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Psychological Issues in Diving

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DAN Explores Depression and Manic Depression and the Drugs Used as Treatment

By Ernest Campbell, M.D., FACS

Little research exists to characterize the relationship between mental conditions and scuba diving. Other than the obvious reasons people shouldn't dive -- i.e., they are out of touch with reality, severely depressed and suicidal or paranoid with delusions and hallucinations -- many people with everyday anxieties, fears and neuroses can dive and do so safely.

Successful divers have psychological profiles that are positively correlated to intelligence and characterized by an average or below-average level of neuroticism. These divers generally score well on studies of self-sufficiency and emotional stability, according to diving physiologist Dr. Glen Egstrom.

Some actual psychological disturbances are well known, but, as for the risks of scuba diving, documented and studied cases are few in number. These include the depressions, bipolar disorder, anxiety and phobias, panic disorders, narcolepsy and schizophrenia.

In addition to the risks caused by the condition itself, we must add the possible hazards of the effects of medications taken singly or, even more dangerously, in combination. No scientific studies show data that can confirm the relative safety or danger of taking any given medication.

In terms of danger to divers, medications usually play a secondary role to the condition for which the medication is prescribed. Plainly a powerful drug, a mood-altering medication, should be used with care by divers. Drugs that carry warnings indicating they are dangerous for use while driving or when operating hazardous equipment should also be considered risky for divers; if they're dangerous for drivers, they're risky for divers. The interaction between the physiological effects of diving and the pharmacological effects of medications is usually an educated, yet empirically unproven, assumption. Each situation requires individual evaluation, and no general rule applies to all. Another unknown is the additive effect of nitrogen narcosis on the actual effects of the medication.

Finally, divers have different chemistries and personalities; because of the effects of various gases under pressure, each diver responds differently to abnormal physiological states and changes in their environment. Diving conditions such as decompression illness, inert gas narcosis, carbon dioxide toxicity, oxygen toxicity, high-pressure nervous syndrome and deep-water blackout all can cause reactions that are similar to a psychoneurotic reaction or an abnormal condition of the brain.

Before advising for or against diving, the certifying physician must know all the possibilities and variations in each case of a diver with psychological issues.

Depressive Disorders

Depression (Unipolar Disorder) and Manic Depression Bipolar Disorder)

Overview of Depressive Illnesses and Their Symptoms

Depression and manic depression, two major types of depressive illnesses, are known as affective disorders, or mood disorders, because they primarily affect a person's mood. Different terms, respectively, for affective disorders include unipolar and bipolar disorders.

Depression is a persistent condition that can interfere with a person's ability to sleep, eat and hold a job and can last for weeks or months at a time. A depressed person almost always feels sad. It becomes difficult to feel any pleasure in life and the person can even become suicidal. Other symptoms include feelings of hopelessness and guilt, loss of interest in normal activities, reduced sex drive, changes in eating habits, insomnia, restlessness and poor concentration.

In this section, we will predominately discuss major depressive disorder and manic depression, encompassing symptoms of depression and mania, with wide mood swings, from deep sadness to the other extreme of elation, often losing touch with reality.

Each year, a large number of American adults -- the figure varying from 10 million to 19 million according to the source -- suffer from an affective disorder.

If you've never experienced depression, chances are that at some point in your life, you will. Women are twice as likely as men to experience major depression, while manic depression occurs equally among men and women. The highest percentage of these illnesses occurs between the ages of 25 and 44, according to Hopkins Technology, LLC.

Where do these illnesses come from? Genetic, biochemical and environmental factors each can play a role in the onset and progression of such illnesses. We all can experience occasional emotional highs and lows, but depressive disorders are characterized by extremes in intensity and duration. Hopkins records also indicate that people hospitalized for depression have a suicide rate as high as 15 percent.

Of all psychiatric illnesses, affective disorders respond well to treatment. If given proper care, approximately 80 percent of patients with major depression demonstrate significant improvement and lead productive lives, according to the National Institute of Mental Health (NIMH). Although the rate of successful treatment success is not as high for manic depression, 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, this does not necessarily mean that you will develop it. On the other hand, if you do develop an affective disorder, it does not explain conclusively why you did. Having a family member with an affective disorder does increase your chances of experiencing depression of an endogenous, or biological, origin. Commonly called clinical depression, these disorders are distinguished 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.

Distressing life events can also trigger reactive depression. Losses and repeated disillusionment, from death to disappointment in love, can cause people to feel depressed, especially if they have not developed effective coping skills. If these symptoms persist for more than two weeks, with a leveling or increasing in intensity, this reactive depression may actually have evolved into a clinical depression.

