering with drugs aimed at these autoreceptors, he says, it should be possible to make drugs that work faster, though none are available yet.

    Similarly, better knowledge of receptors has led to drugs like Serzone and Remeron, which have fewer sexual side effects because they block certain post-synaptic serotonin receptors.

    A new SSRI, Celexa, approved last fall, avoids still other pitfalls than standard SSRIs by triggering fewer interactions with other drugs.

    Researchers are also discovering other ways to help people who don’t respond to standard drugs. For instance, some data suggest that taking a blood pressure drug called pindolol with an SSRI makes the SSRI act sooner by acting on the presynaptic autoreceptors to stop the negative feedback loop.

    SSRIs can also be made more effective by taking them with other drugs like lithium (normally used for manic-depression), a synthetic thyroid hormone called T3, an anti-anxiety medication called Buspar or tricyclic anti-depressants, says Ewing.

    Sometimes, combining two “atypical” anti-depressants like Wellbutrin, Effexor, Serzone or Remeron, also helps people who have not responded to other drugs.

    The bottom line is that “if you’re doing well on your current anti-depressant and can stand the side effects, stay on it,” says Ewing. After all, anything you switch to may bring new side effects. “It’s a mistake to go off a drug you’re responding to.”

    But if you’re not responding well, don’t give up. Psychotherapy, the talking treatment, can be very effective, even without medications, for many people. The herbal antidepressant St. John’s Wort seems to help many people, too.

    And if you do want to switch to a different prescription anti-depressant, talk to you doctor. If he or she can’t provide an answer, see a psychiatrist or psychopharmacologist. Remember: Depression and anxiety are highly treatable problems.

    SIDEBAR

    Some of the new anti-depressants in the pipeline

    Substance P blockers: In terms of published data, Merck Research Laboratories is the leader. Six months ago, it reported in Science that its drug MK-869, worked as well as Paxil in depressed people. Since then, the company says it has finished an unpublished study with less clear results and is now pursuing an unnamed substance P blocker it feels is more potent.

    A number of other companies, including Pfizer Inc. and Eli Lilly & Co. are also working on substance P blockers.

    Corticotropin releasing hormone (CRH) blockers: Published data are scanty, but informal reports “look promising,” says Dr. Steven Hyman, director of the National Institute of Mental Health. A 1998 study in Munich showed that mice missing a receptor for CRH exhibited reduced anxiety and stress, suggesting that CRH blockers might be effective in humans.

    Improvements to SSRIs, or selective serotonin reuptake inhibitors. Many companies are working on this. Lilly and Sepracor are working on R-fluoxetine, a Prozac variant with fewer side effects. Celexa, already on the market by Forest Laboratories, Inc., causes less agitation than standard SSRIs.

    Other serotonin-based drugs. Solvay Pharmaceuticals is working on flesinoxan, which boosts serotonin by increasing the activity of a particular receptor called 5-HT1A.

    Norepinephrine reuptake inhibitors. This is a new class of drugs that would boost a different neurotransmitter, norepinephrine. So far, Pharmacia & Upjohn’s drug, reboxetine, appears closest to getting approval for marketing.

    RIMAS, or reversible inhibitors of monoamine oxidase. The idea is to tinker with MAO inhibitors so a patient doesn’t have to follow a special diet. A drug called moclobemide is already on the market in Great Britain, Canada and Europe to do this. It’s not clear whether any company will bring it to market in the US.

    Glutamate drugs. Some scientists think this important neurotransmitter may play a role in depression, as it does in Alzheimer’s disease and schizophrenia. Lilly is exploring this.

    Herbal antidepressants. The leader is St. John’s Wort, already shown to be effective in European studies. McLean Hospital is studying a sustained release form of the drug. There’s another study at 12 centers nationwide. If you want to participate, call 617 855 2862 for the first study, or 919 668 8991 for the second. (On the web, you can find out more about the second study at http://hypericum.rti.org.)

    Fish oil seen cutting risk of Mental Illness

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    Fish oils that are already believed to reduce the risk of heart disease may help combat a number of serious psychiatric illnesses as well, researchers said yesterday.

    At an international conference sponsored by the National Institutes of Health, scientists said that though the data are preliminary, a growing body of evidence suggests that higher consumption of essential fatty acids in the oils, notably one called omega-3, appears linked to a lower risk of depression and better treatment of manic-depression and schizophrenia.

    Essential fatty acids must be consumed in the diet or as supplements because the body cannot make them. A major dietary source of omega-3 is fatty fish such as mackerel, Atlantic salmon, bluefish, halibut, herring, and sockeye salmon.

    The researchers did not make specific recommendations for consuming fish or omega-3 supplements. But previous research suggested that eating fish two to three times a week is healthful, says Larry Lindner, executive editor of the Tufts University Health & Nutrition Letter.

    People seeking to increase their consumption of omega-3 fatty acids also can eat green leafy vegetables, nuts, flaxseed, and canola oils, which contain fatty acids that the body can make into two chemicals, called EPA and DHA, that are thought to produce the health benefits. The researchers said they had no definitive answers on whether DHA, which is found in breast milk, should be added to infant formula in America, as it is in Europe and Asia.

    Consuming high quantities of omega-3 supplements, however, can suppress immune function, conceivably leaving people more vulnerable to infection. On the other hand, Lindner said, omega-3 supplements seem to help people with arthritis, an auto-immune disorder. A 3,000-milligram daily dose has been shown to reduce arthritis symptoms caused by immune system damage to joint tissue. Omega-3 also can reduce the ability of the blood to clot, which means it could be hazardous in a person with a bleeding disorder.

    The research includes data suggesting that countries where large quantities of fish are eaten have lower rates of depression than countries where fish is not a major part of the diet, said Dr. Joseph R. Hibbeln, chief of the outpatient clinic at the National Institute on Alcohol Abuse and Alcoholism at the National Institutes of Health.

    Major depression is 60 times more prevalent in some countries than others, Hibbeln said. Fish consumption appears to be an “important protective factor.”

    Lindner called the link between fish oils and reduced incidence of depression “provocative,” but said it was “too early to make a recommendation that people suffering from a mood disorder should eat more fish or start taking omega-3 supplements.”

    Hibbeln’s team found that higher blood levels of two omega-3 fatty acids (EPA and DHA) in both normal people and alcoholics correlated with higher levels of an important brain chemical, serotonin. This suggests, he said, that consuming omega-3 fatty acids may influence production of serotonin. Many scientists believe that low levels of serotonin are linked to depressive, suicidal, or violent behavior.

    In one study of 18 suicidal patients, higher blood levels of EPA were linked to lower scores on tests that predict suicide, Hibbeln noted. The emerging data, taken as a whole, suggest that EPA and DHA may reduce depressive and suicidal behavior.

    Dr. Andrew L. Stoll, director of psychopharmacology at Brigham and Women’s Hospital in Boston, reported what he called “very exciting” results from a study of about 50 patients with manic-depression, or bipolar disorder, which affects an estimated 2 million Americans.

    About half the patients were given 10 grams a day of omega-3 (equal to several servings of fish) in a special formulation and the other half received a placebo made of olive oil. All patients continued to receive their usual medications as well.

    The study was planned to last nine months, said Stoll, but after four months the rate of relapse in the omega-3 group was dramatically lower, prompting researchers to stop the study early. Although it is not totally clear how omega-3 works, Stoll said, it appears to act like lithium and valproate, two manic-depression medications that block transmission of neurochemical signals inside brain cells.

    Omega-3 fatty acids also appear to help reduce symptoms of schizophrenia in people taking standard medications, said Dr. Malcolm Peet, head of psychiatry at the University of Sheffield in the United Kingdom. Schizophrenia, which affects 1 percent of the population, produces delusions, hallucinations, apathy, and withdrawal.

    Peet has found that levels of fatty acids are lower in people with schizophrenia. In three small studies, he said, giving omega-3 supplements to schizophrenic patients appears to lessen the severity of symptoms.

    Kava root is hot herb for anxiety

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    Traditionally, whenever the people of the South Pacific islands wanted to welcome a visitor or provide a social lubricant for communal rituals, they drank a potent potion made from the roots of an intoxicating pepper plant, kava kava.

    The jaw-breaking job of turning the tough root of the piper methysticum into homemade brew fell to young virgins — male or female, depending on the island — who spent hours chewing the root, then spitting out the masticated mush into a communal pot, where it was left to mature for several hours before being quaffed.

    The effects, says herbal “medicine hunter” and kava promoter Chris Kilham of Lincoln, were nearly instantaneous: a feeling of profound well-being and relaxation.

    What more could one ask? Okay, maybe a little scientific validation. And access.

