By O. Ivan. Hunter College.
AVANDIA is not recommended in patients with NYHA Class III and IV cardiac status discount chloromycetin american express. Meta-Analysis of Myocardial Ischemia in a Group of 42 Clinical TrialsA meta-analysis was conducted retrospectively to assess cardiovascular adverse events reported across 42 double-blind order chloromycetin visa, randomized purchase chloromycetin uk, controlled clinical trials (mean duration 6 months). These studies had been conducted to assess glucose-lowering efficacy in type 2 diabetes, and prospectively planned adjudication of cardiovascular events had not occurred in the trials. Some trials were placebo-controlled and some used active oral antidiabetic drugs as controls. Placebo-controlled studies included monotherapy trials (monotherapy with AVANDIA versus placebo monotherapy) and add-on trials (AVANDIA or placebo, added to sulfonylurea, metformin, or insulin). Active control studies included monotherapy trials (monotherapy with AVANDIA versus sulfonylurea or metformin monotherapy) and add-on trials (AVANDIA plus sulfonylurea or AVANDIA plus metformin, versus sulfonylurea plus metformin). A total of 14,237 patients were included (8,604 in treatment groups containing AVANDIA, 5,633 in comparator groups), with 4,143 patient-years of exposure to AVANDIA and 2,675 patient-years of exposure to comparator. Myocardial ischemic events included angina pectoris, angina pectoris aggravated, unstable angina, cardiac arrest, chest pain, coronary artery occlusion, dyspnea, myocardial infarction, coronary thrombosis, myocardial ischemia, coronary artery disease, and coronary artery disorder. In this analysis, an increased risk of myocardial ischemia with AVANDIA versus pooled comparators was observed (2% AVANDIA versus 1. An increased risk of myocardial ischemic events with AVANDIA was observed in the placebo-controlled studies, but not in the active-controlled studies. This increased risk reflects a difference of 3 events per 100 patient-years (95% CI -0. Forest Plot of Odds Ratios (95% Confidence Intervals) for Myocardial Ischemic Events in the Meta-Analysis of 42 Clinical TrialsA greater increased risk of myocardial ischemia was also observed in patients who received AVANDIA and background nitrate therapy. For AVANDIA (N = 361) versus control (N = 244) in nitrate users, the odds ratio was 2. This increased risk represents a difference of 12 myocardial ischemic events per 100 patient-years (95% CI 3. Most of the nitrate users had established coronary heart disease. Among patients with known coronary heart disease who were not on nitrate therapy, an increased risk of myocardial ischemic events for AVANDIA versus comparator was not demonstrated. Myocardial Ischemic Events in Large Long-Term Prospective Randomized Controlled Trials of AVANDIAData from 3 other large, long-term, prospective, randomized, controlled clinical trials of AVANDIA were assessed separately from the meta-analysis. These 3 trials include a total of 14,067 patients (treatment groups containing AVANDIA N = 6,311, comparator groups N = 7,756), with patient-year exposure of 21,803 patient-years for AVANDIA and 25,998 patient-years for comparator. Duration of follow-up exceeded 3 years in each study. ADOPT (A Diabetes Outcomes Progression Trial) was a 4- to 6-year randomized, active-controlled study in recently diagnosed patients with type 2 diabetes nas_ve to drug therapy. It was an efficacy and general safety trial that was designed to examine the durability ofAVANDIA as monotherapy (N = 1,456) for glycemic control in type 2 diabetes, with comparator arms of sulfonylurea monotherapy (N = 1,441) and metformin monotherapy (N = 1,454). DREAM (Diabetes Reduction Assessment with Rosiglitazone and Ramipril Medication, published report2) was a 3- to 5-year randomized, placebo-controlled study in patients with impaired glucose tolerance and/or impaired fasting glucose. It had a 2x2 factorial design, intended to evaluate the effect of AVANDIA, and separately of ramipril (an angiotensin converting enzyme inhibitor [ACEI]), on progression to overt diabetes. In DREAM, 2,635 patients were in treatment groups containing AVANDIA, and 2,634 were in treatment groups not containing AVANDIA. Interim results have been published 3 for RECORD (Rosiglitazone Evaluated for Cardiac Outcomes and Regulation of Glycemia in Diabetes), an ongoing open-label, 