Thus, the treatment of major depression is literally a billion dollar industry. Surprisingly, little research has been done on the effectiveness of the different treatments for depression.

The best way to scientifically evaluate the effectiveness of therapy is to conduct a randomized controlled clinical trial. In these trials, patients are randomly assigned to treatment and control groups. Both the patient and the investigators are kept “blind” as to whether the patient is in the treatment or control group. Usually the control group receives a placebo (inactive) therapy. The clinical trial then waits to see if the treatment group does better than the control (placebo) group.

acheter Paxil (Paroxetine)

Up to thirty million American men are affected at the present time. More new cases arise (or don’t arise!) every day, on the order of 600,000-700,000 new cases each year. That means that almost two thousand American men roll over every night and say, “This never happened to me before.” Even so, most of these men have not yet sought treatment.

The incidence goes up substantially with age, increasing significantly above the age of sixty-five-which is rapidly approaching for the baby boomers. Although erectile dysfunction becomes more likely with advancing age, there is certainly no age cutoff for a sexually fulfilling life. Some men enjoy sexual activity into their eighties and nineties.

Although impossible to document, almost every adult male experiences at least one occasion when he is not satisfied with the outcome. When surveyed, at least 50 percent will complain of difficulties at some point in life about some degree of erectile insufficiency. The definitive research quoted is the Massachusetts Male Aging Study, published in 1994.2 This survey was the first comprehensive look at sexual activity since the Kinsey survey forty years earlier.3 The researchers studied 1,290 men and found that over half of them complained of some degree of erectile dysfunction. This was broken down into those with minimal (17 percent), moderate (25 percent) or severe (10 percent) erectile dysfunction.

Strikingly, almost 40 percent of the men had some degree of erectile dysfunction by the age of forty. By the time their subjects reached seventy, two-thirds of them reported erectile dysfunction. These percentages represent huge numbers of men of a similar age in society. Moreover, if you add in cofactors like heart disease, diabetes, high blood pressure, ulcers, arthritis, and allergies, the percentage of men with erectile dysfunction went up even higher. The same thing was found among men taking medications in several categories. Psychological factors that increased risk or erectile dysfunction included depression, excessive alcohol use, and anger.

The greatest risk factor of all was found to be smoking. Smokers were almost three times as likely as nonsmokers to be completely unable to achieve an erection. Thus, the incidence of erectile dysfunction is huge, perhaps as high as 150 million men worldwide. Assuming two-thirds of men have at least some trouble by the age of seventy as shown in the Massachusetts Male Aging Study, most men will experience problems if they live long enough. That doesn’t have to be discouraging news, however. Instead, it should let you know that you’re not alone. Be sure to speak up to your physician if there is a problem. Help is readily available, so you are only alone if you choose to be.

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Whenever groups of people come together, a society emerges. No matter how primitive or sophisticated, people develop a culture which lays down what patterns of human behavior are acceptable (or not) and establishes a basic system of signs and symbols to allow everyone to judge the importance and significance of what is done (or not done).

So whatever happens, we have a general agreement about what it means. This may be words, gestures, scents, tastes, textures, sounds, images, and so on. The test of acceptability depends on the context. Words or gestures may be acceptable from an individual wearing a particular set of clothes, e.g. a uniform, in a particular place, but offensive from another who does not display the right status to behave in that way.

We will also distinguish between different classes and groups. Whether we become members will depend on our social identity. Do we speak with an accent or speak a dialect, do we write in sentences or in SMS format, where do we live, what work do we do, how do we dress, and so on. More fundamentally come issues of sexual identity and gender which tend to fix the power structures. Most cultures have proved to be patriarchal, i.e. male dominated. From this come the rules of behavior deciding how much private space we should enjoy, whether and where people may touch or stare at each other, and so on. As we grow up we are socialized and learn how to fit into this complex society through our facial expressions, gestures and dress.