    Westerners are beginning to get both. In fact, although there are other herbs that are said to allay anxiety, it’s kava that seems poised to take off like St. John’s Wort, the herbal antidepressant that was virtually unheard of a couple of years ago in this country and now commands $200 million a year in sales.

    “The kava market has come out of nowhere. It’s gone from next to nothing to $40 to $50 million in sales in one year,” says Thomas Aarts, executive editor of the Nutrition Business Journal in San Diego. At that, it’s still a small chunk of the booming business in dietary supplements, which has grown 14 percent a year for the last three years to $11.5 billion now, driven in part by the popularity of herbals.

    “Kava is a hot herb,” agrees Matthew Patsky, a stock analyst who specializes in the natural food and nutrition industry for Adams, Harkness & Hill, a Boston investment bank. “It works great for me.”

    Others say kava induces a state of relaxation without fogging the mind as some prescription tranquilizers can. Kava produces “a delightful feeling,” enthuses Kilham, who consults for herbal products companies that import or market kava.

    Since many things that sound too good to be true are, some caveats: The scientific evidence on the benefits and possible risks of kava is still limited. There have been 38 double-blind, placebo-controlled studies on St. John’s Wort, also known as hypericum, says Dr. Harold Bloomfield, a California psychiatrist who has written a book on it.

    By comparison, there are only a half dozen decent studies on kava, he says. “We need many, many more — this is preliminary research at best.”

    Dr. Steven E. Hyman, director of the National Institute of Mental Health, agrees, calling the kava data “quite weak.” But NIMH is intrigued enough that it may fund research on it.

    If the research is not yet there, the need is: An estimated 23 million Americans wrestle with crippling, life-wrecking, chronic anxiety, and millions more suffer milder forms.

    Granted, there are mainstream treatments available, including anti-anxiety drugs like Valium, Xanax and Klonopin, which are often effective but can cause cause physical dependence. Non-habit forming drugs like Prozac, an anti-depresssant, also work against anxiety, as does cognitive-behavior therapy and other “talking” psychotherapy.

    Despite all this, there’s still enough angst out there that the potential demand for herbal tranquilizers is huge.

    You should, of course, consult your doctor before self-medicating for severe anxiety — or any other serious medical problem. But if you decide to try kava, here’s what you need to know.

    The active ingredients in kava go by two interchangeable names: kavalactones or kavapyrones. Check the label — it should say each capsule is “standardized” to roughly 75 milligrams of kavalactones or kavapyrones, meaning the concentration is consistent from batch to batch. (Note: Kava pills come in varying strengths — from 100 to 250 mg — and the percentage of kavalactones also varies. A 250-mg capsule of 30 percent extract would contain 75 mg of kavalactones.)

    The German Commission E, a government-appointed panel that reviews herbal remedies, has approved kava to combat anxiety, stress and restlessness and recommends a dose of 60 to 120 milligrams a day of kavapyrones.

    Gail Mahady, a pharmacist and plant medicine specialist at the University of Illinois, adds that side effects are apparently rare. A monograph she’s writing for the World Health Organization will endorse the use of kava for anxiety symptoms.

    Some people are allergic to it, however, especially those with known allergies to pepper, and kava can cause a temporary yellowing of the skin if used too long. The German commission recommends using it for not more than three months and says pregnant or nursing women and people with serious depression should not take it at all.

    For many people, though, kava appears to be both safe and effective at the recommended doses, says Varro Tyler, a plant medicine specialist emeritus at Purdue University.

    In fact, six carefully-done studies of kava extracts, all done in Germany since 1989, show kava is “quite satisfactory” when compared to a placebo or a prescription anti-anxiety drug such as oxazepam (Serax), Tyler adds.

    Kava is not only a potent muscle relaxant, it also acts, just as alcohol and prescription anti-anxiety drugs do, on so-called GABA receptors in the brain, which regulate anxiety. Kava may also quiet a brain region, the amygdala, which also governs anxiety.

    So far, there’s “no evidence of physical or psychological dependence,” adds Dr. David Mischoulon, a psychiatrist and psychopharmacologist at Massachusetts General Hospital.

    But even those sympathetic to herbal remedies urge caution, among them Dr. Laura Kramer, a psychiatrist at the American WholeHealth Arlington-Cambridge Center.

    Unless your doctor advises otherwise, she says, you should not drive or operate machinery while taking kava because it may make you drowsy. Nor should you take it with other drugs that act on the central nervous system, including alcohol or prescription anti-anxiety drugs like benzodiazepines. At high doses, kava may cause intoxication.

    “You have to treat kava as a medication — you have to respect it,” she says.

    And start with low doses, about 70 to 85 mg of kavalactones, taken at night, says California psychiatrist Bloomfield. If that’s not enough, he says, take a second pill in the morning.

    If, after a week, that is still not enough, you can add a third pill at midday. But once you’re feeling consistently more relaxed, taper down by one pill every few days.

    And if, despite three pills a day, you’re still very anxious, don’t waste any more time. Call your doctor.

    SIDEBAR 1:

    For general information on anxiety, call:

    • 1-888-8-ANXIETY, National Institute of Mental Health information line, which will mail you a pamphlet. (You don’t have to dial the `y’ to get through.)
    • The Center for Anxiety and Related Disorders at Boston University: 617-353-9610.
    • Or you can contact the following organizations:
    • National Alliance for the Mentally Ill, 200 N. Glebe Road, Suite 1015, Arlington, Va. 22203-3754. Tel: 800-950-NAMI (950-6264).
    • Anxiety Disorders Association of America, Dept. A, 6000 Executive Boulevard, Suite 513, Rockville, MD 20852. Tel: 301-231-9350.
    • Freedom from Fear, 308 Seaview Ave., Staten Island, N.Y., 10305. Tel: 718-351-1717.
    • American Psychiatric Association, 1400 K Street NW, Washington, DC 20005. Tel: 202-682-6000.
    • American Psychological Association, 750 1st Street NE, Washington, DC 20002-4242. Tel: 202-336-5500 or 800-374-2721.
    • Association for Advancement of Behavior Therapy, 305 7th Avenue, New York, NY 10001. Tel: 212-647-1890.
    • National Mental Health Association, 1201 Prince Street, Alexandria, Va., 22314-2971. Tel: 800-969-6642.
    • National Mental Health Consumers’ Self-Help Clearinghouse, 1211 Chestnut Street, Philadelphia, Penn. 19107. Tel: 800-553-4539.

    SIDEBAR 2:

    Topical reading, for more information on herbal remedies for anxiety, you might read:

    • “Healing Anxiety with Herbs,” by Dr. Harold Bloomfield, HarperCollins.
    • “Rational Phytotherapy — A Physician’s Guide to Herbal Medicines,” by Volker Schulz, Varro E. Tyler, and Rudolf Hansel, Springer-Verlag N.Y.
    • “Kava — Medicine Hunting in Paradise,” by Chris Kilham, Park Street Press.

    SIDEBAR 3:

    Other herbs may ease anxiety.

    Kava is currently the hottest herbal treatment for anxiety, but other plant medicines may also help. Before you experiment, though, talk to your doctor. Many herbs can cause allergic reactions. And don’t take multiple psychoactive drugs of any type — including alcohol and herbals — at the same time, unless a doctor says otherwise.

    Among the herbs often used for anxiety are these:

    • Valerian. This herb has been used for more than 1,000 years as a minor tranquilizer and sleep inducer. Both the German Commission E and the World Health Organization have reviewed it and deemed it safe and effective. For insomnia, the suggested dose is 450 to 600 milligrams of valerian extract at bedtime. It may take two to four weeks before you see any effect.

    Eight placebo-controlled, double-blind studies show valerian reduces the time it takes to fall asleep. Data also suggest that valerian improves mood and scores on a commonly-used anxiety rating scale. But the stuff smells awful, and doses vary. So read the labels and stick to the recommended doses.

    • St. John’s Wort. This herbal anti-depressant may also help with anxiety, says the German Commision E, though the data are skimpy. Unlike kava, which works right away, St. John’s Wort — taken as a 300 mg pill three times a day — takes two to four weeks to kick in. Dr. Harold Bloomfield, a California psychiatrist, often starts patients on kava for its immediate effects and adds St. John’s Wort, then tapers off kava as St. John’s Wort kicks in. St. John’s Wort can cause sun sensitivity.
    • Chamomile. The German Commission E and WHO approve this for nervous upset and mild insomnia — especially as a tea or extract. Though a 1994 study shows it contains apigenin, an anti-anxiety agent, it’s weaker than valerian and kava. People who are allergic to ragweed, chrysanthemums, and other plants in the daisy family should avoid it.
    • Passion Flower. Hops. Lavender. Lemon balm. All these herbs are approved by the German Commission E, but there’s little scientific data to support their use for anxiety.
    • Catnip. Pure folklore. There are few, if any, studies of its safety and efficacy. (Like valerian, catnip jazzes up cats but sedates people — for utterly mysterious reasons.)