6-year cardiovascular outcomes study in patients with type 2 diabetes with an average treatment duration of 3. RECORD includes patients who have failed metformin or sulfonylurea monotherapy; those who have failed metformin are randomized to receive either add-on AVANDIA or add-on sulfonylurea, and those who have failed sulfonylurea are randomized to receive either add-on AVANDIA or add-on metformin. In RECORD, a total of 2,220 patients are receiving add-on AVANDIA, and 2,227 patients are on one of the add-on regimens not containing AVANDIA. For these 3 trials, analyses were performed using a composite of major adverse cardiovascular events (myocardial infarction, cardiovascular death, or stroke), referred to hereafter as MACE. Myocardial infarction included adjudicated fatal and nonfatal myocardial infarction plus sudden death. As shown in Figure 2, the results for the 3 endpoints (MACE, MI, and Total Mortality) were not statistically significantly different between AVANDIA and comparators. In preliminary analyses of the DREAM trial, the incidence of cardiovascular events was higher among subjects who received AVANDIA in combination with ramipril than among subjects who received ramipril alone, as illustrated in Figure 2. This finding was not confirmed in ADOPT and RECORD (active-controlled trials in patients with diabetes) in which 30% and 40% of patients respectively, reported ACE-inhibitor use at baseline. In their entirety, the available data on the risk of myocardial ischemia are inconclusive. Definitive conclusions regarding this risk await completion of an adequately-designed cardiovascular outcome study. There have been no clinical studies establishing conclusive evidence of macrovascular risk reduction with AVANDIA or any other oral antidiabetic drug. In studies in which AVANDIA was added to insulin, AVANDIA increased the risk of congestive heart failure and myocardial ischemia. These trials included patients with long-standing diabetes (median duration of 12 years) and a high prevalence of pre-existing medical conditions, including peripheral neuropathy, retinopathy, ischemic heart disease, vascular disease, and congestive heart failure. The total number of patients with emergent congestive heart failure was 21 (2. The total number of patients with emergent myocardial ischemia was 24 (2. Although the event rate for congestive heart failure and myocardial ischemia was low in the studied population, consistently the event rate was 2-fold or higher with coadministration of AVANDIA and insulin. These cardiovascular events were noted at both the 4 mg and 8 mg daily doses of AVANDIA. Occurrence of Cardiovascular Events in 5 Controlled Trials of Addition of AVANDIA to Established Insulin TreatmentEvents are not exclusive; i. In a sixth, 24-week, controlled, randomized, double-blind trial of AVANDIA and insulin coadministration, insulin was added to AVANDAMET? (rosiglitazone maleate and metformin HCl) (n = 161) and compared to insulin plus placebo (n = 158), after a single-blind 8-week run-in with AVANDAMET. Patients with edema requiring pharmacologic therapy and those with congestive heart failure were excluded at baseline and during the run-in period. In the group receiving AVANDAMET plus insulin, there was one myocardial ischemic event and one sudden death.
The incidence of somnolence during the 24 hour IM treatment period in clinical trials in agitated patients with schizophrenia or bipolar mania was 6% for intramuscular olanzapine for injection and 3% for placebo chloromycetin 500 mg without a prescription. Adverse Events Occurring at an Incidence of 2% or More Among Oral Olanzapine-Treated Patients in Short-Term purchase chloromycetin on line, Placebo-Controlled Trials Table 1 enumerates the incidence cheap chloromycetin master card, rounded to the nearest percent, of treatment-emergent adverse events that occurred in 2% or more of patients treated with oral olanzapine (doses >/=2. Treatment-Emergent Adverse Events: Incidence in Short-Term, Placebo-ControlledMetabolic and Nutritional Disorders Extremity pain (other than joint)Articulation impairmentUrinary tract infectionEvents reported by at least 2% of patients treated with olanzapine, except the following events which had an incidence equal to or less than placebo: abdominal pain, agitation, anorexia, anxiety, apathy, confusion, depression, diarrhea, dysmenorrhea 