Because most cultures are male and men have political and social power, male imagery also tends to dominate. Maleness and male potency is equated with more general access to power and success in society. In its most extreme form, machismo in some cultures applauds obvious displays of masculinity and requires men to demonstrate a strong sense of pride and honor both in themselves and in their roles as leader of the family and father of their children.

So in male dominated cultures, when something goes wrong with a man’s ability to have sexual intercourse, this can have devastating psychological effect. Men affected are likely to feel intense shame and loss. They will change their behavior to conceal their inadequacy, fearing the judgment of their male peers and the loss of respect from women. This extreme defensiveness is often completely unnecessary because, in most cases, Viagra, Cialis or Levitra can quickly resolve the problem. But some men feel so deeply inhibited, that a strong culture of silence prevents them from discussing the matter with anyone.

Research suggests that, at some time during their lives, the majority of men may experience some degree of ED. There are all kinds of reasons for this. It is most usually situational, e.g. some emotionally disturbing event has just occurred and this disturbs the mood and motivation. At other times, there may be a physical injury or some other passing illness that makes sexual intercourse temporarily unavailable or unacceptable. More generally, it is estimated that about 10% of the male population will experience recurring impotence problems at some point in their lives. But a significant number do not seek treatment.

Many men focus on the fact that ED has affected them to the exclusion of the more relevant questions of what the cause might be and whether treatment is available. Had it not been for the publicity surrounding the development and launch of Viagra, it is probable that this omerta (to borrow a words from the mafia) would have persisted in the West. As it is, an increasing number of men affected by ED are prepared to admit the problem and do something about it. The most responsible do go to their doctors to get professional guidance. The remainder are still inhibited and exploit the privacy of the internet to buy Viagra or now Cialis and Levitra online.

No matter how medication is acquired, ED is less of a problem in relationships and, even if men are still silently anxious about how they will perform in the future, their partners are released from their short-term difficulties. For while their men are unable to perform, they are defensive and difficult to live with. Worse, the culture often does not permit partners to ask their men about the problem. Women are therefore condemned to suffer in silence. If men are at least able to resume intimacy and the mood of desperation has lifted, the general quality of life has been improved for their partners.

Can I say that here? Sorry, I’ll be back with you in a minute. I just have to ask the editor of this site whether I can be so obviously sexist. We’ve been getting so politically correct about what we can or cannot say, I get confused about how much of what I think I can write. OK. He says I can keep the meaning but I should write it in a more subtle way.

Subtle I can do.

Now where was I?

Our world had come crashing down (along with everything else that should have been rising up). And then this drug company comes along and tells us they’ve invented a cure!

A cure! That’s great!!!! It’s a what? It’s a tablet. And it’s only available on prescription?

But that means I have to tell someone I have ED. I can’t get the cure unless I tell someone.

What kind of a cure is that?!?!!?

Why can’t they just put it in the water supply so we can all be cured without having to tell anyone?

Is Pfizer run by women? Have they devised this plot to humiliate us?

[The editor is telling me this is not subtle enough. We all know that Pfizer is run by men - as a top US company, there's only the usual token woman on the Executive leadership Team of ten (http://www.pfizer.com/about/leadership_and_structure/meet_executive_leaders.jsp)]

Damn! It’s not a conspiracy, then.

So we gotta go and see a doctor? That’s the price we have to pay for this cure?

What about this internet thing? Why can’t we just buy Levitra online?

Whaddya mean I could be sick? I’m not sick! There’s nothing wrong with me. This is just a temporary difficulty.

So this ED could just be a symptom of something more serious?

Perhaps I should go see a doctor.

But ten years ago, the medical profession was not prepared for the scale of demand. Before Viagra hit the market, doctors in general practice had not seen many patients wanting to discuss their sexual problems. There were a number of specialised units in both public and private hospitals and, of course, there were a number of commercial clinics offering a confidential service. But the spirit of wounded male pride barred the doors and, because there was no easy remedy for ED, not many men would break down those doors to get advice. This also allowed doctors the luxury of never having to confront their own prejudices. They did not have to discuss sensitive issues with their patients.