Whatever the cause, the presence of depressive or manic-depressive illness indicates an imbalance in the brain chemicals known as neurotransmitters. This means the brain's electrical mood-regulating system is not operating as it should.

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

Underlying their mood swings, most people with depression have anger and anxiety. Certifying or allowing a diver with depression to continue to dive carries with it significant dangers to the diver, his buddy and others on the dive excursion who may be attempting a rescue. It is possible that some scuba fatalities were actually suicides, apparently decided on the spur of the moment, but this is very difficult to prove.

Clearly, any condition that clouds a diver's ability to make decisions underwater poses dangers; diving under such conditions should not be allowed. In addition, we rarely have knowledge about drug changes resulting from the physiological effects of diving. Since such mood-altering drugs used to treat depression are clearly potent, people should use caution when they dive, paying particular attention to the warnings about use.

Discontinuing the drug to dive, even for a short period of time, may be unwise. The effects of a hiatus can play havoc with your body chemistry and affect your sense of well-being.

Depression

If symptoms of depression persist for longer than two weeks (see sidebar for a listing of the most commons signs), divers experiencing four or more of the symptoms of either depression, manic-depression or symptoms of both should seek professional help and stop diving until the problem is 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 should be alert to the dangers of diving for individuals who have these conditions or who take medications that might alter consciousness or affect a diver's ability to make decisions underwater.

Advice About Diving

Should a person with depression be certified as "fit to dive"? The merits of each case should be considered, including the type of drugs required, the response to medication and the length of time free of depressive or manic incidents. Most, particularly those divers who have responded well to medications over a long term, probably could receive clearance to dive.

We should also consider the following factors: decision-making ability, responsibility for other divers, and drug-induced side effects that could limit a diver's ability to gear up and move in the water.

In all cases, prospective divers should be mindful of the safety of buddies, dive instructors, divemasters and other individuals affected by a diving incident. Prospective divers should provide full disclosure of their conditions and medications to the dive instructor and certifying agency.

MEDICATIONS

For depression and bipolar disorders
(NOTE: In all cases, the generic name is first, followed by various brand names.)

Buprenorphine/Buprenex

Buprenorphine has been used to treat depression that has not responded to usual medication regimens used to start treatment, such as Prozac and Zoloft.

Possible side effects that may be adverse to diving:

  • Drowsiness: A few patients may feel tired after taking buprenorphine.
  • Low blood pressure: Avoid standing quickly from a sitting or lying position when using this medication.
  • Headache.

Buproprion/Wellbutrin or Zyban

Buproprion is used to treat depression, attention deficit disorder, manic-depression and smoking cessation.

Possible side effect that may be adverse to diving:

  • Increased incidence of seizure activity, dose-related.

Buspirone/Buspar

Buspirone, used to treat anxiety or depressive symptoms, aggressiveness, irritability or agitation. This medication may augment the effectiveness of an antidepressant by reducing anxiety, aggression and obsessive-compulsive symptoms.

Possible 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 30-60 minutes after taking a dose, with walking or standing.

Carbamazepine/Tegretol

This medication can prevent or reduce the severity of mood swings; it is also helpful in preventing the recurrence of depression.

Possible side effects that may be adverse to diving:

  • Drowsiness: This is usually a problem only in the first few weeks. If this persists, use caution while driving or working with dangerous machinery.
  • Dizziness: Usually temporary, this will disappear with continued use. Avoid this by rising or changing positions slowly.

Lamotrigine/Lamictal

Lamotrigine belongs to a group of medications called anticonvulsants, which are used to control seizure disorders. In psychiatry, lamotrigine may also be used to stabilize mood, especially in manic-depressive disorders.

Possible side effects that may be adverse to diving:

  • Dizziness or drowsiness: Know how you react to this medicine before driving or operating dangerous machinery.
  • Balance problems, dizziness, headache, blurred vision, tremor and nausea.

Lithium/Lithonate, Eskalith, Lithobid or 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.

Possible side effects that may be adverse to diving:

  • Muscular weakness: This usually diminishes with continued use of the medication.
  • Drowsiness: This usually goes away with time. If you are drowsy, use caution with driving or operating dangerous machinery.

NOTE: Too much lithium can cause toxicity, with nausea and vomiting, diarrhea, tremor, dizziness, sleepiness, slurred speech and balance problems.

Monoamine-Oxidase Inhibitors (MAOIs):

Phenelzine/Nardil and Tranylcypromine/Parnate

MAOIs are used to treat depression and anxiety disorders. This medication is usually well tolerated.

