Depression Treatments

online conference transcript

Dr. Louis Cady: on the latest advances in depression treatments, antidepressant medication, ECT (electroconvulsive therapy) and psychotherapy treatments for depression.

David: HealthyPlace.com moderator.

The people in blue are audience members.

David: Good Evening. I'm David Roberts. I'm the moderator for tonight's conference. I want to welcome everyone to HealthyPlace.com. Our topic tonight is "Depression Treatments". Our guest is psychiatrist, Louis Cady, M.D.

Dr. Louis Cady is a board-certified psychiatrist based in Evansville, Indiana. In addition to his private practice, Dr. Cady, has written two books, gives lectures, and is one of the few male psychotherapists who conducts a weekly support group for women on women's issues. 

The reason Dr. Cady is here tonight is because one of his areas of expertise is Depression, especially treatment-resistant depression.

Good Evening Dr. Cady and welcome to HealthyPlace.com. We appreciate you being here tonight. Many people who visit our site have been living with depression for years and can't seem to "get over it". How difficult is depression to treat?

Dr. Cady: Good evening David and guests. It is a pleasure to be here.

Depression is both an easy and a difficult condition to treat. Let me explain in the next several sentences.

Depression, as we understand it, is a biological disturbance in the brain and not a defect in moral character, moral laxity, etc. Treatments for depression which are currently available these days, are generally safe and effective. This wasn't always the case.

If depression is treated skillfully and carefully by an expert, it's usually not that difficult to bring it to heel. If it's been a problem for a long period of time, or if it's severe, it can be more of a problem, require quite a lot of time to get the medicine right, and, of course, we can't forget the aspect of psychotherapy or talk therapy to help people deal with the psychological realities of it as well.

I know, a long answer to what looks like a simple question, but hopefully this will frame our discussion for this evening.

David: Why is it that some people can recover from their depression in a shorter period of time than others?

Dr. Cady: Several explanations. Some people's depression isn't as bad as other's, and some people respond better and more briskly to antidepressant medications. And some people have a moment of startling, clear insight in their psychotherapy which affords them a glimpse into a different, better way of making decisions and conceptualizing the existential (and other!) aspects of their existence. Particularly in relationships which are not good, business situations which are not going well, and when they have a warped and distorted view of the world. Also, the newer antidepressants simply work faster than the old-timey way of treating depression with tricyclic antidepressants.

David: A few minutes ago, you mentioned about being treated by an expert who is skillful. Can you clarify what that means and how an individual would find that type of person to treat them?

Dr. Cady: Certainly. I see two primary psychopharmacological ("pill prescribing") misadventures in physicians from whom I get patients who are not doing well:

• underdosing
• overdosing

In underdosing, the medication is never pushed up high enough to get the job done. In overdosing, the medication is typically started so high, or "too hot" - to use the Goldilocks analogy - that the unfortunate patient gets so many side-effects from the first dose... or first few doses... that they are already off to a bad start.

Finally, antidepressant medications should be selected carefully for the type of depression which one is treating. Every medication on the US market right now could be thought of in a particular "niche" for a particular type of depression, or, conversely, in particular "niches" where their prescribing could be harmful. Therefore, "choosing wisely" in terms of selecting the right agent, and then prescribing with a suitable level of sophistication and technical finesse - in other words, not turning your patient into a zombie or putting them up on the ceiling with anxiety from the first dose of medication they pop into their mouths... these are the criterion I would look at for "skillful".

David: Are there tests that can be given to determine what is wrong, brain chemical wise" and which medication should be used?

Dr. Cady: Excellent question. At one time, is was thought that the "Dexamethasone suppression test" could tease apart "real", "biological" or "melancholic" depression for the more reactive, "psychological" types. Not true. There is currently no available blood test in clinical practice which can determine which antidepressant to select. On the other hand, the astute clinician can, if listening to the patient clearly and empathically, come up with some reasonable hypotheses about what neurotransmitters might be out of whack. One classic example would be a woman suffering from premenstrual dysphoric disorder, with carbohydrate cravings, "low mood" on a monthly basis, and classic signs and symptoms of depression. That is a serotonin deficiency unless proven otherwise. Accordingly, a medication which boosts serotonin (SSRIs) should be selected. That would not include such things as Wellbutrin - a great medication, to be sure, but not one specifically indicated for this condition. That is an example of how I would BEGIN to conceptualize which medication to select.