2, hallucinations, headache, hostility, hyperkinesia, myalgia, nausea, nervousness, paranoid reaction, personality disorder 3, rash, thinking abnormal, weight loss. Denominator used was for females only (olanzapine, N=201; placebo, N=114). Commonly Observed Adverse Events in Short-Term Combination Trials In the bipolar mania combination placebo-controlled trials, the most commonly observed adverse events associated with the combination of olanzapine and lithium or valproate (incidence of >/=5% and at least twice placebo) wereCommon Treatment-Emergent Adverse EventsAssociated with the Use of Oral Olanzapinein 6-Week Combination Trials -- BIPOLAR MANIA Adverse Events Occurring at an Incidence of 2% or More Among Oral Olanzapine-Treated Patients in Short-Term Combination Trials Table 2 enumerates the incidence, rounded to the nearest percent, of treatment-emergent adverse events that occurred in 2% or more of patients treated with the combination of olanzapine (doses >/=5 mg/day) and lithium or valproate and with incidence greater than lithium or valproate alone who participated in the acute phase of placebo-controlled combination trials. Treatment-Emergent Adverse Events: Incidence in Short-Term,Placebo-Controlled Combination Clinical TrialsEvents reported by at least 2% of patients treated with olanzapine, except the following events which had an incidence equal to or less than placebo: abdominal pain, abnormal dreams, abnormal ejaculation, agitation, akathisia, anorexia, anxiety, arthralgia, cough increased, diarrhea, dyspepsia, emotional lability, fever, flatulence, flu syndrome, headache, hostility, insomnia, libido decreased, libido increased, menstrual disorder 2, myalgia, nausea, nervousness, pain, paranoid reaction, personality disorder, rash, rhinitis, sleep disorder, thinking abnormal, vomiting. Denominator used was for females only (olanzapine, N=128; placebo, N=51). For specific information about the adverse reactions observed with lithium or valproate, refer to the ADVERSE REACTIONS section of the package inserts for these other products. Adverse Events Occurring at an Incidence of 1% or More Among Intramuscular Olanzapine for Injection-Treated Patients in Short-Term, Placebo-Controlled Trials Table 3 enumerates the incidence, rounded to the nearest percent, of treatment-emergent adverse events that occurred in 1% or more of patients treated with intramuscular olanzapine for injection (dose range of 2. Treatment-Emergent Adverse Events: Incidence in Short-Term (24 Hour), Placebo-Controlled Clinical Trials with Intramuscular Olanzapine for Injection in Agitated Patients with Schizophrenia or Bipolar ManiaEvents reported by at least 1% of patients treated with olanzapine for injection, except the following events which had an incidence equal to or less than placebo: agitation, anxiety, dry mouth, headache, hypertension, insomnia, nervousness. Additional Findings Observed in Clinical Trials The following findings are based on clinical trials. Dose Dependency of Adverse Events in Short-Term, Placebo-Controlled Trials Extrapyramidal Symptoms -- The following table enumerates the percentage of patients with treatment-emergent extrapyramidal symptoms as assessed by categorical analyses of formal rating scales during acute therapy in a controlled clinical trial comparing oral olanzapine at 3 fixed doses with placebo in the treatment of schizophrenia. TREATMENT-EMERGENT EXTRAPYRAMIDAL SYMPTOMS ASSESSED BY RATING SCALES INCIDENCE IN A FIXED DOSAGE RANGE, PLACEBO-CONTROLLED CLINICAL TRIAL OF ORAL OLANZAPINE IN SCHIZOPHRENIA -- ACUTE PHASE *Percentage of Patients Reporting Event Percentage of patients with a Simpson-Angus Scale total score >3. Percentage of patients with a Barnes Akathisia Scale global score >/=2. The following table enumerates the percentage of patients with treatment-emergent extrapyramidal symptoms as assessed by spontaneously reported adverse events during acute therapy in the same controlled clinical trial comparing olanzapine at 3 fixed doses with placebo in the treatment of schizophrenia. TREATMENT-EMERGENT EXTRAPYRAMIDAL SYMPTOMS ASSESSED BY ADVERSE EVENTS INCIDENCE IN A FIXED DOSAGE RANGE, PLACEBO-CONTROLLED CLINICAL TRIAL OF ORAL OLANZAPINE IN SCHIZOPHRENIA -- ACUTE PHASE Any extrapyramidal eventPatients with the following COSTART terms were counted in this category: dystonia, generalized spasm, neck rigidity, oculogyric