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Diving Medicine Online

Diving Medicine
is the study, diagnosis and treatment of illnesses related to the undersea environment.


Depressive Disorders (Depression and Manic Depression) (Bipolar disorder)

Overview of Depressive Illnesses and Its Symptoms

 Depressive and manic depressive illnesses are the two major types of depressive illness, also known as affective disorders, or mood disorders, because they primarily affect a person's mood. Different terms, respectively, include unipolar and bipolar disorder. In this section, we will predominately discuss major depressive disorder and manic depression, which encompasses symptoms of depression and mania or hypomania, a more moderate syndrome than full-blown mania.

 It is estimated that over 17.4 million adults in the U.S. suffer from an affective disorder each year--that's one out of every seven people. If you've never been depressed, chances are that at some point in your life, you will become affected. Women are twice as likely as men to experience major depression while manic depression occurs equally among the sexes. The highest percentage of these illnesses occur between the ages of 25 and 44.

 Where do these illnesses come from? Genetic, biochemical and environmental factors can each play a role in onset and progression. While we all experience occasional highs and lows, depressive  disorders are characterized by their extremes in intensity and duration. People with severe, untreated depression have a suicide rate as high as 15 percent. In fact, the number one cause of suicide in the U.S. is untreated depression. Even so, of all psychiatric illnesses, affective disorders are among the most responsive to treatment. If given proper care, approximately 80 percent of patients with major depression demonstrate significant improvement and lead productive lives. Although the treatment success rate is not as high for bipolar disorder, a substantial number experience a return to a higher quality of life.

The Cause of Affective Disorders

 Research shows that some people may have a genetic predisposition to affective disorders. If someone in your family has had such an illness, that does not necessarily mean you will develop it, nor does it explain conclusively why you did. It does increase your chances of experiencing depression of an endogenous nature (biological in basis). This is commonly referred to as clinical depression to distinguish it from short-term states of depressed mood or unhappiness. Even if you don't have a genetic predisposition, your body chemistry can trigger the onset of a depressive disorder, due to the presence of another illness, altered health habits, substance abuse, or hormonal fluctuations.

 Depression can also be triggered by distressing life events, resulting in reactive depression. Losses and repeated disillusionment, from death to disappointment in love, can cause anyone to feel depressed especially if they have not developed effective coping skills. If these symptoms persist for more than two weeks, maintaining or increasing in intensity, this reactive depression may actually have evolved into a clinical depression.

 Regardless of its cause, the presence of depressive or manic-depressive illness indicates an imbalance in the brain chemicals called neurotransmitters. In other words, the brain's electrical mood-regulating system is not working as it should.

An episode of depression can usually by treated successfully with psychotherapy or antidepressant medication, or a combination of both. The choice depends on the exact nature of the illness. With treatment, up to 80% of depressed people show improvement, usually in a matter of weeks.

Most depressed people also have a lot of anger and anxiety underlying their mood swings. Certifying or allowing a depressed diver to continue to dive carries with it significant dangers to the diver and to his buddy. It is possible that there are some scuba fatalities that were suicides - apparently decided upon at the moment.

Any mood condition that clouds a diver's ability to make decisions in the underwater environment is clearly dangerous and should not be allowed. Mood altering drugs used to treat depression are clearly potent and must be used with caution when diving, paying particular attention to the warnings about use in hazardous situations. Rarely do we know the pharmacological changes that take place from the physiological effects of diving on the effects of the drug. Also, discontinuance of the drug in order to dive, even for a short period of time, may be unwise.



 Here are some of the symptoms of depression:

    Prolonged sadness or unexplained crying spells
    Significant changes in appetite and sleep patterns
    Irritability, anger, worry, agitation, anxiety
    Pessimism, indifference
    Loss of energy, persistent lethargy
    Feelings of guilt, worthlessness
    Inability to concentrate, indecisiveness
    Inability to take pleasure in former interests, social withdrawal
    Unexplained aches and pains
    Recurring thoughts of death or suicide

 Symptoms of Mania (Bipolar disorder)