David: I used the term "treatment-resistant depression." Is there truly such a thing as depression that can't be treated or that is highly resistant to treatment?

Dr. Cady: Yes. In severe cases of intractable depression, where all antidepressants fail, and ECT (electro-shock therapy) fails, psychosurgery to break the obsessively ruminative feedback loop in the unfortunate sufferer's brain has and can be used. This is a RARE procedure, is not done in a cavalier fashion and there are all sorts of hoops that a treatment team must jump through. In my four years of training at Mayo, where we saw some of the worst cases of depression, I saw only ONE case of a patient with intractable depression that came to this state and ultimately had the surgery and benefited from it. I want to emphasize that that is a rare situation, however. Typically, treatment resistant depression is simply a case where the right medications, or the right combination of medications has not yet been tried. One of my mentors of psychopharmacology - Dr. Steven Stahl, has come up with some very creative combinations. His book, Essential Psychopharmacology, 1998 (new edition coming out this summer) is a goldmine of information on what he calls "heroic pharmacotherapy."

David: We have plenty of audience questions, Dr. Cady. Let's get started:

amaranth: Does cognitive therapy really work?

Dr. Cady: Yes, cognitive therapy really works. It was designed by Aaron T. Beck, and popularized by David Burns in his great book, FEELING GOOD: The New Mood Therapy.

It should be noted that psychotherapy certainly works in the type of depression, which, although it is biologically derived, may be psychologically caused and exacerbated. Thus, cognitive therapy, as well as interpersonal therapy, behavioral therapy, and even the more classic psychoanalytic or psychodynamic psychotherapies can all work. However, it typically takes more time.

And just one more thing. Biological treatment of depression with medications does not mean that psychological issues should be ignored. They should be dealt with appropriately in psychotherapy. On the other hand, if the depression is primarily biological - meaning there's a terrible history of it in the family, you started out as a happy camper, and you have no reason to be depressed - but are anyway - then cognitive therapy will probably not make you better and you will need biologically oriented treatment.

David: Is the "best" treatment for depression a mixture of medications and therapy? or can medications alone do the trick in a lot of cases?

Dr. Cady: Good question, David. Antidepressant medication and psychotherapy is probably the best combination of the type of depression treatment where there is a clear evidence that it is moderate to severe, has biological (neurotransmitters out of whack) problems, and the person actually has reasons to be depressed and is doing maladaptive things cognitively.

This is the kind of "middle of the road," garden variety depression, and "medication plus psychotherapy" is definitely the way to go. But, the other two extremes are the exclusively psychologically mediated difficulties where psychotherapy should be used, and the exclusively biological (see above) where endless hours of therapy will only frustrate the patient and not really accomplish anything...because they didn't need that to start with. Does that make sense?

David: Yes, and here's another question from the audience:

Ablueyed: My depression feels very urgent and life-threatening. The thing is I don't talk a lot, I'm afraid of both being with people and being alone. Are these common symptoms of depression and how do I overcome them?

Dr. Cady: You have touched on some key elements of depression - you have a sense of urgency and of a threat to your life (see Darkness Visible - by William Styron, where he noted the same thing), but have difficulty talking about it. Basically everything you mentioned is a symptom of depression. The classic symptoms of depression are : sleep difficulties, feelings of sadness and despair/depression, loss of interest, feelings of guilt and worthlessness, poor energy, poor concentration, appetite changes, feelings of being sped up or slowed down and thoughts of suicide. Five out of nine of those is a gold standard diagnosis for depression. BTW - you need to have them for two weeks, and the symptoms of depression can't be caused by any other biological or psychiatric problem. In terms of how to overcome them. Here are some suggestions:

1. You're here. That's a start. Learning about the illness is one of the first steps to overcoming it. I congratulate you for being here.
2. Learn what treatments are available. If you have a difficult time talking with people, this might be a good way to ease into an understanding about it.
3. Finally, make an attempt - please, for your own sake - to find someone you can trust and talk to. Just talk a little bit about what's going on. You don't have to regurgitate your entire life history or go into every gruesome detail. Find out if you can trust this person; then you can begin building a good, solid, psychotherapeutic relationship.

I hope that this begins to answer your question. Good luck to you. It was a pleasure answering your question.

David: On the subject of talking to a therapist, here's a question:

imahoot: Is it typically because of fear why someone has difficulty talking to a therapist?