crisis, opisthotonos, torticollis. Patients with the following COSTART terms were counted in this category: akinesia, cogwheel rigidity, extrapyramidal syndrome, hypertonia, hypokinesia, masked facies, tremor. Patients with the following COSTART terms were counted in this category: akathisia, hyperkinesia. Patients with the following COSTART terms were counted in this category: buccoglossal syndrome, choreoathetosis, dyskinesia, tardive dyskinesia. Patients with the following COSTART terms were counted in this category: movement disorder, myoclonus, twitching. The following table enumerates the percentage of patients with treatment-emergent extrapyramidal symptoms as assessed by categorical analyses of formal rating scales during controlled clinical trials comparing fixed doses of intramuscular olanzapine for injection with placebo in agitation. Patients in each dose group could receive up to three injections during the trials (see CLINICAL PHARMACOLOGY ). Patient assessments were conducted during the 24 hours following the initial dose of intramuscular olanzapine for injection. There were no statistically significant differences from placebo. TREATMENT-EMERGENT EXTRAPYRAMIDAL SYMPTOMS ASSESSED BY RATING SCALES INCIDENCE IN A FIXED DOSE, PLACEBO-CONTROLLED CLINICAL TRIAL OF INTRAMUSCULAR OLANZAPINE FOR INJECTION IN AGITATED PATIENTS WITH SCHIZOPHRENIA *Percentage of patients with a Simpson-Angus total score >3. The following table enumerates the percentage of patients with treatment-emergent extrapyramidal symptoms as assessed by spontaneously reported adverse events in the same controlled clinical trial comparing fixed doses of intramuscular olanzapine for injection with placebo in agitated patients with schizophrenia. There were no statistically significant differences from placebo. TREATMENT-EMERGENT EXTRAPYRAMIDAL SYMPTOMS ASSESSED BY ADVERSE EVENTS INCIDENCE IN A FIXED DOSE, PLACEBO-CONTROLLED CLINICAL TRIAL OF INTRAMUSCULAR OLANZAPINE FOR INJECTION IN AGITATED PATIENTS WITH SCHIZOPHRENIA * Other Adverse Events -- The following table addresses dose relatedness for other adverse events using data from a schizophrenia trial involving fixed dosage ranges of oral olanzapine. It enumerates the percentage of patients with treatment-emergent adverse events for the three fixed-dose range groups and placebo. The data were analyzed using the Cochran-Armitage test, excluding the placebo group, and the table includes only those adverse events for which there was a statistically significant trend. Vital Sign Changes -- Oral olanzapine was associated with orthostatic hypotension and tachycardia in clinical trials. Intramuscular olanzapine for injection was associated with bradycardia, hypotension, and tachycardia in clinical trials ( see PRECAUTIONS ). Weight Gain -- In placebo-controlled, 6-week studies, weight gain was reported in 5. A categorization of patients at baseline on the basis of body mass index (BMI) revealed a significantly greater effect in patients with low BMI compared to normal or overweight patients; nevertheless, weight gain was greater in all 3 olanzapine groups compared to the placebo group. During long-term continuation therapy with olanzapine (238 median days of exposure), 56% of olanzapine patients met the criterion for having gained greater than 7% of their baseline weight. Laboratory Changes -- An assessment of the premarketing experience for olanzapine revealed an association with asymptomatic increases in SGPT, SGOT, and GGT ( see PRECAUTIONS ). Olanzapine administration was also associated with increases in serum prolactin ( see PRECAUTIONS ), with an asymptomatic elevation of the eosinophil count in 0. Given the concern about neutropenia associated with other psychotropic compounds and the finding of leukopenia associated with the administration of olanzapine in several animal models ( see ANIMAL TOXICOLOGY ), careful attention was given to examination of hematologic parameters in premarketing studies with olanzapine. There was no indication of a risk of clinically significant neutropenia associated with olanzapine treatment in the premarketing database for this drug. In clinical trials among olanzapine-treated patients with random triglyceride levels of /=500 mg/dL anytime during the trials. In these same trials, olanzapine-treated patients (N=962) had a mean increase of 27 mg/dL in triglycerides from a mean baseline value