Then the advertising hype generated demand. The trickle of male patients became a flood. Doctors were overwhelmed and reacted in the only rational way possible. They gave out prescriptions for Viagra without a professional investigation of the cause of each patient’s ED. There just was not time (and many of the doctors were like their patients and felt too embarrassed to talk about ED and perform the necessary physical examinations) so everyone got what they wanted - quick and easy access to Viagra, a tablet that proved to be as good as its advertising hype.

Well, ten years is a long time. Today, the medical profession is back on track. Education and training have been modified to prepare all newly qualified doctors for dealing with cases of sexual difficulties. Existing doctors have had updating courses. The necessary lab resources are in place. New technology offers better diagnostic options. New drugs are available with Cialis and Levitra joining the market alongside Viagra.

Yes, the process will take a little longer than those original consultations ten years ago, but that is to your advantage. Back then everyone was gambling that there was nothing too seriously wrong with you. Now, quick and easy tests are available in a carefully devised schedule so that you only escalate to the more serious tests if there is a real need. Doctors have taken the lottery out of diagnosis without spending big bucks to investigate the problem unless it is absolutely necessary.

It is better to be safe and leave those big bucks to the bedroom where they belong!

Do you ever wonder what happens after casual disposal? Your local waste management authority comes round to collect the refuse which is then dumped. There is little or no effort to sort the waste. Most authorities simply drive to the nearest landfill site and tip each load on to the growing mound of other rubbish. This pile then rots down as rain washes through it so, sooner or later, dissolved drugs end up in the watertable and potentially get recycled into your drinking water. The medications flushed go more directly into the water supply. So here is the worry. The rivers downstream from you supply water to the local towns and cities. That water supply contains what the experts call a “sub-lethal” cocktail of antibiotics, sedatives, painkillers, hormones and whatever else you so casually threw away. Perhaps you have no interest in the people downstream of you. I wonder what the people upstream think of you.

But, back to Ambien. Ambien is, of course, a nonbenzodiazepine hypnotic. I am never reassured by the prefix “non”. In fact, Ambien works in exactly the same way as a conventional benzodiazepine and is probably just as addictive. For this reason, Ambien is listed by the Drug Enforcement Agency (DEA) as a controlled substance in Schedule IV. You will be pleased and delighted to know that the US Government has your interests at heart. It always wants to protect you and the environment (”always” is probably a slight exaggeration). State and Federal regulations limit the handling and disposal of controlled substances to DEA-authorised individuals and organisations. The DEA’s Office of Diversion Control aims to prevent the diversion of legitimately manufactured (or used) controlled substances into the illegal drug traffic. If there is no-one else immediately available to handle the disposal, the controlled substances should be collected by a law enforcement officer. So, if your local pharmacy has not registered with the DEA, their only way of disposing of your unwanted drugs is to call the cops. No wonder they looked so pleased when you asked.

But San Mateo County, California has placed collection boxes inside the entrance halls of eleven police departments. Anyone can walk in and leave their unwanted medications (including Ambien but excluding all illegal substances) and walk out - no questions asked. And is this a welcome service? Over the first fifteen months of the program, local citizens have deposited 1,800 pounds of medications (not all Ambien, of course). So there is clearly a demand for this kind of service.

It is pure self-interest, of course. Who wants to get high from drinking tap water? Hmmm. Wait, that is not quite the right question. How many men want to take female hormones - I am sure breasts would be alright. And do we really want all those bacteria out there to get used to all those antibiotics in the water? If you don’t know the answers to these and other questions of social conscience (or self-interest), take an Ambien and sleep on it.