    New depression therapy intriguing

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    For years, severely depressed people have had one last resort if antidepressant drugs and talking therapy failed: ECT or electroconvulsive therapy — better known as “shock” therapy.

    In ECT, electrodes placed on the scalp send electrical pulses to the brain, which, to be effective, must be strong enough to trigger a seizure. To prevent pain and injury from convulsions during the therapy, the patient is given general anesthesia.

    Roughly 80 to 90 percent of the time, ECT works well, better, in fact, than drugs, which help in 60 to 70 percent of cases. Because of its effectiveness, 50,000 people a year turn to ECT.

    But the downside, and it’s a big one, is that ECT causes confusion after treatments (three times weekly for several weeks), and memory loss, some of which may be irreversible. And mood may improve for only three to six months.

    Now, however, brain researchers say they may have found another way to jolt the brain out of depression — TMS, or transcranial magnetic stimulation — that has many potential advantages over ECT. It’s still not clear whether TMS will be as potent as ECT, but it does appear to have fewer side effects.

    With ECT, for instance, much of the electric current from electrodes is stopped by the scalp and skull. The current that does get through spreads through the entire brain, causing a generalized seizure — a kind of electrical storm.

    In fact, if there’s no seizure, there’s no improvement in depression, perhaps because seizures trigger an increase in the brain chemical serotonin, just as many antidepressant drugs do, says Dr. Richard Weiner of Duke University, who heads the American Psychiatric Association task force on ECT.

    With TMS, it’s not an electric current but a magnetic field that passes through the brain, generated by a coil of wire that’s placed on the head and turned rapidly on and off. The magnetic field then excites nerve cells in the brain — only where it is aimed, usually the left prefrontal cortex (behind the forehead), where electrical activity is often abnormal in depressed people.

    Not only can TMS be precisely targeted, it does not cause seizures or memory problems, and anesthesia is not necessary. “Those are huge plusses,” says Dr. Alvaro Pascual-Leone, a neurologist at Beth Israel Deaconess Medical Center.

    TMS is still experimental, which means that if you want to try it, you have to participate in one of the clinical trials now under way around the country. Worldwide, it has been tried in only about 1,000 people, says Dr. David Avery, associate professor of psychiatry and behavior science at the University of Washington.

    In fact, published data exist on only 200 patients, says Dr. Mark George, a psychiatrist, neurologist and radiologist, at the Medical University of South Carolina.

    And only two of the published studies — involving a total of 29 patients — were double blind, that is, designed so that neither patients nor researchers knew who was getting real TMS and who was getting a sham procedure in which the brain was not stimulated. Even in these studies, the technicians knew which patient was getting what.

    Despite all these caveats, the early findings have set brain researchers buzzing, most recently at a Society of Biological Psychiatry meeting 10 days ago in Toronto.

    In a study of 17 patients published in 1996 in the British medical journal Lancet, for instance, Pascual-Leone said patients given TMS showed a 50 percent improvement on a commonly-used depression rating scale. “That’s better than any antidepressant ever, better than ECT. It’s a remarkable efficacy in any time frame, and these were psychotically depressed people,” said George.

    In a larger study presented at the meeting, Pascual-Leone got a 60 percent response when he treated people with TMS for 10 days (not five, as in his earlier study) and the benefits lasted several months.

    George’s double blind study of 12 people, published in the December 1997 issue of the American Journal of Psychiatry, was a bit less dazzling. After two weeks of TMS, patients scored about 20 percent better on depression tests.

    But his new results on 30 patients, also presented in Toronto, were more encouraging: a nearly 50 percent improvement in depression for patients given low frequency TMS. (Those given high frequency TMS fared less well, showing only a 30 percent decrease in depression, which was similar to those who got sham treatment.)

    The emerging data on TMS is exciting to researchers and doctors in part because depression is so common. Over a lifetime, 7.4 percent of women and 2.8 percent of men suffer a bout of major, incapacitating depression. When less serious forms of depression are included, one quarter of women have an episode at some point in life, as do 15 percent of men.

    Also encouraging, researchers say, is the suggestion that TMS may be also useful for other illnesses that affect the brain, including post-traumatic stress disorder, obsessive-compulsive disorder, and perhaps Parkinson’s disease.

    But TMS is of intense academic interest as well because of the light it could shed on the brain disruptions believed to be present — as the cause or the effect — in depression.

    PET scans of depressed individuals have shown a decreased blood flow to the left prefrontal cortex, along with decreased metabolism of glucose, says Dr. Holly Lisanby, a Columbia University psychiatrist who is starting a study of combined TMS and drug therapy.

    The theory behind magnetic stimulation, says Dr. Eric Wassermann, a neurologist at the National Institute of Neurologic Disorders and Stroke, is that it boosts the excitability of these prefrontal nerves, that is, it kind of jolts them out of their sluggishness.

    But depression is so complex that other areas of the brain are undoubtedly involved, too, including the cingulate gyrus, which lies deep in the limbic system (which controls emotion).

    In other words, much as they’d like one, scientists still have no grand theory to explain how vastly different treatments for depression — drugs, ECT and TMS — may act on different regions of the brain but all produce an improvement in mood.

    “If we can figure out what TMS is doing,” says George, “we are almost there in terms of understanding depression. That is the driving hope I have, an addition to finding what might help a lot of people.”

    SIDEBAR:

    For more information on transcranial magnetic stimulation, you can visit the web at

    www.ists.unibe.ch

    www.psycom.net/depression.central.transcranial.html

    www.nami.org

    If you want to enroll in a clinical trial, including a multi-center trial testing a combination of TMS and anti-depressant medication, you may call Dr. Alvaro Pascual-Leone at 617-667-0203.

    Is there a “hidden epidemic” of male depression?

    by

    Alan Schlingenbaum, a 43-year-old computer consultant in Wellesley, was a regular guy. Which is to say, he got his work done and acted “the way a male acts on the world,” he says.

    What he “wasn’t so good at” was intimacy — with his wife, his friends and himself.

    His wife — now his ex-wife — dragged him into therapy with Terrence Real, a Watertown social worker and author of “I Don’t Want to Talk About It,” the best-selling book about men and depression.

    Sure enough, after a few sessions, Real told him he was depressed.

    “What are you talking about? You’re crazy!” Schlingenbaum retorted. Then he read Real’s book and became a convert.

    Through therapy and a men’s group, he says he’s turned his covert depression into overt depression and is the better for it: “Just what I’ve learned so far is paying off for me in the kinds of relationships I have.”

    Real, who is co-director, with psychologist Carol Gilligan, of the Harvard University Gender Research Project and a senior faculty member of the Family Institute of Cambridge, contends that depression is a “hidden epidemic” among men. If covert depression is taken into account, he argues, men are just as depressed as women, despite reams of statistics to the contrary.

    “There’s a cultural collusion in covering this up,” he says, because men are brought up to disavow their feelings.

    The result of all this unacknowledged depression, Real says, is an “unholy triad” of behavior — self-medication (by drinking, gambling, drugging, compulsive spending, sex, TV or work), isolation and lashing out (irritability, abuse and murder).

    Not a pretty picture, but could all those “bad” guys be depressed?

    “That’s ridiculous. . . It’s like saying you really have something but it looks like something else. If it looks like something else, it is something else,” says Dr. Myrna Weissman, a Columbia University psychiatrist who studies the incidence of psychological disorders.

    Slapping a diagnosis on men who act out may even do harm because it “gives someone the sick role when maybe they’re just not very nice,” says Weissman, whose widely respected data, published in July in the Journal of the American Medical Association, show that over a lifetime, 7.4 percent of women and 2.8 percent of men suffer major depression, the most serious form.

    “Gambling is not depression. Some people who drink are depressed, but that doesn’t mean alcoholics are depressed,” she says. And if men are beating their wives, “they should stop, but I don’t think saying they are depressed is necessarily helpful.”

    Even when questions are designed to avoid gender bias, she says, women suffer far more than men — in country after country.

    But even psychiatric epidemiologists disagree about what counts as serious depression.

    Dr. Alan Romanoski, a Johns Hopkins University psychiatric epidemiologist, agrees with Weissman that “it’s wrong to infer depression,” that is, a particular emotional state, just from observed behavior. “Life is tough enough trying to figure out the conscious world without trying to take on the subconscious, too.”

    Take drinking — and the feelings presumed to underlie it. Psychiatrists used to think if someone could only understand why he drank, he’d stop, Romanoski says. But they had “no success whatsoever treating alcoholism and as a result, psychiatry fell into disrepute in the recovery movement and rightly so.”