of 185 mg/dL. In placebo-controlled trials, olanzapine-treated patients with random cholesterol levels of /=240 mg/dL anytime during the trials significantly more often than placebo-treated patients (N=836) (8. In these same trials, olanzapine-treated patients (N=2528) had a mean increase of 1 mg/dL in cholesterol from a mean baseline value of 203 mg/dL, which was significantly different compared to placebo-treated patients (N=1420) with a mean decrease of 4 mg/dL from a mean baseline value of 203 mg/dL. ECG Changes -- Between-group comparisons for pooled placebo-controlled trials revealed no statistically significant olanzapine/placebo differences in the proportions of patients experiencing potentially important changes in ECG parameters, including QT, QTc, and PR intervals.
Data from one of these studies are summarized in Table 9 cheap chloromycetin 250mg without prescription. Table 9: Glycemic Parameters in a 26-Week Placebo-Controlled TrialDifference from placebo (adjusted mean)When administered at the same total daily dose purchase chloromycetin toronto, AVANDIA was generally more effective in reducing FPG and HbA1c when administered in divided doses twice daily compared to once daily doses buy chloromycetin 250 mg with amex. However, for HbA1c, the difference between the 4 mg once daily and 2 mg twice daily doses was not statistically significant. Long-term maintenance of effect was evaluated in a 52-week, double-blind, glyburide-controlled trial in patients with type 2 diabetes. Patients were randomized to treatment with AVANDIA 2 mg twice daily (N = 195) or AVANDIA 4 mg twice daily (N = 189) or glyburide (N = 202) for 52 weeks. Patients receiving glyburide were given an initial dosage of either 2. All treatments resulted in a statistically significant improvement in glycemic control from baseline (Figure 4 and Figure 5). At the end of week 52, the reduction from baseline in FPG and HbA1c was -40. For HbA1c, the difference between AVANDIA 4 mg twice daily and glyburide was not statistically significant at week 52. The initial fall in FPG with glyburide was greater than with AVANDIA; however, this effect was less durable over time. The improvement in glycemic control seen with AVANDIA 4 mg twice daily at week 26 was maintained through week 52 of the study. Mean FPG Over Time in a 52-Week Glyburide-Controlled StudyFigure 5. Mean HbA1c Over Time in a 52-Week Glyburide-Controlled StudyHypoglycemia was reported in 12. The improvements in glycemic control were associated with a mean weight gain of 1. In patients treated with AVANDIA, C-peptide, insulin, pro-insulin, and pro-insulin split products were significantly reduced in a dose-ordered fashion, compared to an increase in the glyburide-treated patients. A Diabetes Outcome Progression Trial (ADOPT) was a multicenter, double-blind, controlled trial (N = 4,351) conducted over 4 to 6 years to compare the safety and efficacy of AVANDIA, metformin, and glyburide monotherapy in patients recently diagnosed with type 2 diabetes mellitus ( ?-T 3 years) inadequately controlled with diet and exercise. The mean age of patients in this trial was 57 years and the majority of patients (83%) had no known history of cardiovascular disease. The mean baseline FPG and HbA1c were 152 mg/dL and 7. Patients were randomized to receive either AVANDIA 4 mg once daily, glyburide 2. The primary efficacy outcome was time to consecutive FPG > 180 mg/dL after at least 6 weeks of treatment at the maximum tolerated dose of study medication or time to inadequate glycemic control, as determined by an independent adjudication committee. The cumulative incidence of the primary efficacy outcome at 5 years was 15% with AVANDIA, 21% with metformin, and 34% with glyburide (hazard ratio 0. Cardiovascular and adverse event data (including effects on body weight and bone fracture) from ADOPT for AVANDIA, metformin, and glyburide are described in WARNINGS AND PRECAUTIONS and ADVERSE REACTIONS, respectively. As with all medications, efficacy results must be considered together with safety information to assess the potential benefit and risk for an individual patient. The addition of AVANDIA to either metformin or sulfonylurea resulted in significant reductions in hyperglycemia compared to either of these agents alone. These results are consistent with an additive effect on glycemic control when AVANDIA is used as combination