Dr. Cady: The quick answer, imahoot, is "possibly." On the other hand, maybe the therapist is just not the kind that gives you warm fuzzies. I've heard tales of some therapists (and doctors, and lawyers, and CPA's, etc., etc.) that I wouldn't send my dog to. Additionally, depressed people aren't usually the kind that can muster a "hale fellow well met" style of engaging with people. Other folks might have an "anxiety disorder" - which is a little bit outside the simple "fear" description.

WBOK: If you've been using the same antidepressant medication for 3 years or more and have had reoccurring depression, should your medication be changed?

Dr. Cady: Quick answer: YES, or raised, or something combined with it. Medications should be pushed to the limit before they are declared a failure. Here are some doses of medications that I would go up to (absent side-effects) before I would consider the medication trial a failure:

Prozac, 80 mg per day. - 200 mg per day. Paxil - 50 - 60 mg per day. Wellbutrin - 450 mg per day. Effexor - 375 mg per day. Celexa - 60 - 80 mg per day. Serzone - 600 mg per day. If you haven't gone all the way to the max on a medication, you can't say that the possibilities have been exhausted.

poet: Dr. Cady, my medications are no longer working. I have suicidal thoughts and constant feelings of worthlessness. Should I consider inpatient treatment for depression?

Dr. Cady: Dear poet: you actually have two choices: not only the inpatient versus outpatient option. But, logically, whether or not you can reasonably expect your medications to work at the dosages they have been prescribing. For example, if you are taking 10 mg of Prozac, or 25 mg of Zoloft per day, or some low dose, aren't any better, and are suffering, and your physician is not raising the dose, then the choice really isn't so much inpatient or outpatient, but are you going to keep plowing the same soil with the same rusty instrument - if you get my drift. Inpatient treatment for depression won't make bad medication dosages work any better. If, on the other hand your depression is severe, you have significant psychological or trauma issues to deal with, and you need the nurturing sanctuary of a protective and caring environment where you can mentally and psychologically "catch your breath" and give your medications a chance to work, then the option of inpatient treatment is certainly a reasonable one and should be considered. I hope that this answered your question logically and completely. Good luck to you.

David: Dr. Cady, if a person can't find reasonable improvement in their level of depression after 6 months, would you say it's time to find another doctor?

Dr. Cady: It depends on what's been happening in the last six months. If one dose of medication has been selected and the physician has been twiddling his/her thumbs for the last six months after it's been prescribed, I would say, yes, it's time to change. If, on the other hand, the condition is extreme and severe, creative and intellectually aggressive and coherent pharmacological strategies are being considered and implemented, the physician has expressed to you a logical PLAN and you believe in him/her, then I would stick with the program.

jakey9999: I am taking Lithium and Zyprexa. Although I get a little relief while taking them, I have no energy. I have tried every over-the-counter remedy, can you suggest anything to increase my energy levels?

Dr. Cady: Good question, jakey9999. Lithium and Zyprexa are not, per se, antidepressants. Both have a known problem with causing sedation and "loss of energy" - with the Zyprexa being a worse offender than the Lithium. Lithium has been historically used to augment antidepressant therapy but, with the advent of the new "gangbuster" antidepressant drugs (Effexor, Wellbutrin, Remeron, Serzone and the like... which can be combined with other drugs), its use as an augmenter has fallen into disuse, except in the most extreme cases. If you have bipolar disorder (and you might, given that you are on lithium), another antidepressant should be considered. Wellbutrin seems to have gotten the nod for this niche in the treatment of depression in bipolar disorder.

maddy: How about the role of ECT or electro-shock therapy? And how safe is that?

Dr. Cady: Maddy, there's a good discussion of electroconvulsive therapy on this web site, I noticed tonight. It's pretty strongly anti-ECT, but I believe both sides should be aired.

My own feeling about ECT (have done it hundreds of times with patients, many more at Mayo in my residency than in my current practice) is that it absolutely works for real, legitimate, heavy duty, biological depression. It also doesn't scramble your brains (although you might have some retroactive memory loss during your hospital stay) - but you won't forget who you are, what you are about, etc. It's pretty safe. It's currently done under total anesthesia and full body muscle paralysis, so the One Flew Over the Cuckoo's Nest scenario simply doesn't apply anymore. It works, it's effective, and it's safe. That being said, it should only be used if a strong, coherent, logical trial of medications has failed or the patient is right there on the brink of suicide and heroic measures are absolutely called for.

