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DEAR DOCTOR: I am a 64-year-old male in good health, although I have a bit of a gut in the middle. My issue is that I have developed an umbilical hernia that looks like a large "outie." It is not very attractive, but it is not causing any pain or discomfort. What course of action should I take?

DEAR READER: Umbilical hernias, or so-called "belly-button hernias," are quite common. They occur because of tissue weakness at the umbilical ring. The weakness allows the contents within the abdomen to bulge into the opening, thus making an "innie" appear like an "outie." In children with umbilical hernias, the hernia develops because of incomplete closure of the belly-button (umbilicus) at birth. In adults, umbilical hernias develop because of increased pressure within the abdomen that stretches and weakens the tissue (fascia) at the umbilicus. Increased pressure in the abdomen can be caused by obesity, pregnancy or fluid in the belly from diseases such cirrhosis or ovarian cancer.

Umbilical hernias are three times more common in women than in men. The material that typically bulges within a hernia is fat from the abdomen and the lining of the abdominal cavity. In the majority of people, the herniation doesn't hurt. However, when the lining of the abdominal cavity (the omentum) becomes stuck within a hernia, the area can become painful. Even worse is when the small intestine becomes stuck. Called an incarcerated hernia, this compression leads to a loss of blood flow to the intestine, which can cause severe pain, altered bowel movements and possible death of the bowel tissue. The omentum and the intestine are more likely to become entrapped in men. Women more commonly have umbilical hernias that are reducible, meaning the material that pushes into the hernia can easily be moved back into the abdomen.

A small umbilical hernia without symptoms doesn't require treatment. That changes if a hernia causes pain or is not reducible. For a small, symptomatic hernia, a surgeon cuts into the skin and locates the hernia sac. He or she then removes the sac or pushes it back into the abdomen; sutures the surrounding fascial layers together; and thus closes the area of weakness. With a larger hernia, a surgeon will have difficulty bringing together the surrounding fascial layers. This is when he or she will place a mesh over the defect and attach the mesh to the surrounding fascial layers. Unless the hernia is very large (more than 9 centimeters in size), a surgically repaired hernia is unlikely to recur or cause pain.

Because of the lack of symptoms from your hernia, you're unlikely to need surgical treatment. But you should be on the alert for pain in the umbilical area and for difficulty pushing the hernia back in to the abdomen. Either problem is a sign that surgery might be needed.

Also, you might be able to decrease pressure on the abdomen by decreasing your "gut in the middle." Improving your diet by cutting back on sugar, exercising and losing weight will put less pressure upon the hernia and may decrease the likelihood of ever needing hernia surgery.

DEAR DOCTOR: Just how addictive are antidepressants? My doctor thinks I should take one, but I know a lot of people who have had trouble stopping them. Do the drugs even work?

DEAR READER: Your questions land us in the midst of an important and ongoing discussion that has been taking place for some time now. Depression is a serious and sometimes life-threatening disorder that affects people of all ages, races and nationalities. According to the World Health Organization, it was the third-leading cause of disability throughout the world in 2004 and tops the list of disabilities in the developed world. A variety of medications to treat depression have been developed over the decades but have been accompanied by persistent questions about efficacy and long-term viability.

A specific group of symptoms, when experienced over time, mark a diagnosis of depression. These include low mood, low energy, feelings of worthlessness and an inability to experience pleasure, which is known as anhedonia. Additional symptoms can include altered sleep patterns, diminished appetite, an inability to concentrate and thoughts of self-harm. Diagnosis of depression, which can range from mild to moderate to severe, depends on accurate self-reporting of symptoms and of their duration.

When it comes to medications, things get complicated. That's because the causes of depression are poorly understood. Research suggests the condition may arise from certain chemical imbalances in the brain, chronic stress and anxiety, response to life events, temperament and a genetic predisposition. Antidepressants tackle the various chemical pathways that are believed to play a role in the disorder. However, depression medications don't work for everyone. As many as two-thirds of patients don't respond to the first drug they try. But by working with their doctors to fine-tune their treatment regimens -- there are a number of classes of antidepressants, each with its own therapeutic pathway -- many patients living with depression do find relief.

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When it comes to stopping pharmaceutical treatment, there's sobering news. Although antidepressants were originally developed for short-term use, six to nine months in most cases, the nature of depression and the scarcity of alternative treatment options meant patients have stayed on the drugs for years at a time.

According to a recent report in The New York Times, which analyzed federal data, more than 15 million people in the U.S. have been taking antidepressants for more than five years. When you look at the two-year mark for antidepressant use, that number jumps to 25 million. It's this long-term use that has been most often associated with adverse effects among patients who stop the drugs. Symptoms of withdrawal may include headache, fatigue, nausea, insomnia, unwanted feelings and unusual physical sensations. Tapering rather than quitting an antidepressant is important, and it should always be done in partnership with the prescribing physician.

While all of this may sound dire, it's important to note that antidepressants, when used properly and as part of a comprehensive treatment program, can be helpful. If you do decide to move forward with a prescription, talk all of this over with your doctor. Make a plan regarding duration, and never make any changes to your drug regimen without medical supervision.

Eve Glazier, M.D., MBA, is an internist and assistant professor of medicine at UCLA Health. Elizabeth Ko, M.D., is an internist and primary care physician at UCLA Health.

Send your questions to askthedoctors@mednet.ucla.edu, or write: Ask the Doctors, c/o Media Relations, UCLA Health, 924 Westwood Blvd., Suite 350, Los Angeles, CA, 90095. Owing to the volume of mail, personal replies cannot be provided.

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