therapy. A total of 670 patients with type 2 diabetes participated in two 26-week, randomized, double-blind, placebo/active-controlled studies designed to assess the efficacy of AVANDIA in combination with metformin. AVANDIA, administered in either once daily or twice daily dosing regimens, was added to the therapy of patients who were inadequately controlled on a maximum dose (2. In one study, patients inadequately controlled on 2. A statistically significant improvement in FPG and HbA1c was observed in patients treated with the combinations of metformin and 4 mg of AVANDIA once daily and 8 mg of AVANDIA once daily, versus patients continued on metformin alone (Table 10). Glycemic Parameters in a 26-Week Combination Study of AVANDIA Plus Metformin4 mg once daily + metformin8 mg once daily + metforminDifference from metformin alone (adjusted mean)In a second 26-week study, patients with type 2 diabetes inadequately controlled on 2. The combination of metformin and AVANDIA resulted in lower levels of FPG and HbA1c than either agent alone. Patients who were inadequately controlled on a maximum dose (2. In this group, increases in LDL and VLDL were also seen. A total of 3,457 patients with type 2 diabetes participated in ten 24- to 26-week randomized, double-blind, placebo/active-controlled studies and one 2-year double-blind, active-controlled study in elderly patients designed to assess the efficacy and safety of AVANDIA in combination with a sulfonylurea. AVANDIA 2 mg, 4 mg, or 8 mg daily was administered, either once daily (3 studies) or in divided doses twice daily (7 studies), to patients inadequately controlled on a submaximal or maximal dose of sulfonylurea. In these studies, the combination of AVANDIA 4 mg or 8 mg daily (administered as single or twice daily divided doses) and a sulfonylurea significantly reduced FPG and HbA1c compared to placebo plus sulfonylurea or further up-titration of the sulfonylurea. Table 11 shows pooled data for 8 studies in which AVANDIA added to sulfonylurea was compared to placebo plus sulfonylurea. Glycemic Parameters in 24- to 26-Week Combination Studies of AVANDIA Plus SulfonylureaTwice Daily Divided Dosing (5 Studies)2 mg twice daily + sulfonylurea4 mg twice daily + sulfonylureaDifference from sulfonylurea alone (adjusted mean)Once Daily Dosing(3 Studies)4 mg once daily + sulfonylurea8 mg once daily + sulfonylureaOne of the 24- to 26-week studies included patients who were inadequately controlled on maximal doses of glyburide and switched to 4 mg of AVANDIA daily as monotherapy; in this group, loss of glycemic control was demonstrated, as evidenced by increases in FPG and HbA1c. In a 2-year double-blind study, elderly patients (aged 59 to 89 years) on half-maximal sulfonylurea (glipizide 10 mg twice daily) were randomized to the addition of AVANDIA (n = 115, 4 mg once daily to 8 mg as needed) or to continued up-titration of glipizide (n = 110), to a maximum of 20 mg twice daily. Loss of glycemic control (FPG ?-U 180 mg/dL) occurred in a significantly lower proportion of patients (2%) on AVANDIA plus glipizide compared to patients in the glipizide up-titration arm (28. About 78% of the patients on combination therapy completed the 2 years of therapy while only 51% completed on glipizide monotherapy. The effect of combination therapy on FPG and HbA1c was durable over the 2-year study period, with patients achieving a mean of 132 mg/dL for FPG and a mean of 6. In two 24- to 26-week, double-blind, placebo-controlled, studies designed to assess the efficacy and safety of AVANDIA in combination with sulfonylurea plus metformin, AVANDIA 4 mg or 8 mg daily, was administered in divided doses twice daily, to patients inadequately controlled on submaximal (10 mg) and maximal (20 mg) doses of glyburide and maximal dose of metformin (2 g/day). A statistically significant improvement in FPG and HbA1c was observed in patients treated with the combinations of sulfonylurea plus metformin and 4 mg of AVANDIA and 8 mg of AVANDIA versus patients continued on sulfonylurea plus metformin, as shown in Table 12. Glycemic Parameters in a 26-Week Combination Study of AVANDIA Plus Sulfonylurea and Metformindaily + sulfonylurea + metformin4 mg twice daily + sulfonylurea + metforminDifference from sulfonylurea plus metformin (adjusted mean)Food and Drug Administration Briefing Document. Joint meeting of the Endocrino Metabolic Drugs and Drug Safety and Risk Management Advisory Committees. Effect of rosiglitazone on the frequency of diabetes in with impaired glucose tolerance or impaired fasting glucose: a randomised controll Lancet 2006;368:1096-1105.