    But unlike Weissman, who studies lifetime rates, Romanski studies the prevalence of major depression at any given moment, and finds that, tallied this way, men and women suffer equally. But with clinically significant, though milder depression, things do get lopsided — with 8 percent of women and 3 percent of men affected, he says.

    But other data seem to support Real’s belief that depression is widespread among males, including national suicide rates — 18.6 annually per 100,000 men, versus 4.4 per 100,000 women.

    And figures from the National Center for Health Statistics, based on 1992 research by Harvard sociologist Ronald Kessler, suggest that over a lifetime, equal numbers of men and women — roughly half of each group — have some kind of psychiatric disorder, though this counts not just depression but anxiety and substance abuse as well.

    Over a lifetime, Kessler says, 24 percent of women have a depressive disorder, versus 15 percent of men; for anxiety, it’s 31 percent for women, 19 percent for men. Substance abuse, however, affects 35 percent of men and 18 percent of women.

    Gender differences in psychiatric illness are changing, he says, “but unfortunately for women, women are catching up more quickly in alcohol and drug problems than men are in depression and anxiety. If sex roles are involved, and they have to be in certain ways, it looks like changes in sex roles have led to worse problems for women relative to men.”

    Still, Harvard psychologist Carol Gilligan finds Real’s thesis “very convincing.” Masculinity “is terribly restricting to men,” she says, in part because it implies “real men don’t get sad.” Part of depression is “about not being able to feel sad.”

    Psychologist William Pollack, co-director of the Center for Men at McLean Hospital, also believes depression is vastly underdiagnosed in men. A 1991 Rand study showed doctors miss 67 percent of depression in men because they’re looking for what Pollack calls “feminized” symptoms like crying, not the irritability, anger and work “burnout” men often express.

    And while Dr. Peter (“Listening to Prozac”) Kramer doesn’t agree totally with Real, he does agree that “undiagnosed depression in men wreaks havoc. They do all sorts of things rather than get treatment.” Depression, he adds, also “causes divorce as often as divorce causes depression, and I’d say more,” whichever spouse is depressed.

    And there are those, like psychiatric epidemiologist Dr. Kostas Lyketsos of Johns Hopkins, who say the real “philosophic question is, is there bad in this world, and are there people who can’t be helped?”

    Real answers this way: “The women’s movement and morally driven thinkers hold men responsible for bad behavior, but don’t hold men empathically. The men’s movement and psychology are tuned in to men’s wounding, but not the damage men inflict on others. My work is about holding men accountable for irresponsible behavior but holding them with empathy and love.”

    The implication of Real’s message is that if men who act out would just get help, they — and the people around them — would be better off. But Lyketsos isn’t buying.

    Imputing depression to men reminds him of the false memory debate in women, in which it was often taken as a given that a woman with psychological problems had been sexually abused and needed extensive therapy to dig out old “memories.”

    “Nobody should be under the illusion that therapy is always good,” he says. With some people, it can “mess them up by creating a dependence and having them constantly question themselves.”

    For men who really are depressed, though, the answer probably is to seek help. And for women involved with them, the first step is also to get the guy into therapy, if he’ll go. If he won’t, the next step, says Real, is to say, “If you don’t think you have a problem, then we have a problem as a couple and we need help.”

    Often, it’s not the men who are “in conscious distress so much as the people who live with them,” he adds.

    Still, Real argues, “the cure for covert depression is overt depression” and “intimacy is the ultimate cure for depression in men.”

    This can be a tall order. “It’s a big pain in the butt to learn all this,” concedes Real. “Men would rather be left alone in some ways.

    “But if you swallow the pill that you have to learn it, you’ll be happier and healthier, your family will be happier and healthier and you’ll live longer. Most men are not stupid. They understand this.”

    Amen!

    SIDEBAR 1:

    More on depression:

    About 70 percent of depressed people, men and women, are helped by antidepressant medications, and this rises to 80 percent or more when psychotherapy is added. Psychotherapy alone works as well as drugs for moderate depression, though it often takes longer.

    Some common symptoms of depression and dysthymia (a less severe form of depression) include:

    • Profoundly “down” or sad mood for several weeks or more.
    • Diminished interest in regular activities.
    • Sleep or appetite disturbances.
    • Difficulty concentrating or thinking.
    • Feelings of guilt, self-criticism or pessimism.
    • Diminished energy.
    • Suidical thoughts or behaviors.

    If you think you or someone you love is depressed, you can contact your health care provider or the following organizations for information or referrals. (If it’s an emergency, go to the nearest hospital or call 911.):

    • National Depressive and Manic-Depressive Association, 1-800-826-3632 or on the web atwww.ndmda.org. The Boston chapter, located at McLean Hospital, can be reached at 617-855-2795.
    • National Mental Health Association, 1-800-969-6642
    • National Institute of Mental Health, 1-800-421-4211. Ask for the DART (Depression Awareness,Recognition and Treatment) Program. On the web it’s www.nimh.nih.gov
    • National Alliance for the Mentally Ill, 1-800-950-NAMI or 1-800-950-6264. The Massachusetts chapter, 1-800-370-9085
    • The Center for Men at McLean Hospital, 617-855-2750
    • Depressive and Related Affective Disorders Association, 410-955-4647, on the web atwww.med.jhu.edu/drada/
    • You might also want to read about men and depression:
    • “I Don’t Want to Talk About It,” by Terrence Real (Simon & Schuster)
    • “New Psychotherapy for Men,” by William Pollack and Ron Levant (Wiley & Sons).(Due out in June.)
    • “Real Boys,” by William Pollack (Random House).(Due out in May.)

    SIDEBAR 2:

    GENDER DIFFERENCES:

    The rates of psychiatric disorders vary between men and women but overall incidence is similar

    PLEASE SEE MICROFILM FOR CHART DATA

    GLOBE STAFF CHART

    So, you’re stuck in sleep-loss hell

    by

    Doctors say it may not ruin your life but it can make your life miserable,

    For years now, Allan Rechtschaffen, a psychology professor emeritus at the University of Chicago, has been watching what happens when he totally deprives rats of sleep.

    He takes a plastic disc with a divider in the middle and puts one rat on each side. Both rats get plenty of food, and one rat — the lucky one — also gets to sleep whenever it wants.

    But every time the other rat dozes off, the disc starts to spin slowly, forcing both rats to jump up and walk forward to keep from falling into a shallow pool of water.

    The result? After two or three weeks of total sleep deprivation — probably the equivalent of 8 to 12 weeks for humans — the sleepless rats all die.

    During their downward spiral, their body temperature goes up, they develop skin lesions and food intake doubles. They show no changes in immune function.

    “We don’t know what the rats die of,” says Rechtschaffen, but “sleep seems to be almost as important for an organism as food.”

    Intuitively, that seems obvious. And researchers have documented some very real consequences of sleep loss, which affects not only America’s 30 to 60 million chronic insomniacs but millions of others who are just too busy to sleep or have a medical problem like sleep apnea or restless leg syndrome.

    Sleep apnea, which affects at least 2 percent of women and 4 percent of men and can trigger potentially serious cardiovascular problems, causes a person to wake up repeatedly to breathe. Restless leg syndrome and involuntary jerking of the legs during sleep can also make it hard to fall and stay asleep.

    Yet the surprising thing about all this research is that while more than 1,000 studies show that a bad night’s sleep — or a string of them — can lead to decreased intellectual function, mood and performance, there’s little evidence so far that sleep loss has direct health consequences.

    Except, of course, if you count the 1,500 deaths and 76,000 injuries a year from driver fatigue, accidents that happen when the brain is vulnerable to “intrusions of microsleep episodes,” says Dr. Charles Czeisler, chief of circadian and sleep disorders medicine at Brigham and Women’s Hospital.

    Still, overall there is “no solid evidence that sleep loss leads to long-term medical problems,” says Gregg Jacobs, an insomnia specialist at Beth Israel Deaconess Medical Center.

    It does cause “psychological suffering,” says psychiatrist William C. Dement, director of the Stanford Sleep Research Center and Sleep Disorders Clinic. “But we can’t say, yes, if you don’t treat your insomnia you are going to die.”

    To be sure, insomniacs are “more likely to report poor health,” notes Cynthia Dorsey, director of McLean Hospital’s sleep disorders center, but it’s not clear which comes first.

    Twenty years ago, researchers found that people who slept more than nine hours or less than six a night had a higher death rate than those whose sleep was closer to the seven or eight hours that most people need. But this was a correlation, not documented cause and effect.

    Recently, there has been new evidence — about a dozen studies — suggesting that immune function may change with sleep loss, but whether this translates into a health risk is also unknown.

    Several years ago, Dr. Michael Irwin , a professor of psychiatry at the University of California at San Diego, published a study of 23 middle-aged male volunteers who were awakened at 3 a.m., making them miss about four hours’ sleep.

