Brief Answer: Reflux due to infection; depression's undertreated Detailed Answer: Hi Ms XXXXXXX Thanks for your query. Firstly, in order to PINPOINT the exact cause of your problems; give you a SOUND professional advice; and, TRUE VALUE FOR YOUR MONEY, I request you to kindly provide additional information as follows :- (a) Did you have weight gain, hair loss, dry and coarse skin, intolerance to cold, constipation or deepening of voice in the past few months/years? (b) What are the various drugs (and their doses) that you are taking for chest pains? Pending receipt of additional information, a (i) THYROID PROBLEM (apart from anxiety with depression); or (ii) ANEMIA can be the cause of constant fatigue, exhaustion, lack of energy, stomach disorder including reflux and, sleep disturbance. INVESTIGATIONS RECOMMENDED:- Thyroid Hormone levels estimation; blood Hemoglobin (Hb%) level and a Peripheral Blood Picture will rule-out/confirm these conditions. These are treatable conditions. I. REFLUX DISEASE :- * Commonest causes of reflux are :- (a) Gastro-esophageal-Reflux-Disease (GERD), which is most commonly due to a stomach/intestinal infection by a bacteria called H.pylori. I would strongly recommend that a 10-14 day's presumptive course of anti-H.pylori therapy, followed by, 3-6 months course of Nexium + Domperidone, will cure this problem permanently. (b) Hiatus hernia, is a condition in which part of the stomach is pulled up in the thorax, thereby making the valve between esophagus and stomach incompetent. However, this condition is LESS LIKELY in your case. (c) Depression/anxiety and mental stress : appropriate anti-depressants + anti-anxiety drugs in effective doses will relieve the reflux problem. (d) Thyroid problem :- If thyroid problem is diagnosed, thyroid hormone replacement will relieve depression and reflux to a great extent. (e) Some of the drugs (particularly anti-anginal tablets) for chest pain cause stomach irritation --> reflux. II. DEPRESSION AND SLEEP DISTURBANCES (a) Constant dryness of mouth is due to Cymbalta and, partly due to co-existing anxiety. (b) If I were your treating doctor, I would have added an anti-anxiety drug, such as clonazepam or alprazolam in effective doses to curb subconscious anxiety state. A peaceful mind promotes good sleep. (c) Addition of a sleep-inducing drug, such as, zolpidem, for a couple of weeks is strongly recommended by me. Zolpidem can be tapered off, once the full effect of anti-anxiety drug is achieved. Consult your doctor and apprise him of my opinion. I am certain that he agrees with my opinion, recommendations and clinical acumen. Hope I have addressed to your concerns to your complete satisfaction and you find my response helpful and informative. I will be happy to answer further queries, if any. Please revert back to me, along with the additional information, as desired. Fond regards and have a nice day, Dr. Rakesh Karanwal

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