How can they use spirituality to help themselves feel better? Anil Coumar: Spirituality is not something we can use to change the reality purchase generic chloromycetin on line. Now buy cheap chloromycetin online, when it comes to depression purchase chloromycetin 500 mg otc, we have always been trained to do one of two things:We have been trained to either suppress it or to express it. The trouble with these 2 approaches is that they have a way of prolonging the depression. For example, if I suppress my anger it might come out as a physical symptom, such as an ulcer, or I may engage in passive aggressive behavior. If I express my anger, I have to deal with the consequences. You might hurt somebody or hurt yourself, therefore prolonging the emotion. There is a 3rd approach, which is to stay with the emotion (depression) every time a problem arises. That approach is sometimes useful, but if the problem keeps occurring, we need to look at the problem. The same way if we stay with an emotion, there is a great chance that we will come to a place of insight about our problem or situation. Whenever I tell someone or ask someone to stay with the problem, they are often confused. This is where the practice of meditation comes in and is useful. In the kind of meditation I practice, one has to stay with the bodily or somatic sensations. The rationale behind it is that every time there is an emotion, it evokes a physiological change in the body which we can feel as a physical sensation. For example, when we are anxious, the heart beats faster, the hands trembles, or we feel butterflies in our stomach. Normally, when we get an unpleasant sensation, our impulse is to get rid of it. However, if we stay with the sensation we will learn about the nature of it. David: Just to summarize for a moment, are you saying that too many times we run away from our problems or look for instant solutions when we really need to figure out what the problem is? Anil Coumar: Correct, and when you use the term "figure out," it implies an intellectual approach. David: Besides meditation, are there any other helpful tools that one can use to improve their mental health? Anil Coumar: Understanding the nature of time is helpful. Most of the time, we are worrying about the future or regretting the past. Both past and future are non-existent, meaning one cannot go into the past or future. This is important to understand, since most of our problems are caused by not being in the present. However, it is difficult, if not impossible, to force the mind to be in the present. What we can do is to understand the content of the mind. Other things apart from meditation that can help us to remain in the here and now are taking a walk, being in nature, listening to music, or whatever activities you like. A person can think about a soothing activity for each sense organ. For example, if we take the eyes, we can look at the beautiful sunset or mountain or even watch TV mindfully. We need to be flexible to come up with an activity that is soothing to us because the same technique is not going to work each time. Each emotion that comes up is not going to be dealt with the same way. I would like to do many things now, in the present, but therapy concentrates on dealing with the past. I would like to overcome this and live in the present. 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. If he pays attention to the present, which is to learn the content of the book in front of him, he will take care of the future. Worrying about the future is not the same as planning for the future. Planning is good as long as we are flexible because the future is so unpredictable we need to be flexible. Anil Coumar: Could you tell me, Nerak, what you mean by getting your spirituality back, because you never lost it. David: Nerak, can you tell us what you mean by that? See what happens and how it affects you when you believe that assumption is a fact. You begin to dislike yourself even more, so it is important to examine our assumptions. Though we lose our faith at times, God always remains faithful to us! It is something we can say we do not believe, but it is there, all the same.