    Irwin found that this modest sleep loss was correlated with a a drop in the activity of natural killer cells, a type of immune cell. But this bounced back fully after a good night’s sleep.

    In another study this year, Irwin deprived 42 middle-aged men of sleep in the early part of the night and found decreases in several immune measures, including a substance called Il-2. It was not clear when these measures began to bounce back.

    But other studies — and there are still too few for a definitive conclusions — suggest a different picture.

    In fact, some measurements of immune function actually go up with sleep loss, says David Dinges , director of the experimental psychiatry unit at the University of Pennsylvania School of Medicine, a researcher who says he has “sleep-deprived more people than anyone else.”

    In a 1994 study of 20 adults deprived of sleep for 64 hours, Dinges found an increase in white blood cells and natural killer cell activity, a measure of immune response.

    At least in the sleep lab, he says, where researchers go to great pains to keep people in a good mood, sleep deprivation seems to be linked to “an increase in immunological defense,” though the overall picture of immune effects is far from clear.

    What is clear, researchers agree, is that sleepless people are not happy campers — or as good thinkers as usual.

    “Sleep deprivation has a clear impact on physical performance, cognitive performance and mood,” says Dr. David White, director of the sleep disorders program at Brigham and Women’s and past president of the American Sleep Disorders Association, a professional organization.

    But lousy mood can be the cause as well as the effect of lousy sleep. “Nobody knows if depression causes insomnia or vice versa — it’s very circular,” says Dinges.

    Anxiety, too, can be part of a vicious circle because “secondary anxiety” can leave people “freaked” about their loss of sleep, says Dr. John Winkelman, associate director of the sleep disorders service at the Brigham.

    Making mood worse after a bad night, or several, is the all-too-keen awareness that you may be having more trouble than usual remembering things or processing information, although motivation — such as trying to keep your job — may offset this.

    Still, there’s no question that if you have a bunch of bad nights in a row, you build up a significant “sleep debt,” which means working memory may fail, reaction time slows and it becomes harder to pay attention.

    Yet this is the devil with which growing numbers of us live — whether we’re insomniacs or just don’t take the time to rest. As a nation, we’re getting 20 percent less sleep than our forebears did a century ago, according to the National Commission on Sleep Disorders Research.

    And we’re clearly paying the price. A Gallup survey this year showed that a third of us have significant daytime sleepiness, which can be dangerous as well as unpleasant. A Harris survey, also done this year, found that 70 percent of people acknowledge that their concentration is poor or fair when they’re sleep deprived.

    So what should you do if you’re stuck in sleep-loss hell?

    For openers, if you’re sleeping only four or five hours a night because you’re too busy or working too hard or socializing too late, put yourself to bed and get more sleep.

    If you’ve got a stubborn case of insomnia, tell your doctor. You may have an underlying problem with anxiety or depression; treating these problems can lead to greatly improved sleep.

    That goes for sleep apnea, too. Many people deny they have trouble breathing during sleep for the obvious reason that they’re too groggy to remember. But apnea is both serious and treatable, so if your spouse says your snoring is terrible, take it seriously.

    Restless leg problems, too, are treatable, usually with medications.

    And if you’ve got chronic insomnia?

    Despite their bad reputation, sleeping pills may be an answer for some people. A relatively new short-acting one called Ambien appears to cause less dependence than the older, longer-acting benzodiazepines in vogue 10 years ago.

    Many people also swear by nonprescription potions like melatonin, which is sold as a dietary supplement, although the scientific jury on that is still out.

    But the best long-term solution for many people is to change behavior and attitude, which means sticking to a regular sleep-wake schedule and trying not to worry about sleep loss.

    “The main problem with insomnia is people worry about their sleep,” says Peter Hauri, author of the bestseller, “No More Sleepless Nights.” If you worry that sleep loss will wreck your health, “you’ll try even harder to sleep and sleep even less.”

    So there’s another tidbit to remember as you toss and turn.

    “The most astonishing thing,” says Dinges, is that one or two good nights’ sleep “has a marked effect in reversing nearly all of the physiological and brain and immune function changes induced by sleep deprivation.”

    SIDEBAR:

    For a better night’s sleep.

    If you’re struggling with sleep, tell your doctor. If he or she can’t help, you can probably find a sleep specialist to diagnose and treat your problem at almost any major hospital.

    You can also practice habits designed to help your sleep:

    • Don’t try too hard to sleep. It can make things worse.
    • Don’t drink alcohol or water, or smoke cigarettes near bedtime; don’t drink caffeinated beverages after midafternoon.
    • Exercise may help, although the data on this are mixed. But don’t exercise within three hours of bedtime.
    • Schedule “worry time” in the early evening, then wind down.
    • Restrict time in bed to seven or eight hours. Spending too much time in bed not sleeping can make it harder to sleep.
    • Get up at the same time every day, even on weekends.
    • Don’t let bed become a negative emotional cue. Stay in bed only when you’re relaxed. If you can’t sleep, get up and do something relaxing until you feel drowsy.

    Herb found to aid mild depression

    by

    Karin Taylor, 58, a tax accountant in Toronto, was stumped. She had a good  marriage, two “wonderful kids,” and a job she loved. 

    “I had no reason whatsoever to feel depressed,” she says. “Yet there it  was.”

    Sure, she was aware in the back of her mind of her family history of  depression, including three relatives who committed suicide. But she had always felt fine, until a year ago, when, for no obvious reason, life just  lost its zest.

    She tried every self-help trick in the book – meditation, positive  thinking, creative visualization. Nothing worked.

    Desperate, she finally saw a doctor and, putting aside her fear of side  effects, agreed to a prescription for Paxil, an antidepressant drug. But  she never took it.

    Just as she was about to, a longtime woman friend came to visit, bringing along an herbal antidepressant called St. John’s wort, or Hypericum perforatum, which is sold as a dietary supplement.

    Taylor tried it – three 300 milligram tablets a day – and now says she  feels “wonderful. I just feel completely natural – no highs, no lows. I  just feel the way I always recall feeling.”

    Taylor’s woman friend swears by it, too, saying the herb “took away the underlying total  gray cloud” that had always been with her, despite 10 years of therapy,  12-step programs, exercise and a prescription antidepressant, Effexor,  which she still takes.

    St. John’s Wort, or Johanniskraut, has become the antidepressant of choice  in Germany, where it outsells Prozac 7-to-1; in fact, it outsells all  other antidepressants combined.

    It’s taking off here, too, says industry analyst Patricia Negron of Adams, Harkness & Hill in Boston. Sales began to grow last fall, she says, and  have “been building ever since.”

    The herb “is probably going to be one of the biggest herbs of 1997,” says  Mark Blumenthal, executive director of the American Botanical Council, a Texas research and educational group. “It’s driven not by market hype but by clinical data.”

    Many people with depression, of course, are successfully treated with “talk therapy,” prescription antidepressants or both. But as alternative medicine grows in popularity, it is perhaps no surprise that people are turning to herbal remedies for psychiatric as well as physical ills.

    Often, mainstream American doctors scorn or ignore herbal remedies because they can’t find studies on the products’ safety or efficacy in medical  journals. With St. John’s wort, they can.

    Last August, the British Medical Journal published a compilation of 23  randomized trials of the herb involving 1,757 patients with mild or  moderate depression. In 15 of the trials, some people were given the medication and others a dummy drug; in eight, people were given either the  herb or standard antidepressants.

    Some of the studies were flawed – definitions of depression were not  always consistent with American definitions, for instance – but the  results were encouraging. They showed that the herb was “significantly superior to placebo” and “similarly effective as standard  antidepressants.”

    Furthermore, side effects like upset stomach occurred in less than 20 percent of people taking the herbal remedy, compared to more than half of  those on standard antidepressants.

    The October, 1994 issue of Geriatric Psychiatry and Neurology was devoted to data on the herbal antidepressant as well.

    Promising as all this seems, there is a major problem: Nobody really understands quite how it works.

    One theory that it acts like a type of prescription antidepressant called a monoamine oxidase inhibitor, or MAOI, has been discredited, easing  concerns that St. John’s wort users would have to avoid foods that react  badly with MAOIs.

    But these findings leave wide open the question of how the herb does work.

    For years, researchers assumed that the key ingredients are hypericin and  pseudohypericin, but these chemicals do not seem to cross the blood-brain barrier, a membrane that protects the brain. That raises the question of  how they can affect brain chemistry.

    One possibility is that the chemicals may act on immune cells that then secrete chemicals that do cross the blood-brain barrier.

    Others think the herb may increase brain levels of the neurotransmitter serotonin, as many prescription antidepressants do. If so, the key  ingredient may be turn out to be a third constituent, hyperforin.