Turbo: If one stops responding to an SSRI, does that mean other SSRI's should not be tried?

Dr. Cady: Not necessarily, Turbo. The dosage might need to be raised. Secondarily, an augmenting agent (such as Wellbutrin - which boosts both dopamine and norepinephrine) could be added to "harmonize" with the serotonin-boosting properties of the SSRI.

WhoAmI: Is it possible that antidepressant medications can make depressed people worse since medications are not tested on humans?

Dr. Cady: It is always possible that medicines can make depressed people worse. I tell my patients that the use of a medication can cause anything from seizures, to allergic reactions to death. People fall over dead every year in doctors' offices after a dose of penicillin in the you-know where.

On the other hand, your statement that antidepressants aren't tested on humans is, if I may be blunt, erroneous, and would come as a great surprise to the FDA. In fact, after they are determined to be both safe, and effective. Medicines are tested in humans in clinical trials before they are released to the market and before they are tested on humans, they're tested on animals to make sure that they

1. work;
2. are non-toxic;
3. would be reasonable and extremely safe to try in people.

But the wrong medicine, for anything, can make you worse. Hope that answers your questions.

shan10: Please try to shed some light why some people gain weight with medications such as Zoloft and Celexa?

Dr. Cady: Shan10, the issue of weight gain is a vexing one for certain antidepressants. The biggest offenders used to be the tricyclics; the most serious offender now is Remeron. The atypical antipsychotics are the champion "weight-gainers", however. Some antidepressants are thought to be weight neutral. Actually, Celexa is one of them, as is Serzone and Wellbutrin. But, like I mentioned above, anybody can have any kind of reaction to any medication and what stimulates somebody to eat more and gain weight may not do it to the next person. The safest thing to do is to ask your doc to switch you to another antidepressant if you're gaining too much weight.

Kaprikel: In the same light as Shan10's question. I am dieting, and taking Wellbutrin and Neurontin, and I cannot seem to lose weight. Can these medications contribute to that?

Dr. Cady: Great question, Kaprikel. Neurontin can tend to put on weight. Wellbutrin typically does not. The best "diet" by the way, that I've found and that's physiologically and biologically sound and rational really isn't a diet, but a commitment to healthy eating.

David: Here are a few audience comments on what's being said tonight. Then we'll get to more questions.

amaranth: In my case, I've been depressed since I was 6 and I've been working to get better since I was 13. No antidepressant medications have worked on me yet. I'm on Remeron and its not doing a thing for me.

lisarp: It's very discouraging and I go deeper with each episode. I have been for a second opinion consult and still am struggling. I become angry when I hear that no one has to be depressed in this day and age.

mazey: I just got out of the psych unit on Monday with a relapse of depression. What they thought would work, didn't, and now the doctors want to make another med change. Last time, I ended up in a medication induced psychosis. I'm afraid of medications.

David: Here's a good question from a young person, Dr. Cady:

Bzuleika: Is there any way to seek professional help without letting my parents know?

Dr. Cady: Bzuleika, it depends. If you're under 18, legally, a physician must have your parents' consent to treat you. Particularly if medicine is prescribed, it's considered "battery" if legal consent isn't obtained. I can't see that a physician would take you on as a patient in this context. On the other hand, you could begin treatment by exploring, with a school counselor, the nature of your feelings, and reasons why you might be feeling depressed. I hope that gives you a general framework to work in.

David: How can one tell if their depression is situational vs. chemical...or that what may have started as situational but has become a chemical imbalance?

Dr. Cady: First part of the question: if it starts "situationally" - and one's autobiographical memory is intact, one can frequently trace back to something like, "It all started when....." and then usually relate it to an event, a trauma, a reversal of fortune, etc. Then, if it worsens into clinical depression, or "major depression" as it's diagnosed, essentially the psychological problem has broadened into one which is now both psychological and biological. Basically, if it's a major depression, or "severe clinical depression" - it's biological - however it started. As noted some 45 minutes or so back in our conference, however, the strategy for dealing with it, should embrace both a psychotherapeutic one and a biologically based one.

David: Some people with depression turn to drinking alcohol to ease their pain, even while they are taking antidepressants. Can you address the effects of that please?