    Heightened mood, exaggerated optimism and self confidence
    Decreased need for sleep without experiencing fatigue
    Grandiose delusions, inflated sense of self-importance
    Excessive irritability, aggressive behavior
    Increased physical and mental activity
    Racing speech, flight of ideas, impulsiveness
    Poor judgment, easily distracted
    Reckless behavior (spending sprees, rash business decisions, erratic driving,     sexual indiscretions)
    In the most severe cases, hallucinations

 Divers experiencing four or more of the above symptoms of either or both depression or mania should seek professional help if symptoms persist for longer than two weeks. Diving should be curtailed until the problem is appropriately managed. Divemasters and instructors should learn to recognize any changes in their divers' appearances, reactions and personalities and be quick to note any of the above signs and symptoms. Medical professionals also need to be aware of the dangers of diving to individuals who have conditions or are on medications that might alter consciousness or cause alteration in decision making ability in the underwater environment.

Advice About Diving

Whether or not a person with depression should be certified as 'fit to dive' should be decided on the merits of each case, the type of drugs required, the response to medication, and the length of time free of depressive or manic problems. Most probably could be allowed to dive, particularly those who have responded well to medications over a long term. Decision-making ability, responsibility to other divers and relationship to drug induced side effects that would limit ability to gear up and move in the water should be taken into consideration. Prospective divers should in all cases provide full disclosure of their condition and medications to the dive instructor and certifying agency - bearing in mind the safety of buddies, dive instructors, divemasters and other individuals who are always affected by diving incidents.
 

Medications used to treat depression and bipolar disorders with some effects adverse to diving.