Possible side effects that may be adverse to diving:

  • Dizziness: This may be due to low blood pressure. Dizziness may occur when one rises or changes positions too quickly. Arise or change positions slowly. This tends to occur only the first two months of treatment or with dosage increases. It may be helpful to take the entire dose at bedtime or taking several smaller doses during the day. Contact your physician before making any dosage changes.
  • Drowsiness: This is usually transient, lasting up to several months, before the symptoms diminish.
  • Tremor: This is an uncommon side effect that may improve with continued use.

Methylphenidate/Ritalin

Methylphenidate is used to treat attention deficit disorder and to augment the effects of antidepressants as a mood elevator.

Possible side effects that may be adverse to diving:

  • Excessive stimulation: Consider decreasing the dose or wait longer between doses.
  • Nervousness may occur when beginning this medication or when increasing the dose.
  • Increased blood pressure. Check weekly while taking Ritalin.
  • Increased resting heart rate reduces to normal after a couple months.
  • Infrequent side effects may include: headache, abdominal discomfort, fatigue.

Mirtazapine/Remeron

Mirtazapine is used to treat depressive and anxiety symptoms.

Possible side effects that may be adverse to diving:

  • 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: Slowly rise from sitting or lying position.
  • Dry mouth: Drink plenty of fluids. Chew sugarless gum or suck on sugarless candy to promote saliva production.

Venlafaxine/Effexor

Venlafaxine is used to treat depressive symptoms and attention deficit hyperactivity disorder.

Possible side effects that may be adverse to diving:

  • Anxiety/restlessness, which 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 and swelling of feet or legs.

S-Adenosyl-L-Methionine (SAMe)

SAMe has been shown 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 that may be adverse to diving:

  • Dry mouth: Drink plenty of fluids. Chew sugarless gum or suck on sugarless candy.
  • Blurred vision: This is an unusual sign.
  • Restlessness, anxiety or elation.
  • Patients with manic-depression may change to a manic state.

Sertraline/Zoloft

Sertraline is used to treat depression, anxiety and obsessive

  • compulsive symptoms.

    Possible side effects that may be adverse to diving:

    • Anxiety / restlessness, which will usually diminish with continued use.
    • Drowsiness: If this occurs, take this medication an 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 the 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 to the middle ears, lungs, sinuses and any air-filled bodily cavity is also a hazard.

    St. John's Wort

    While the herb St. John's Wort is used to treat mild to moderate depression and possibly anxiety, it 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 that may be adverse to diving:

    • Anxiety / restlessness, which will usually disappear with continued use.
    • Fatigue, which is uncommon and usually disappears with continued use.
    • Concentration: Some studies demonstrate improved concentration and attention.
    • Dizziness: This is uncommon and usually goes away with continued use.

    Tricylic Antidepressants -- Tofranil, Elavil, Endep, Norpramine, Pertofrane, Pamelor, Aventyl, Surmontil, Vivactil, Adapin, Sinequan, Anafranil

    In fixed-dose combination with other agents (e.g., Etrafon, Triavil, Limbitrol). Tricyclic antidepressants are used to treat depression, anxiety and chronic pain.

    Possible side effects that may be adverse to diving:

    • 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. If this occurs, take this medication an hour before bedtime. This usually goes away with continued use.
    • Dizziness: This may occur when one rises 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: Usually temporary, rarely serious and diminishes with continued use.

    Topiramate/Topamax

    Topiramate belongs to a group of medications called anticonvulsants, used to control seizure disorders. In psychiatry, topiramate may also be used to stabilize mood, especially in manic-depression.

    Possible side effects that may be adverse to diving:

    • Dizziness / drowsiness: Usually goes away with continued use.
    • Difficulty concentrating: May not appear until after the first month of taking the medication.
    • Tingling feelings of extremities: May disappear after first month of treatment.
    • Double vision: May be temporary side effect.

    Trazodone/Desyrel

    Trazodone is used to treat depression, some sleep problems and agitation.

    Possible side effects that may be adverse to diving:

    • Drowsiness: You should not drive a car or operate dangerous machinery until you know how this drug affects you. Taking the evening dose 10 hours before rising in the morning may make this more tolerable.
    • Dry mouth: Usually temporary. Suck on sugarless candy or chew sugarless gum. Use fluoridated toothpaste at least twice daily.
    • Dizziness: May occur when one rises from a lying or sitting position too quickly, especially four to six hours after taking the medication. Rise and change positions more slowly to let your body adjust.

    Valproic Acid/Depakote

    Valproic acid belongs to a group of medications called anticonvulsants, used to control seizure disorders, but in psychiatry valproic acid may also be used to stabilize mood, especially in manic-depressives.