To understand how the opiates and their derivatives work, think in practical terms. People who are unconscious feel no pain. So the more severe the pain, the greater the need to produce unconsciousness. For less severe pain, you need to block the pain signals and prevent them from reaching the brain. There may still be an active source of pain in the body, but the drug prevents us from becoming aware of it. It is rather the way you distract someone by changing the subject. If pain was the original subject, you produce a different sensation that takes your mind off it. But therein lies the rub (as Hamlet did not quite say). Quite often, the distracting sensation is so pleasant that people prefer that state to any other. They come to crave that level of pleasure all the time.

This should emphasize the seriousness of any decision to take pain medication. Physical and psychological dependence is a major danger if you take most of the opiates. It is a less serious problem if you take one of the atypical opioids like ultram or the NSAIDs, because they are not addictive. However, the advice of a doctor who knows your medical history is always a good idea to make sure that you will not be at risk from side effects. Some people do react adversely to medications, particularly when different medications are combined.

It is also a good idea to talk to your doctor about how to manage the pain. Ultram does not “cure” the source of the pain. All it does is to change the way you “feel” it. That leaves the doctor with the job of curing whatever the problem is causing the pain, assuming it can be cured. Unfortunately, some illnesses and diseases cannot be cured and will cause you chronic pain, i.e. the pain will last over time. In such cases, the knee-jerk reaction is to take more ultram for longer periods of time.

This may not be such a good idea. The more you take, the more likely it is that you will experience one or more of the side effects. Secondly, your body builds up a tolerance for the medication so you are continually forced to increase the dose to get the same painkilling effect. This drives up the cost both physically and in cash terms. So the decisions about how much ultram to take and over what period of time are always a balancing act. You need to weigh up the benefits against the risks.

This makes the management of pain a very personal problem. Your family and friends can help keep you positive. Your financial situation may be strong. People have different levels of tolerance for pain. The management of your pain is something only you can do. Talking to doctors can give you guidance and advice but, at the end of the day, you are the one who should stay in control, making the decisions about what is best for you. If you must up the strength of the medication to one of the opiates, you will have to deal with the risk of addiction. Some of the NSAIDs also have worrying side effects over time. Make sure you take an informed decision.

So here’s the bad news. No matter how much you may want to consider ED a private matter. No matter how defensive and resentful you may feel if your physician tactfully asks you how you are getting on in “that” department, there’s a real need to openly discuss ED with your physician. And you are going to get asked the question by any physician who keeps up-to-date with best practice. Erectile dysfunction can have destructive effects on your relationship with your partner, and the diagnosis and treatment of the problem will not only have a positive effect on you as a couple, but it will also help to bridge between you and your physician as tests prove whether those first symptoms of ED really are an early warning of vascular problems. That’s either your heart itself, or the blood vessels taking the blood round your body, or the pressure of the system. To continue the bad news, avoiding any trip to consult your physician and simply buying Viagra online, or Cialis or Levitra is potentially dangerous. You may be leaving a serious heart condition as a time bomb in your system.

How do we know this?

In the Massachusetts Male Aging Study (MMAS), just over half the thirteen hundred men aged between forty and seventy years experienced one or more periods of ED - about 10% had a complete loss of function. It established a clear link between diabetes, cardiovascular disease and ED. About nine years later, a second team of researchers polled the same group of respondents2. The prevalence rate of ED was found to increase with age and was most common among those with below average levels of education diagnosed with high blood pressure, heart disease and diabetes. This confirmed a general trend of data that about 80% of cases of ED have an organic origin, and arteriosclerosis is probably the most common. This is where the walls of the arteries thicken, and fatty substances, cholesterol, dead cells, calcium and fibrin (a clotting material in the blood) slowly accumulate and limit the flow of blood.

Continuing the flow of good news: as part of the ageing process, the layer of cells lining the interior surface of all blood vessels, called the endothelial layer, decreases the production of nitric oxide. This makes erectile dysfunction more likely when blood flow is reduced through the penis. More generally, endothelium helps to control blood pressure, blood circulation and the clotting process, so poor sexual performance is a critical first symptom of what may become heart disease if not treated. This is even more of a threat to long-term smokers because nicotine both directly affects the vascular endothelium and restricts the smooth-muscle contraction in the cavernosal body producing ED.