    Other theories are that the herb lowers levels of the stress hormone cortisol or that it acts on receptors called GABA on brain cells.

    However it works, St. John’s wort is cheap – about $ 10 for a month’s supply in health food stores, compared to about $80 for a two-to-four-week supply of Prozac.

    It also seems to have little toxicity, unlike some prescription antidepressants that can cause agitation, inhibition of sex drive, dry mouth, urinary retention and, in rare cases, abnormal bleeding.

    The herb seems to help “with no side effects, really, for mild  depression,” says Dr. Michael Jenike, associate chief of psychiatry at  Massachusetts General Hospital. “I’m sure Prozac would come out ahead for any kind of moderate to severe depression. But for mild depression, St. John’s wort may be just as good.”

    Dr. Harold H. Bloomfield, a psychiatrist in Del Mar, Calif., agrees, noting that the herb “is used by well over 20 million people” in Europe.

    Because it is not clear how well, if at all, St. John’s wort works in more severe depression, most researchers warn that you should not even consider  it – or any do-it-yourself approach – if you are seriously depressed or  suicidal.

    Instead, get to a psychiatrist or other licensed mental health professional who can assess your situation and offer treatment that’s already well-tested in this country.

    And never take St. John’s wort along with any other psychoactive medication, warns Varro Tyler, a plant medicine specialist emeritus from Purdue University.

    Jenike agrees. “Absolutely, you should not mix” this with other medications, “and I would be very careful with alcohol, too.” Mixing antidepressants, even mainstream prescription forms, can be fatal.

    St. John’s wort has also been associated with sun sensitivity in animals,  which means users might be more sensitive to sunburn.

    Despite such caveats, if you’re one of the millions of Americans like Taylor’s woman friend who have been slogging through life in a gray cloud, the herbal  antidepressant might help.

    In fact, the National Institute of Mental Health and the Office of  Alternative Medicine are are excited enough about it that they are  planning to seek proposals from psychiatrists willing to study it.

    “Everyone wants to apply,” says Jerry Cott, chief of the pharmacological  treatment research program at NIMH.

    Taylor’s woman friend is already a convert. She used to think antidepressants of any  kind were “unnatural.” Now, she says, “it was the gray cloud I lived under  that was unnatural.”

    Anxiety, it’s not just a state of mind

    by

    Jake McDowell, now 10 years old and a budding author, no less, was only eight when he began to think he was going crazy.

    It started when he heard that one of his Waltham classmates had an infection in his heart and needed a heart transplant.

    Jake’s anxiety about his classmate grew into an overwhelming fear of germs. “He was petrified of sitting next to anybody,” even in circles of kids at school, says his mother, Debbie.

    Soon, he wouldn’t sit on her lap, either. Every time he touched anyone he’d wash his hands. When his parents told him to stop, he’d try to lick his hands clean instead.

    It took a year of missed diagnoses — one therapist said Jake’s troubles were due to his father’s travelling — before doctors at McLean Hospital diagnosed obsessive compulsive disorder, or OCD, and gave him drugs and behavior therapy that worked a near-miracle in ridding Jake of his fears.

    For Susan Sechrist, 29, it was plain old free-floating, heart-thumping, sleep-robbing, concentration-wrecking anxiety that made life miserable. At 18, Sechrist, who lives in East Greenbush, N.Y., quit school, thinking she was “high strung and creative.”

    Today, with the right diagnosis — generalized anxiety disorder, or GAD — and treatment, she’s back in college, and engaged.

    Everybody gets worried from time to time, even worried enough to lose sleep or come down with a queasy stomach.

    For 23 million Americans, though, anxiety is not just an occasional problem but a devastating chronic condition that takes over a person’s life, all day, every day, impairing the ability to function at home or work.

    But in the last several years, scientists have made stunning progress in unravelling the biological roots of anxiety, discovering neural pathways in the brain for specific types of severe anxiety such as panic disorder, post-traumatic stress disorder and obsessive-compulsive disorder.

    Partly as a result, it is now clearer than ever that “the workings of the brain are involved in all our mental life and behavior,” says Dr. Steven E. Hyman, director of the National Institute of Mental Health.

    “Descartes is dead,” says Hyman. “The old mind-body distinction does nothing but get in our way. Both medications and psychotherapy are effective because they work on the brain.”

    In fact, far from being emotional wimps, as laid-back folks might think, people with anxiety disorders often have identifiable — and treatable — brain disorders.

    It now appears, for instance, that at least some cases of obsessive-compulsive disorder are caused indirectly by bacterial infections. And panic attacks may be triggered by an overactive “suffocation alarm” in the body.

    Likewise, persistent fears, like those in panic and post-traumatic stress disorders, may stem from an overzealous amygdala, the brain’s first-response system for danger.

    Joseph LeDoux, a neuroscientist at New York University and a pioneer in the study of the neural pathways, has found that, in rat brains at least, the amygdala responds much faster to fear than the cortex, or higher brain centers.

    In fact, the almond-shaped amygdala acts twice as fast, probably so that animals can start a fight-or-flight response at the first hint of danger, rather than wait for the cortex to do its slower, more analytical work.

    When survival is at stake, in other words, evolution has pushed the brain to “decide” that it’s better to assume instantly that a snake-like stick is a snake — rather than vice-versa — and to check it out later.

    When we do see something that looks dangerous, like a snake, all the incoming signals go first to the thalamus, a kind of relay station deep in the brain, says LeDoux. The thalamus then sends signals to the visual cortex for full analysis. But it also sends signals on a fast bypass to the amygdala, which readies the body for battle or flight — firing up heart rate, breathing and muscles.

    This hair-trigger reaction of the amygdala explains why we “have emotional reactions to things we don’t understand,” says LeDoux. “We respond, then we realize why we are responding.”

    The amygdala’s ability to bypass the rest of the brain may underlie the fact that we often have unconscious fears that words cannot explain. This fits, says LeDoux, with the fact that in kids, the amygdala develops before the hippocampus, the brain structure that forms conscious memories.

    Though not everyone agrees with this explanation, LeDoux says it also explains why “it’s possible for you to be abused as a child and have unconscious emotional memories implanted through the amygdala without ever being able to verbally understand why those fears exist.”

    In other words, Freud was right. Sort of.

    As Hyman puts it, “We may have long-lasting emotional memories of experiences that we can’t explicitly remember, not because we have repressed them but because the amygdala matures before the hippocampus.”

    There are other examples, too, of the way our neural hard-wiring processes fear, which is defined as a response to an immediate, real situation, and anxiety, which focuses on future threats and thoughts and for which neural messages travel a somewhat different circuit, starting in the cortex and eventually feeding into the amygdala pathway.

    Years ago, Dr. Michael Jenike, associate chief of psychiatry at Massachusetts General Hospital, began to suspect a biochemical basis for OCD when he found that some anti-depressant drugs helped, but not others.

    Recently, PET and MRI scans of the brain have bolstered the idea that the brains of people with OCD are abnormal, says Jenike. They often have less “white matter,” the fibers that connect nerves with one another, and more “gray matter,” the nerve cell bodies, than others.

    And researchers have found that when they deliberately trigger obsessions in these patients by spreading germs on their hands, the frontal lobe and the thalamus “light up” on brain scans, showing precisely which neural pathways are involved.

    Even more telling, says psychologist David H. Barlow, head of the new center for Anxiety and Related Disorders at Boston University, is the finding that when obsessive-compulsive patients are treated, whether by drugs or cognitive-behavioral therapy, brain scans often go back to normal, showing that both types of therapy act on the brain.

    Researchers are also closing in on some of the reasons that abnormal brain patterns in anxiety develop in the first place.

    In OCD, for instance, there often appears to be damage to a brain structure called the striatum.

    Recently, Dr. Susan Swedo, acting scientific director of the national mental health institute, has found that, in kids with OCD, this damage can be caused by a streptococcus infection. The body reacts to the infection by making antibodies that then attack the striatum.

    Researchers have also found biological triggers for panic.

    The exact cause is still unclear, but some panic attacks begin when an instability in the nervous system triggers sudden changes in heart rate that can be frightening, says Dr. David Spiegel, medical director of the BU anxiety center.

    Panic attacks also occur, he says, in people who have an “overactive suffocation alarm,” a system in the brain that monitors oxygen and carbon dioxide in the bloodstream.

    If carbon dioxide levels get too high, the body may interpret this as suffocation, which can trigger panic. Panic can also occur if carbon dioxide drops too low, as often happens in people who hyperventilate — that is, who breathe too fast or too deeply, as anxious people do. The result can be dizziness and other symptoms that trigger panic.

    In other words, sensations from the body can be just as frightening and have the same effect as seeing a snake, says Hyman.