Dr. Cady: Alcohol can definitely anesthetize the pain and agony of depression temporarily. The problem is that it is a symptomatic, bandaid approach to things, such as the pain, and in some cases, the insomnia, brought on by depression. If used to treat insomnia, one can achieve tolerance (e.g., "get used to the stuff") requiring more and more, until one wakes up not only depressed but an alcoholic on top of it. Additionally, the use of alcohol WITH PROZAC OR PAXIL should be carefully considered. Both of these two medications ("the two P's") cause an inhibition in the liver enzyme system responsible for breaking down alcohol (as well as cough syrup and a host of other compounds). So you not only have to be aware of the dangers of alcohol but the dramatically greater dangers of mixing it with specific drugs.

EKeller103: Doctor, could you please discuss depression related to/ caused by Obsessive Compulsive Disorder (OCD)?

Dr. Cady: Good question, EKeller 103. The way I would conceptualize this would be probably two-fold:

First, OCD is classically thought to be a Serotonin deficit. Serotonin deficits are rampant in depression. Hence, what causes the OCD - lack of serotonin - is probably one of the difficulties in your depression.

Secondly, I have my patients learn the mantra "stress causes depression...stress causes depression..." so that they will realize that when they get (or got) depressed, it wasn't due to some moral laxity, etc, but related to (typically) overwhelming stress. People that have OCD and find themselves behaving in irrational, obsessive and compulsive ways are STRESSED. Obsessive Compulsive Disorder is considered "ego dystonic" - which means that you know that you are not acting right... you just can't help it. This is stressful. So, there could be both an underlying biological relationship between the two, as well as an underlying psychological, causally exacerbating link between the two.

Ablueyed: I've been reading this self-help book called "You Can Feel Better" and it describes our feelings as being caused by our thoughts, and that if you can think differently, this will change your mood. Do you believe in this?

Dr. Cady: To an extent, Ablueyed, this is true. One participant had mentioned cognitive therapy. Aron Beck, who founded cognitive therapy, noted that some of his patients who had undergone ECT (electroconvulsive therapy, electro-shock therapy) were simply not getting better. He determined that their problem was their thinking processes. Hence, he set about reversing their depressions by changing their thinking processes.

So the quick answer is, "I believe this" - that is, what you think about determines your reality. Earl Nightingale called this his "strangest secret" and sold a platinum 78 rpm vinyl recording (and later, a book) called "The Strangest Secret" based on this principle: "we become what we think about." On the other hand, to take a seriously depressed, imminently depressed patient and say, "see here, madame (or sir): your only problem is you've not selected the right things to think about" won't get the job done. There's a biological problem there. (See above). In that case, the combination of psychotherapy (to deal with "what they're thinking about"), as well as medication therapy, should be used. Hope this answers your question accurately and completely.

David: Here's the link to the HealthyPlace.com Depression Community. You can click on this link and sign up for the mail list at the top of the page so you can keep up with events like this. There's a lot of info there on depression and antidepressant medications.

AnnFP: So, in your experience, what happens as people try to rebuild their lives and climb out of a major clinical depression. How do they judge whether they are being successful at combatting their depression?

Dr. Cady: Most people, in my experience, and if they are truly getting better, have some idea that they are making process. This is tremendously exciting and motivating for them, because they can see a causal link between the medications and the psychotherapy they are using and the mental adjustments they are making correlated with their progress. This is "positive reinforcement." Also, the psychotherapeutic process facilitates pointing out to patients - if they are not yet aware - the subtle yet distinct changes that they are making in their lives as they get better.

Riki: What do you do if you have tried all the depression medications out there and still don't get any results from the depression lifting?

Dr. Cady: Riki, at this point, I have only one patient that I'm getting close to "trying all the medications out there" who hasn't significantly improved. The problem with "trying all the medications out there" is that, frequently:

1. they are not pushed up to the maximum dose;
2. they are changed too soon;
3. they are never tried in what Stahl calls "heroic combination pharmacotherapy."

If you consider, for example combining one of two SSRI's with Remeron, with Effexor, and with Wellbutrin, you have literally dozens of permutations of what could be tried. I'm not suggesting, willy nilly, simply putting people on a bunch of medications without thought of what you're doing. But, logically, trying someone on Prozac, then Paxil, then Luvox, then Celexa (five SSRI's in their order of market appearance) and saying, "we've tried five things and they haven't worked" is not a logical way to do things. That was probably at least three or four too many in the SSRI class before trying something a little more creative. This is simply an example of the thought process I encourage clinicians to consider.

topsy: I have seldom felt anger during my life, and my psychiatrist has said that depression is "anger turned inward". He has mentioned "constructive anger". What does he mean by constructive anger?