    Possible side effects that may be adverse to diving:

    • May cause drowsiness. Know how you react to this medicine before driving or operating dangerous machinery.

    Nefazodone/Serzone

    Nefazodone is used to treat depression and anxiety symptoms.

    Possible side effects that may be adverse to diving:

    • Drowsiness: Know drugÕs side effects for you when deciding to drive a car or operate dangerous machinery.
    • Dry mouth: 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 four to six hours after taking your medication. Rise and change positions more slowly to let your body adjust.
    • Low blood pressure: Uncommon, it may subside with continued use.
    • Blurred Vision: Unusual, usually temporary, and usually subsides with continued use.

    Paroxetine/Paxil

    Paroxetine is used to treat depression, anxiety and obsessive-compulsive disorder.

    Possible side effects that may be adverse to diving:

    • Anxiety / restlessness: Usually disappears with continued use. If this causes difficulty, contact your psychiatrist.
    • Drowsiness: If this occurs, take this medication one hour before bedtime. Disappears with continued use.
    • Dry mouth: 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: Usually temporary, will diminish with continued use.
    • Tremor: Tends to go away with continued use.
    • Bruising / bleeding: Use of paroxetine can slightly increase risk of bruising and bleeding; can be significant when also taking aspirin or non-steroidal anti-inflammatory drugs (e.g naproxen, ibuprofen, ketoprofen, flurbiprofen, diclofenac, sulfasalazine, sulindac, oxaprozin, salsalate, piroxicam, indomethacin, etodolac). This might be a danger if there is excessive bleeding due to the barotrauma of diving (e.g., middle ears, sinuses, lungs or any air-filled structure in the body).

    For more information on depression and medications, consult with your doctor, with the DAN medical department or with Dr. Campbell.

    REFERENCES

    National Institute of Mental Health, Information Resources and Inquiries Branch, 6001 Executive Boulevard, Room 8184, MSC 9663, Bethesda, MD 20892-9663, Telephone: +1-301-443-4513, FAX: +1-301-443-4279, Depression brochures: +1-800-421-4211, TTY: +1-301-443-8431, FAX4U: +1-301-443-5158, Email: nimhinfo@nih.gov, Website: http://www.nimh.nih.gov

    National Alliance for the Mentally Ill, Colonial Place Three, 2107 Wilson Blvd., Suite 300, Arlington, VA 22201-3042, +1-703-524-7600; 1-800-950-NAMI, Website: http://www.nami.org

    National Depressive and Manic Depressive Association, 730 N. Franklin, Suite 501, Chicago, IL 60601, +1-312- 642-0049; +1-800-826-3632, Website: http://www.ndmda.org

    National Foundation for Depressive Illness, Inc., P.O. Box 2257, New York, NY 10016, +1-212-268-4260; 1-800-239-1265, Website: http://www.depression.org

    National Mental Health Association, 1021 Prince Street, Alexandria, VA 22314-2971, +1-703 684-7722; +1-800-969-6642, FAX: +1-703-684-5968, TTY: +1-800-433-5959, Website: http://www.nmha.org

    Robins LN and Regier DA (Eds) (1990). Psychiatric Disorders in America, The Epidemiologic Catchment Area Study, New York: The Free Press.

    Glen Egstrom, PhD, Medical Seminars, 1994. Stress and Performance in Diving by Arthur J Bachrach, Glen H Egstrom, 1987.

    Frank E, Karp JF, and Rush AJ (1993). Efficacy of treatments for major depression. Psychopharmacology Bulletin, 29:457-75.

    Lebowitz BD, Pearson JL, Schneider LS, Reynolds CF, Alexopoulos GS, Bruce MI, Conwell Y, Katz IR, Meyers BS, Morrison MF, Mossey J, Niederehe G, and Parmelee P (1997). Diagnosis and treatment of depression in late life: Consensus statement update. Journal of the American Medical Association, 278:1186-90.

    Robins LN and Regier DA (Eds) (1990). Psychiatric Disorders in America, The Epidemiologic Catchment Area Study, New York: The Free Press.

    Vitiello B and Jensen P (1997). Medication development and testing in children and adolescents. Archives of General Psychiatry, 54:871-6.

    http://www.hoptechno.com/effect.htm

    National Depression and Manic-Depression Association, http://www.ndmda.org/medfacts.htm

    NIMH, http://www.ndmda.org/medfacts.htm

    http://www.biopsychiatry.com/sameart.html

    U.S. Department of Education, http://www.ldonline.org/ld_indepth/add_adhd/add_doe_facts.html#anchor550162

    From the September/October 2000 issue of Alert Diver.