    While finding these and other biological triggers of anxiety is a step forward, patient advocates say, many people still spend years suffering — undiagnosed — in silence.

    All too often, both lay people and doctors still think that “anxiety is something you can just snap out of,” says Barlow of BU. “But people with anxiety disorders lose as much quality of life and time from work as people with chronic heart disease, lung disease and severe depression.”

    In that sense, at least, Jake McDowell was relatively lucky.

    For months, says his mother Debbie, Jake seemed to be getting worse. His fear of germs grew into a terror that people he loved would die. Then he became terrified of his socks because their pressure on his skin “felt like rocks,” she says.

    “We’d sit with 20 pairs of socks in his room in the morning,” says Debbie. “It came to the point where he couldn’t go to school because he wouldn’t get his socks on.”

    Within a week of the right diagnosis, he started a behavioral program, called exposure and response prevention therapy, through which he got a reward for wearing his socks for 15 minutes a day, then for 10 minutes more each day until his fears vanished. His progress was “remarkable,” says his mother.

    Jake also began taking drugs — Anafranil and Zoloft. Today, all he takes is Zoloft, and he has learned to talk himself out of his fears. Now, says Debbie, if he gets scared someone might die, “he knows it’s OCD, and this is not necessarily going to happen.”

    In fact, she says with pride, Jake now leads a normal life.

    Except, of course, that he’s already written a memoir about his experiences and will speak at an upcoming conference on the disorder.

    SIDEBAR 1:

    All had to be perfect.

    Fran Sydney of Fairfield, Conn., is 51 now and has lived with the knowledge that she has obsessive compulsive disorder for 10 years.

    But she’s really had OCD since she was five, she says, though for most of this time neither she nor anyone else had the slightest idea what was the matter with her.

    At first, she just had an odd tendency to stack things, “to put them in order, for symmetry, by color or whatever. Then it got worse,” she recalls.

    At 15, she was in a car accident in which a boy was killed. As Sydney’s anxieties mounted, she found herself constantly “folding things perfectly, lining them up” — rituals, she now understands, that were a desperate attempt “to take away the obsessions with things being out of control,” especially the fear that people close to her would die.

    At 23, she married, hoping that marriage would soothe her fears. But her first baby strangled to death during birth, the umbilical cord wrapped around his neck.

    “That’s when it really took hold,” she says. “I started to get into cleanliness, along with everything else.” Her towels were perfectly folded, the labels all lined up. The house was spotless. And Sydney was terrified.

    A year later, she gave birth to a child who survived, but that only seemed to make her OCD worse. “If a piece of laundry fell at the side of the washer, I’d do it over,” not because of germs, but because everything had to be perfect.

    “It’s not that you just want to do this,” she says of the rituals that were taking over her life. “This is something you have to do, and if it’s not done, you feel so overwhelmed with anxiety, or this dread or whatever, that it feels like your child is running across the street and will be hit by a car.”

    Still petrified that something would happen to her child, she remembers thinking, “If I have another one, I’ll be less worried.” So she had two more, but it didn’t help.

    Increasingly, she’d find herself in her alphabetically-organized kitchen, trying to decide whether to put a can of green beans under “G” for green or “B” for beans. As soon as she got home from the grocery store, she’d wash everything she’d bought.

    Worst of all was the effect her behavior was having on her kids and her marriage. “These kids could not do anything,” she says. “We were prisoners in the house.” Her husband left her, in large part, she says, because of her disorder.

    As the kids became teen-agers, they couldn’t have friends over because Sydney felt she would have to follow the guests around, cleaning after every step.

    Yet Sydney, like many people with the disorder, was able to hide her symptoms from everyone but her family.

    If friends invited her over for dinner, she would not reciprocate because she couldn’t have them in her house. She even “had a best friend who didn’t know anything about this,” she says. Once, when her friend wanted to drop in spontaneously, Sydney told her she’d locked her keys in the house. “I didn’t want her to watch my rituals. I’d have to wash the floor anywhere she went. That was a real low point.”

    Finally, after seeing numerous psychiatrists and psychologists who thought she was just anxious or depressed, Sydney saw a newspaper article about a double-blind study at Yale University of a new medication for obsessive compulsive disorder.

    Sydney immediately recognized that OCD was her problem and sought treatment at Yale. That was 10 years ago.

    As soon as she started treatment, she began to get better. She used a combination of drug therapy, with Luvox, and cognitive restructuring — a way of learning to change her thoughts to reduce anxiety.

    Today, Sydney, a real estate agent, is happy, remarried, enormously proud of her kids, now 23, 25 and 27 — and pleased with herself for finally getting help.

    People with OCD go undiagnosed for years, she says, from shame and because doctors do not always recognize the symptoms — like spending hours a day hand-washing or checking and re-checking repeatedly to be sure a stove is off.

    Her advice is as passionate as it is hard-won: “There is hope. There’s help. The only shame is in not getting help.”

    SIDEBAR 2:

    TREATMENTS FOR SPECIFIC ANXIETY DISORDERS

    The more researchers tease apart the subtle and not-so-subtle differences among various anxiety disorders, the better they get at fine-tuning therapy — both drugs and cognitive-behavioral treatments — to each specific problem. A primer:

    – Generalized anxiety disorder (GAD) affects 7 million Americans, according to the National Institute of Mental Health, and is marked by a tendency to anticipate disaster even if there is little reason to, and to worry excessively about health, money, family or work. People with generalized anxiety often can’t relax, sleep or concentrate and have physical symptoms such as trembling and muscle tension. Unlike everyday stress, their worries seriously impair functioning at home and work. People with GAD know their anxiety is excessive; they just can’t control it.

    Treatments lag behind those for other anxiety disorders. But behavioral therapy — in which a patient practices relaxation techniques and is taught other ways to cope — often helps. So does cognitive therapy, which involves working consciously to change the thoughts that trigger anxiety. Once you become conscious of the thought: “I’m going to fail this exam,” for instance, you can replace it with a more realistic one: “I’ve prepared as best I can and will probably do OK.”

    Medications can also help, in particular an anti-anxiety drug called BuSpar, which is not addictive and has been proved effective in some people, and tranquilizers like Valium, Xanax and Klonopin, which are effective but cause dependence.

    Other drugs also seem promising, especially a class of anti-depressants called SSRIs (for selective serotonin re-uptake inhibitors). These include Prozac, Zoloft, Paxil and Luvox.

    – Obsessive compulsive disorder (OCD) causes its victims to have repeated, intrusive thoughts and perform repetitive rituals. They know their behavior makes no sense, but they cannot stop it and can spend hours every day performing rituals like handwashing. An estimated 3.9 million Americans have the disorder.

    There is strong evidence that a particular behavioral treatment, “exposure and response prevention,” is effective. If a person is obsessed with germs, for instance, he lets the therapist put germs on his hands and is then taught how to manage the anxiety without compulsive, immediate handwashing.

    Drugs are also effective, particularly SSRIs and a different type of antidepresssant called Anafranil. In very extreme cases, brain surgeons can relieve symptoms by making make tiny cuts in specific areas of the brain affected by OCD.

    – Panic disorder, which affects 3.3 million Americans, is marked by sudden, repeated episodes of terror — panic attacks. Physical symptoms include chest pain, heart palpitations, shortness of breath, dizziness, feelings of unreality and fear of dying.

    In addition to the immediate terror, panic attacks can also leave a person with a phobia about the place where attacks occurred, such as a theater or shopping mall.

    Panic attacks can also leave people terrified of anything — like sex, exercise or caffeine — that also causes a rapid heart beat or other disturbing physical sensations.

    Panic attacks respond well to cognitive-behavior therapy, including a new variant called interoceptive exposure in which the therapist induces the physical sensations associated with panic, like dizziness, and the patient learns to reinterpret these as signs of anxiety, not of imminent death.

    Phobias related to panic disorder can be effectively treated with exposure therapy, in which a patient is exposed to the terrifying place or object and taught not to fear it.

    Drugs also work well, including high doses of tranquilizers. But increasingly, doctors favor SSRIs instead, because they have few side effects and don’t cause dependence. They sometimes also use an antidepresssant called Tofranil.

    • Phobias, which affect 7.2 million Americans, are extreme, disabling and irrational fears of something or some place that poses little actual danger. The fear leads to extreme avoidance of objects or situations, making some people housebound.
    • Drugs are not very effective against phobias, but cognitive-behavioral therapy often works, especially “exposure” therapy.
    • Post-traumatic stress disorder (PTSD) is marked by persistent nightmares, flashbacks, numbed emotions and a tendency to startle easily. PTSD can follow many traumatic experiences, including rape, war, child abuse, natural disasters or being taken hostage, and 5.7 million Americans are thought to be affected.

