Depression—it’s more than an occasional down-in-the-dumps feeling. It’s a low mood, despair or hopelessness that lasts for weeks, months, or even longer. In fact, most health professionals today consider depression a chronic illness that requires long-term treatment, much like diabetes or high blood pressure. The most common treatments are psychotherapy and antidepressants ,which work to correct the chemical imbalance in the brain thought to cause depression. There are several different classifications of antidepressants, depending on which brain chemical the drug affects. For example, selective serotonin reuptake inhibitors (SSRIs) increase the production of serotonin in the brain; monoamine oxidase inhibitors (MAOIs) block monoamine oxidase, an enzyme that breaks down neurotransmitters. All antidepressants have some side effects, the most common being headache, nausea, constipation, dry mouth, agitation and sexual problems. But most occur in the early weeks of therapy and lessen over time.

However, some side effects can be serious. In October 2004, the U.S. Food and Drug Administration (FDA) directed manufacturers to add a boxed warning, the most serious type of warning used on prescription drugs, to the labeling of all antidepressant medications to alert the public about the increased risk of suicidal thinking or suicide attempts by children and adolescents taking antidepressants. In May 2007, after a more detailed analysis of antidepressant clinical trials, the FDA directed that the warning be extended to include young adults up through age 24.

Earlier this year, a study published in the Journal of the American College of Cardiology concluded that women with no history of cardiac problems but who used antidepressants are at heightened risk for sudden cardiac death (SCD), though the exact reason for the link remains unclear. And most recently, a report published in the December 14 Archives of Internal Medicine shows that postmenopausal women who take antidepressants have an increased risk of stroke and death compared to women of the same age who don’t take the drugs.

For the study, researchers looked at data from 136,293 women who participated in the Women’s Health Initiative (WHI) of the National Institutes of Health, a 15-year study of more than 160,000 U.S. women to examine risk factors for and potential preventative measures against cardiovascular disease, cancer and osteoporosis. At enrollment, none of the participants were taking antidepressants but at their first follow-up visit, either one or three years after study entry, about 5,500 reported currently taking an antidepressant. Six years later, the researchers compared that group’s subsequent history of cardiovascular disease with that of the remaining participants who had not started taking antidepressants.

While there was no difference in the rates of heart attacks, those taking antidepressants were 45 percent more likely to suffer a stroke than the participants not taking the medications. No difference in stroke risk was found between the two major classes of antidepressants, SSRIs or tricyclic antidepressants (TCAs). However, there did appear to be a higher risk of hemorrhagic stroke caused by a bleed in the brain in SSRI users. When overall death rates were examined, those on antidepressants were found to have a 32 percent higher risk of death from all causes than non-users. However, because depression itself is known to be a risk factor for cardiovascular problems, it remains unclear whether taking anti-depressants is solely responsible for the increased risk of stroke.

“Although these results raise concerns about adverse effects of antidepressants, it is important to note that depression itself has been implicated as a risk factor for coronary heart disease, stroke, early death, and other adverse outcomes,” said lead author Dr. Jordan W. Smoller, of the Massachusetts General Hospital Department of Psychiatry. “In addition, inadequately treated depression is associated with substantial disability, impairments in quality of life, and health care costs.”

Joanne Murphy, Research Liaison Officer for The Stroke Association, said that while the study did seem to show a link between antidepressants and stroke, the overall risk is relatively small. “We are already aware of links between depression and the risk of stroke and we are currently funding further studies to look into this,” she said. “Everyone can help reduce their risk of stroke by making lifestyle changes, such as reducing their blood pressure, giving up smoking, reducing alcohol intake, improving their diet and getting plenty of exercise.” Murphy stressed that “anyone who is at all concerned should consult their GP.”

For many patients who are severely obese, the health benefits of gastric bypass surgery may far outweigh the risks of the procedure. New research suggests that bariatric surgery can actually increase the life expectancy of many who suffer from obesity. The details of the study appear in the recentArchives of Surgery.

Bariatric surgery is a procedure commonly performed on those who are dangerously obese to induce weight loss. Gastric bypass surgery helps to achieve weight loss by creating a small stomach pouch with a stapler device and connecting it to the distal small intestine. The upper part of the small intestine is then re-attached in a Y-shape. After the surgery, overeating is prevented by having limited stomach capacity that causes nausea and vomiting when capacity is exceeded.

The new findings, based on the creation of a mathematical model, indicate that in most cases, life expectancy is improved by opting for the gastric bypass procedure. The study suggests that as many as 5% or more of seriously obese Americans should consider the surgery.

Exceptions to beneficial improvement of life expectancy were found to be among certain high risk groups having a 30-day mortality rate of 9.5 percent or higher following surgery, or when the surgery was not deemed to have the potential of adding life-years of 2 percent or more. In the report, researcher Daniel P. Schauer, M.D., of the University of Cincinnati, and colleagues concluded, “While not all patients are guaranteed a good outcome, our model indicates that gastric bypass increases life expectancy for most patient subgroups.”

For their analysis, the researchers used a Markov state transition model to generate estimated benefits and risks of the gastric bypass procedure in morbidly obese patients. The model was based on data from two nationally representative surveys, and a 2007 observational trial of nearly 8,000 patients who had undergone gastric bypass, in addition to a control group.

The baseline 30-day mortality in the model was 0.2 percent, while the baseline efficacy of surgery in extending life expectancy was 53 percent. Results of the analysis indicated that the gastric bypass procedure slashed death rates in half during seven years of follow-up.

An average 42-year-old woman with a BMI of 45 was found to gain an estimated 2.95 years in life expectancy by opting to under gastric bypass surgery, according to the model. The greatest benefits in life expectancy were noted in younger women having a relatively high BMI. A 35-year-old woman with BMI of 55 could expect to live five extra years by having the surgery However, BMI at the time of surgery was found to be a more important factor than age. For a 35-year-old woman having a BMI of 45 the life expectancy gain would shown to be about 3.2 years, while for a woman having a similar BMI at age 55, would gain about 2.5 years.

For men, the benefits were less, especially in relation to their age. A 35-year-old man could gain about 10 percent in life expectancy, whereas a man at 75 years of age with a BMI of 35 could expect a gain of only one or two months of life. According to the authors, “Younger patients have lower surgical risk and more time over which to realize the benefits of surgery. For older patients, the gain is smaller, and for some, gastric bypass surgery will decrease life expectancy.”

Regarding their findings, the researchers wrote, “The decision analysis presented here is a step forward in understanding optimal patient selection but also highlights some of the areas for which better data are needed.”

Obesity is a growing concern among Americans and is associated with an increase in the risk of heart attack, heart disease, and other cardiovascular issues. Prior research has shown that gastric bypass procedures result in substantial, long-term loss of weight. In addition, the surgeries can lead to improved cardiovascular health, recovery from diabetes, and a significant reduction in mortality of between 23 percent and 40 percent. Bariatric surgery is recommended by the U.S. National Institutes of Health for obese people having a body mass index (BMI) of at least 40, as well as for those with a BMI of 35 when other serious medical conditions, such as diabetes, also exist.