Buprenorphine/Buprenex
Buprenorphine has been used to treat depression that has not responded to usual medication regimens.
Side Effects Adverse to divers:
· Drowsiness: A few patients may feel tired from buprenorphine.
· Low Blood Pressure: Avoid standing from a sitting or lying position quickly.
· Headache
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Buproprion/Wellbutrin/Zyban
Buproprion is used to treat depression, attention deficit disorder, bipolar disorders, and smoking cessation.
Side effect that is adverse to diving:
Increased incidence of seizure activity, dose-related.
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Buspirone / Buspar
Buspirone is used to treat anxiety or depressive symptoms, aggressiveness, irritability, or agitation, and may be used to augment the effectiveness of an antidepressant or treat certain antidepressant-induced side effects.
Side Effects that may be adverse to diving;
Drowsiness: Occurs rarely. Make sure you know how you react to this medicine before driving or using dangerous machinery. Dizziness: This is uncommon, but may occur especially 30-60 minutes after taking a dose, with walking or standing.
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Carbamazepine / Tegretol
This medication can be used to prevent or reduce the severity of mood swings. It is also helpful in preventing the recurrence of depression.
Side Effects that may be adverse to diving.
Drowsiness: This is usually only a problem the first few weeks you are on Carbamazepine. If this is a problem, be very cautious while driving or working with dangerous machinery.
Dizziness: This is usually temporary and will go away with continued use. You may avoid this by rising or changing positions slowly.
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Lamotrigine
Lamotrigine belongs to a group of medications called anticonvulsants. Anticonvulsants are used to control seizure disorders. In psychiatry lamotrigine may also be used to stabilize mood, especially in Bipolar Affective Disorders.
Possible side effects adverse to diving include:
· Dizziness or drowsiness: Know how you react to this medicine before driving or operating dangerous machinery.
Other possible side effects include:
· Balance problems, dizziness, headache, blurred vision, tremor, nausea.
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Lithium (Lithonate, Eskalith, Lithobid, Lithane)
This medication has several uses. When taken regularly, Lithium helps prevent or reduce the severity of mood swings. Lithium can also be used to augment the effectiveness of an antidepressant.
Side effects adverse to diving may occur:
· Muscular weakness: This usually goes away with continued use.
· Drowsiness: This usually goes away with time. If you are drowsy, use caution with driving or operating dangerous machinery. .
Too much Lithium can cause toxicity.
· Nausea and vomiting, diarrhea, tremor, dizziness, sleepiness, slurred speech, balance problems.
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Monoamine-Oxidase Inhibitors:
Nardil/Phenelzine and Parnate/Tranylcypromine
MAOI’s are used to treat depression and anxiety disorders.
This medication is usually very well tolerated. However possible side effects include:
· Dizziness: This may be due to low blood pressure. Dizziness may occur when you get up quickly or rapidly change positions. Arise or change positions slowly. This tends to occur only the first 2 months of treatment or with dosage increases. Taking all the dose at bedtime, or taking several smaller doses during the day may be helpful. Contact your physician before making any dosage changes.
· Drowsiness: This is usually transient, lasting up to several months.
· Tremor: This is an uncommon side effect, which may improve with continued use of the medication.
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Methylphenidate / Ritalin
Methylphenidate is used to treat Attention Deficit Disorder, and to augment the effects of antidepressants.
Possible side effects adverse to diving include:
· Excessive stimulation: Consider decreasing the dose or waiting longer between doses.
· Nervousness: This may occur when beginning to take this medication or increasing the dose.
· Increased blood pressure: Have your blood pressure checked weekly while on this.
· Increased resting heart rate: This tends to return to normal after a couple months.
· Infrequent side effects may include: headache, abdominal discomfort, fatigue.
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Mirtazapine (Remeron)
Mirtazapine is used to treat depressive and anxiety symptoms.
 Possible side effects adverse to diving include:
· Drowsiness: Mirtazapine should be taken one hour before bedtime. Make sure you know how you react to this drug before driving or using dangerous machinery. Drowsiness often disappears with increased dose.
· Dizziness: Arise from sitting or lying position slowly. .
· Dry Mouth: Drink plenty of fluids. Chew sugarless gum or suck on sugarless candy to promote saliva production.
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Venlafaxine / Effexor
Venlafaxine is used to treat depressive symptoms and attention deficit hyperactivity disorder.
Possible side effects adverse to diving include:
· Anxiety/restlessness: This may diminish with continued use.
· Drowsiness: Make sure you know how you react to this medicine before driving or using dangerous machinery.
· Dry Mouth: This may diminish with continued use. Dry mouth may increase your risk for dental disease. Chew sugarless gum and brush at least daily with fluoridated toothpaste.
· Rare side effects include: Seizure, fainting, muscle tightness, menstrual changes, excitability, trouble breathing, swelling of feet or legs.
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S-Adenosyl-L-Methionine (SAMe)
SAMe has been cited to alleviate depression, reduce symptoms of fibromyalgia, slow progress of osteoarthritis, improve memory, reduce alcohol-induced liver damage, and possibly reduce symptoms of attention deficit hyperactivity disorder.
Possible side effects adverse to diving include:
· Dry Mouth: Drink plenty of fluids. Chew sugarless gum or suck on sugarless candy.
· Blurred vision: Unusual.
· Restlessness, anxiety, &/or elation
· Patients with bipolar depression may switch to a manic state. .
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 Sertraline / Zoloft
Sertraline is used to treat depression, anxiety, and obsessive-compulsive symptoms.