    As with GAD, treatment options have lagged behind those for other anxiety disorders, but cognitive-behavioral therapy can help, as can group psychotherapy. Several antidepresssants have been tried, but none has proved universally effective.

    SIDEBAR 3:

    For general information on anxiety, call:

    • 1-888-8-ANXIETY. (You don’t have to dial the `y’ to get through.)
    • The Center for Anxiety and Related Disorders at Boston University: 617-353-9610.

    For information on OCD:

    • 1-800-NEWS-4-OCD (a hotline operated by Solvay Pharmaceuticals, Pharmacia & Upjohn, which make and distribute Luvox.)
    • Web site: http://www.ocdresource.com\

    You can also contact the following organizations:

    • Anxiety Disorders Association of America, Dept. A, 6000 Executive Blvd., Suite 513, Rockville, MD 20852. Tel.: 301-231-9350.
    • Freedom from Fear, 308 Seaview Ave., Staten Island, NY 10305. Tel. 718-351-1717.
    • National Anxiety Foundation, 3135 Cluster Dr., Lexington, KY 40517-4001. Tel.: 606-272-7166.
    • Obsessive-Compulsive (OC) Foundation, Inc., P.O. Box 70, Milford, CT 06460. Tel.: 203-878-5669.
    • American Psychiatric Association, 1400 K St. NW, Washington, DC 20005. Tel.: 202-682-6220.
    • American Psychological Association, 750 1st St. NE, Washington, DC 20002-4242. Tel.: 202-336-5500.
    • Association for Advancement of Behavior Therapy, 305 7th Ave., New York, NY 10001. Tel.: 212-647-1890.
    • National Alliance for the Mentally Ill, 200 N. Glebe Rd., Suite 1015, Arlington, VA 22203-3754. Tel.: 800-950-NAMI (950-6264).
    • National Institute of Mental Health:

    Toll-free information services:

    • Depression: 1-800-421-4211
    • Panic and Other Anxiety Disorders: 800-647-2642.
    • National Mental Health Association, 1201 Prince St., Alexandria, VA 22314-2971. Tel.: 703-684-7722.
    • National Mental Health Consumers’ Self-Help Clearinghouse, 1211 Chestnut St., Philadelphia, PA 19107. Tel: 800-553-4539.
    • Phobics Anonymous, P.O. Box 1180, Palm Springs, CA 92263. Tel.: 619-322-COPE (332-2673).
    • Society for Traumatic Stress Studies, 60 Revere Dr., Suite 500, Northbrook, IL 60062. Tel.: 847-480-9080.

    Loneliness Can Be The Death Of Us

    by

    A little over 100 years ago, a small band of Italians left Roseto Val Fortore, a village in the foothills of the Apennines, in hopes of a better life amid the slate quarries of eastern Pennsylvania.

    Naming their new village Roseto, the group soon recreated the strong community ties they had nurtured in Italy. They lived in three-generation households, centered their lives on family and built their houses so close together that all it took to have in a neighborly chat was a walk to the front porch.

    By the 1960s, Roseto stood out like a distinctly un-sore thumb, becoming a magnet for researchers. While Roseto shared the same water supply, doctors and hospital with nearby villages, the town had only 40 percent as many heart attack deaths.

    At first, researchers thought the Rosetans might carry some special, protective genes. But this was not the case, for Rosetans who moved away — even to the nearby village of Bangor — lost whatever magic the town possessed against heart disease.

    That magic, now known as “the Roseto effect,” is as simple as it is elusive in America today: Close ties to other people.

    A growing body of data shows that closeness with other people has a strong protective effect against illness and death. And that the lack of such ties — social isolation — can kill just as surely as smoking, obesity or high blood pressure.

    That is one of the conclusions of a new book, “Overcoming Loneliness in Everyday Life,” due out in June by a husband and wife team of McLean Hospital psychiatrists, Jacqueline Olds and Richard Schwartz, and journalist Harriet Webster.

    Loneliness is no longer just a painful experience, but a “major public health problem,” says Schwartz, “and most psychiatrists haven’t registered the strength of the medical data on this.”

    In 1950, only 10 percent of households consisted of just one person, according to census figures. By 1994, this number had soared to 24 percent. That means 12 percent of the adult population now lives alone.

    And this trend is particularly strong among older people, who are more likely than ever before, and more likely than younger people, to live alone. While fewer than 10 percent of people aged 25 to 44 live alone, census data show, nearly a quarter of those 65 to 74 do, and 40 percent of people 75 and older.

    While some people certainly maintain a high level of happiness — about three in 10, in fact, according to surveys by University of Chicago researchers cited in the May issue of Scientific American — others are clearly lonely. A 1990 Gallup poll found that more than 36 percent of Americans are lonely.

    For many people, the worst part of loneliness is that it is often accompanied by shame. It is not okay in this culture to feel lonely, Olds and Schwartz write in their book, “because American culture prizes self-sufficiency above all else.”

    “Our notion of success is being able to purchase what you need and not be obligated to anyone,” Schwartz explains in an interview.

    “Yet in other cultures,” Olds adds, “people have always accepted leaning on each other as part of life.”

    The mere fact of living alone, of course, does not mean a person is destined to be lonely, though it probably does increase the odds, notes Dr. Gene Cohen, director of the Center on Aging, Health and Humanities at George Washington University in Washington.

    Nor should loneliness be confused with depression, he says, though both involve feelings of sadness. Loneliness is a state “you can pull out of,” says Cohen, “and you often maintain the motivation to get involved with other people.”

    With depression, “you may lose the motivation to be involved,” he says, and while social support can help assuage depression, some people also need professional help, including “the talking therapies or the judicious use of medication.”

    Certainly, the ability to spend time alone happily — creative solitude, if you will — is one of the great joys of life, and a hallmark of a mature personality.

    But the evidence is now overwhelming in two directions: Social isolation — having few, meaningful interpersonal ties –can have severe medical consequences, and close ties with people can significantly increase health and longevity.

    Consider:

    – People who are isolated but healthy are twice as likely to die over a period of a decade or so as healthy people who are not isolated, according to a 1988 review of studies on 37,000 people in the United States, Finland and Sweden. Among adults of working age, the more-isolated men are one to four times more likely to die of all causes at any age than less-isolated men, and more-isolated women are one to three times more likely to die than less-isolated women, says sociologist James House, of the Survey Research Center at University of Michigan.

    – Living alone after a heart attack significantly raises the risk of subsequent cardiac problems, according to a 1992 study of more than 1,000 people by Columbia University researchers published in the Journal of the American Medical Association.

    – People with heart disease have a poorer chance of survival if they are unmarried and do not have a confidant than if they are married, have a confidant, or both, according to a study of 1,368 people by Duke University researchers in the same journal.

    – Women with advanced breast cancer who join a support group live twice as long as those who do not, according to a study several years ago by Dr. David Spiegel, a Stanford University psychiatrist.

    – Similarly, people with malignant melanoma who participate in group intervention live longer than those who do not, according to a 1993 study by Dr. Fawzy I. Fawzy, a UCLA psychiatrist.

    – While chronic stress, such as taking care of a spouse with dementia, leads to marked declines in immune response, having a strong network of friends offsets this decline, according to studies by Ronald Glaser, an Ohio State University microbiologist, and his wife, Janice Kiecolt-Glaser, a psychiatrist.

    “Primates, which we are, are a social species,” says Glaser. “We run in packs, in troops. Social interaction between individuals” is an important “buffer to the physiological changes that stress is inducing.”

    And this may be particularly true for older people, whose immune systems decline with age.

    “The research clearly shows that social isolation is a major health hazard for elderly people. Socially isolated elders have higher rates of physical and mental illness and even death. . .” said Karl Pillemer, director of the Applied Gerontology Research Institute at Cornell University, in an e-mail interview last week.

    An older person who is isolated is also at increased risk of being abused, according to Pillemer’s studies, which show that older people who were abused had less contact with friends and family than those who were not, in some cases because the abuser forbad such contact.

    Many Americans, young and old, turn to therapists, self-help groups and medications to combat isolation, but there may be a better way, and it’s not just seeking friends for friendship’s sake.

    “The idea is that you need to be willing to enter into relationships of mutual obligation,” says Olds.

    “The really naive notion of our time is that the way you make friends is just by being fascinated with someone, that you are drawn by pure attraction,” says Schwartz.

    “But the fact is, people’s lives are so hectic that those purely fun relationships often don’t get sustained. It’s the relationships where people are really useful to each other that do get sustained, that deepen and that therefore fulfill people’s needs for longterm intimacy,” Olds adds.

    If that has an old-fashioned ring to it, they say, so be it. After all, old wives’ tales often endure precisely because they do contain gems of hard-won wisdom.

    Like this one: To have a friend is to be one