In a study completed in 2002(1), 980 patients who reported ED were diagnosed as follows:

• 18% of patients had undiagnosed high blood pressure;
• 16% had diabetes;
• 15% had a benign growth in the prostate;
• 5% had heart disease resulting from a reduced flow of blood,
• 4% had prostate cancer, and
• 1% had depression.

Just so we are absolutely clear, the main link between ED and cardiovascular disease is the vascular endothelium. If you have less nitric oxide, ED can be the first major symptom of what will become a more general endothelial cell dysfunction leading to cardiovascular disease or diabetes (1).

So, if that is all the bad news, the good news is that there are many ways to treat ED - successfully in most cases. Because of the choices of treatment, we can usually find combinations of treatment that are compatible (and, yes, this may be a choice between Viagra, Cialis and Levitra, or one of the other slightly more invasive medications or devices). In the past, some of the medications to reduce high blood pressure and to lower the level of lipids in your blood were incompabile with the treatments for ED. If we physicians are involved early enough, we can also help you to stop smoking and reduce your weight, both of which will give you many more years of active life.

1. M. Kirby; G. Jackson; J. Betteridge et al. Is erectile dysfunction a marker for cardiovascular disease? International Journal Clinical Practice 2002; 55(9):614-8.

2. C.B. Johannes; A.B. Araujo; H.A. Feldman et al. Incidence of erectile dysfunction in men 40 to 69 years old: longitudinal results from the Massachusetts Male Aging Study. Journal of Urology 2000; 163(2):460-3.

After her book, Jerilyn Ross went on to found the Anxiety Disorders Association of America (ADAA), a non-profit organisation which both supports research to prevent, treat and cure anxiety disorders, and offers help to improve the lives of all people who suffer from them - the ADAA is a most useful resource for all who suffer from or have an interest in anxiety disorders. The importance of this organisation is its preference for long-term treatment through therapy rather than reliance on a quick fix through medication. It does not deny the value of medication, but it sees its role as being in partnership with therapy. In part, this reflects Ms Ross’ own experience of treatment at the Roosevelt Hospital Phobia Clinic in New York. After learning to live with her own phobias, she went on to obtain a postgraduate degree in psychology and has specialised in the study and treatment of those who have problems comparable to her own.

One of the most popular medications on the market for the treatment of anxiety disorders is xanax. This is one of the benzodiazepines and a sedative hypnotic. The reason for its success is that a sedative calms a person while awake and reduces the general level of excitement, while a hypnotic makes a person feel drowsy and can induce sleep. Getting the dosage right as tolerance builds up is critical to a successful use of xanax. It is inconvenient to fall asleep, but too little calming effect does not prevent panic or reduce acute anxiety.

Why has xanax maintained its pre-eminence? Let us go back to 1994 again (the year of Triumph Over Fear). The National Comorbidity Survey found that 17% of people living in the US suffered from an anxiety disorder in the preceding 12 months and almost one quarter had some lifetime history of disorder. The estimated cost of anxiety in 1994 was $65bn - the cost of all treatments was $15bn, but the cost of lost production was $50bn. Think what the costs of anxiety would be in 2008.

Medical insurance has already become a major headache for families. Medicare is struggling to cope. So while the idea of individualised treatment for anxiety disorders definitely remains the ideal, the problem of cost directs the vast majority of people in the direction of xanax. This is an extremely effective medication to relieve the major symptoms of anxiety panic and compulsion. Using xanax is an entirely rational response to the current political and economic situation in the US. As an outsider, I hope that a realignment of federal priorities will move in the direction of the policies so passionately advocated by the ADAA. Only then can ordinary Americans get personal care with longer-lasting results rather than “conveyor-belt” care out of the xanax bottle.