Possible side effects adverse to diving include include:
· Anxiety/restlessness: This will usually diminish with continued use.
· Drowsiness: If this occurs, take this medication 1 hour before bedtime. This usually diminishes with continued use.
· Dry mouth: This may diminish with continued use. Dry mouth may increase your risk for dental disease. Chew sugarless gum and brush at least daily with fluoridated toothpaste.
· Tremor: This tends to diminish with continued use.
· Bruising/bleeding: Use of sertraline can slightly increase risk of bruising and bleeding, but this can be significant when aspirin or non-steroidal anti-inflammatory drugs (e.g naproxen, ibuprofen, ketoprofen, flurbiprofen, diclofenac, sulfasalazine, sulindac, oxaprozin, salsalate, piroxicam, indomethacin, etodolac) are also taken. Barotrauma is a hazard.
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St. John's Wort
St.John's wort is used to treat mild to moderate depression and possibly anxiety. This medication is not recommended for treatment of severe depression, including depression with suicidal thoughts, psychotic features (hallucinations, confused thoughts), or melancholia (weight loss, early morning awakening, very low energy).
Possible side effects include:
· Anxiety/restlessness: This will usually go away with continued use.
· Fatigue: This is uncommon and usually goes away with continued use.
· Concentration: Some studies demonstrate improved concentration and attention.
· Dizziness: This is uncommon and usually goes away with continued use.
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Tricylic Antidepressants
Tricyclic antidepressants are used to treat depression, anxiety, and chronic pain.
Possible side effects inimical to diving include:
· Drowsiness: This is usually a problem only during the first few days of starting or increasing the dose. Be cautious with driving and operating dangerous machinery until this symptom clears up. If this occurs, take this medication 1 hour before bedtime. This usually goes away with continued use.
· Dizziness: This may occur when you get up too quickly or rapidly change positions. Avoid this by changing positions slowly, especially during the night.
· Dry Mouth: This may disappear with continued use. Dry mouth may increase risk of dental disease. Chew sugarless gum, suck on sugarless candy, drink plenty of water, and brush at least daily with fluoridated toothpaste.
· Blurred Vision: This is usually temporary, rarely serious, and diminishes with continued use. Contact your physician if severe. .
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Topiramate / Topamax
Topiramate belongs to a group of medications called anticonvulsants. Anticonvulsants are used to control seizure disorders. In psychiatry topiramate may also be used to stabilize mood, especially in Bipolar Affective Disorders.
Possible side effects adverse to divers include:
· Dizziness/drowsiness: Usually goes away with continued use.
· Difficulty concentrating: May not appear until after the first month of taking topiramate.
· Tingling feelings of extremities: May disappear after first month of treatment.
· Double vision: May be temporary side effect.
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Trazodone / Desyrel
Trazodone is used to treat depression, some sleep problems, and agitation.
Possible side effects adverse to divers include:
· Drowsiness: Do not drive a car or operate dangerous machinery until you know how this drug affects you. Taking the evening dose 10 hours before arising the next morning may make this more tolerable.
· Dry mouth: This is usually temporary. Suck on sugarless candy or chew sugarless gum. Use fluoridated toothpaste at least twice daily.
· Dizziness: This may occur when you arise from a lying or sitting position too quickly, especially 4-6 hours after taking your medication. Rise and change positions more slowly to let your body adjust.
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Valproic Acid / Depakote
*FDA Black box warning - Pancreatitis and liver failure
Valproic acid belongs to a group of medications called anticonvulsants. Anticonvulsants are used to control seizure disorders, but in psychiatry Valproic Acid may also be used to stabilize mood, especially in Bipolar Disorders.
Possible side effects adverse to diving include:
This medication may cause drowsiness. Know how you react to this medicine before driving or operating dangerous machinery.
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Nefazodone / Serzone
*FDA Black box warning - liver failure
Nefazodone is used to treat depression and anxiety symptoms.
 Possible side effects adverse to divers include:
· Drowsiness: Do not drive a car or operate dangerous machinery until you know how this drug affects you.
· Dry mouth: This is usually temporary. Suck on sugarless candy or chew sugarless gum. Use fluoridated toothpaste at least twice daily.
· Dizziness: This may occur when you arise from a lying or sitting position too quickly, especially 4-6 hours after taking your medication. Rise and change positions more slowly to let your body adjust.
· Low Blood Pressure: This is uncommon and may subside with continued use.
Blurred Vision: This is unusual, usually temporary, and usually subsides with continued use.

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Paroxetine / Paxil
Paroxetine is used to treat depression, anxiety, and obsessive-compulsive disorder.
Possible side effects inimical to diving include:
· Anxiety/restlessness: This will usually go away with continued use. If this causes difficulty, contact your psychiatrist.
· Drowsiness: If this occurs, take this medication 1 hour before bedtime. This usually goes away with continued use.
· Dry Mouth: This may disappear with continued use. Dry mouth may increase risk of dental disease. Chew sugarless gum and brush at least daily with fluoridated toothpaste.
· Blurred Vision: This is usually temporary and will diminish with continued use.
· Tremor: This tends to go away with continued use.
· Bruising/bleeding: Use of paroxetine can slightly increase risk of bruising and bleeding, but this can be significant when aspirin or non-steroidal anti-inflammatory drugs (e.g naproxen, ibuprofen, ketoprofen, flurbiprofen, diclofenac, sulfasalazine, sulindac, oxaprozin, salsalate, piroxicam, indomethacin, etodolac) are also taken. This might be a danger with barotrauma.


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