Dr. Cady: "Anger turned inward" was Freud's classical psychoanalytic concept of where depression came from. "Constructive anger" - which your therapist has mentioned, could refer to the fact that he/she perceives you as legitimately and appropriately angry at something or someone who traumatized you or did you an injustice. This would be appropriate anger, and could be "constructive" in the sense that it clues you into things in your life that you need to look at or change per se, however, free-floating, non-specific, uncontained, non-directed , and inwardly corrosive can be a terribly disempowering thing to deal with. You might want to check out "Dr Weisinger's Anger Work Out Book" and examine your anger through the lens that this particular author suggests. Good luck.

Alan2: Can I ask Dr. Cady to comment on the medications, Depakote and Risperdal, as they are used for Bipolar Disorder?

Dr. Cady: Great question, Alan2. Old style way to treat bipolar disorder: one mood stabilizer; if that didn't work, add a second mood stabilizer. New way to treat: one mood stabilizer and an "atypical antipsychotic." That is exactly the combination you mention with Depakote and Risperidal, respectively. It's a good combo. Here are some caveats. Depakote should be dosed up to the level where you either have side-effects or are better. The blood level numbers for this may range between 100 - 150 on the lab test. These are higher numbers than are typically seen in the use of Depakote for seizures. Also, periodic liver function tests should be obtained - every three months is a good idea - to make sure that your liver is still happy with the Depakote. In rare cases, it can cause your liver to become upset and you to become sick if it continues. Risperidal is one of those atypical antipsychotics about which we talked earlier which can contribute to weight gain. Watch out for that. But, if one is feeling great on this combination, it's a good one. Certainly it's logical and appropriate for bipolar disorder.

Kaprikel: I believe that my depression is probably situational, caused by unresolved grief. I find it very painful to discuss this in therapy, so I try to avoid it. How can I deal with this when its too painful to talk about?

Dr. Cady: Your insightful characterization of the source of your depression is excellent and augurs well for your eventually working through it. One thing that you might do, if you currently find it difficult to talk about, is to read every book you can find on dealing with grief issues. There are grief support groups to which you could belong, or attend, which might also be helpful. Many of these groups do not demand that you speak, so you could sit there, take it all in, and realize that you are not the only one with this type of problem. However, I cannot emphasize enough the need for an EMPATHIC, emotionally attuned therapist to work with. If you can find this sort of person with whom to work, the difficulty in "opening up", I suspect, will fade. Please try to find someone like this to work with. It will help, I promise!

whiteray: What treatment would be best for an individual with childhood originated PTSD (Post-Traumatic Stress Disorder) as well as likely hereditary depression?

Dr. Cady: For the PTSD from childhood - excellent, skillful psychotherapy to work through the issues (kind of like the "constructive anger" question we reviewed above.) For the "hereditary depression" - we can translate that, I think - if I read your question correctly - as a biological depression. My proposal would be a "full court press," psychopharmacologically speaking. I'm talking good, solid, rational, drug therapy, pushed up to the limit, and used in appropriate combination with therapy, if required.

David: I'm wondering if you know of any new antidepressant medications or depression treatments on the horizon that we should be looking for, that would help those with depression?

Dr. Cady: Raboxitene is a norepinephrine specific reuptake inhibitor which is used in Europe and is currently awaiting FDA approval in this country. Also, there is a great deal of excitement about the Corticotropin releasing hormone (CRH) class of drugs which seem to have potent antidepressant effects. Finally, there is a great deal of interest in "Neuropetide Y" which seems to be a solid antidepressant in its action.

These and other developments can be researched by anybody including the lay public, at Pub Med - from the National Library of Medicine. Good luck.

David: I want to thank Dr. Cady for being our guest tonight and doing a wonderful job. We appreciate you sharing your knowledge, expertise and insights with us. I also want to thank everyone in the audience for coming tonight and participating.

Dr. Cady: Thank you for the opportunity to be here, David.

David: Thank you again Dr. Cady and good night everyone.

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Disclaimer: We are not recommending or endorsing any of the suggestions of our guest. In fact, we strongly encourage you to talk over any therapies, remedies or suggestions with your doctor BEFORE you implement them or make any changes in your treatment.