Anxiety is a normal reaction to stress and can actually be beneficial in some situations. For some people, however, anxiety can become excessive. While the person suffering may realize their anxiety is too much, they may also have difficulty controlling it and it may negatively affect their day-to-day living. There are a wide variety of anxiety disorders, including post-traumatic stress disorder, obsessive-compulsive disorder, and panic disorder to name a few.

Anxiety, Stress, Depression, Bipolar, Schizophrenia, PTSD, & OCD

Content:
Anxiety
Stress
Depression
Bipolar
Schizophrenia
PTSD
OCD
Mental Health Treatment Approaches
Psychotropic Medications

Mental Health

Mental health includes our emotional, psychological, and social well-being. It affects how we think, feel and act as we cope with life. It also helps determine how we handle stress, relate to others, and make choices. Mental health is important at every stage of life, from childhood and adolescence through adulthood.

Mental illnesses are serious disorders which can affect your thinking, mood, and behavior. There are many causes of mental disorders. Your genes and family history may play a role. Your life experiences, such as stress or a history of abuse, may also matter. Biological factors can also be part of the cause. Mental disorders are common, but treatments are available.

NLM: National Library of Medicine, MedlinePlus

Anxiety Disorders

What is Anxiety Disorder?
Causes
Signs & Symptoms
Who Is At Risk?
Diagnosis
Treatments
Living With
Clinical Trials

What is Anxiety Disorder?

The following anxiety disorders are discussed on this website:

generalized anxiety disorder (GAD)
obsessive-compulsive disorder (OCD),
panic disorder,
post-traumatic stress disorder (PTSD), and
social phobia (or social anxiety disorder).

Causes

NIMH supports research into the causes, diagnosis, prevention, and treatment of anxiety disorders and other mental illnesses. Scientists are looking at what role genes play in the development of these disorders and are also investigating the effects of environmental factors such as pollution, physical and psychological stress, and diet. In addition, studies are being conducted on the “natural history” (what course the illness takes without treatment) of a variety of individual anxiety disorders, combinations of anxiety disorders, and anxiety disorders that are accompanied by other mental illnesses such as depression.

Scientists currently think that, like heart disease and type 1 diabetes, mental illnesses are complex and probably result from a combination of genetic, environmental, psychological, and developmental factors. For instance, although NIMH-sponsored studies of twins and families suggest that genetics play a role in the development of some anxiety disorders, problems such as PTSD are triggered by trauma. Genetic studies may help explain why some people exposed to trauma develop PTSD and others do not.

Several parts of the brain are key actors in the production of fear and anxiety. Using brain imaging technology and neurochemical techniques, scientists have discovered that the amygdala and the hippocampus play significant roles in most anxiety disorders.

The amygdala is an almond-shaped structure deep in the brain that is believed to be a communications hub between the parts of the brain that process incoming sensory signals and the parts that interpret these signals. It can alert the rest of the brain that a threat is present and trigger a fear or anxiety response. The emotional memories stored in the central part of the amygdala may play a role in anxiety disorders involving very distinct fears, such as fears of dogs, spiders, or flying.

The hippocampus is the part of the brain that encodes threatening events into memories. Studies have shown that the hippocampus appears to be smaller in some people who were victims of child abuse or who served in military combat. Research will determine what causes this reduction in size and what role it plays in the flashbacks, deficits in explicit memory, and fragmented memories of the traumatic event that are common in PTSD.

By learning more about how the brain creates fear and anxiety, scientists may be able to devise better treatments for anxiety disorders. For example, if specific neurotransmitters are found to play an important role in fear, drugs may be developed that will block them and decrease fear responses; if enough is learned about how the brain generates new cells throughout the lifecycle, it may be possible to stimulate the growth of new neurons in the hippocampus in people with PTSD.

Current research at NIMH on anxiety disorders includes studies that address how well medication and behavioral therapies work in the treatment of OCD, and the safety and effectiveness of medications for children and adolescents who have a combination of anxiety disorders and attention deficit hyperactivity disorder.

Signs & Symptoms

Unlike the relatively mild, brief anxiety caused by a stressful event (such as speaking in public or a first date), anxiety disorders last at least 6 months and can get worse if they are not treated. Each anxiety disorder has different symptoms, but all the symptoms cluster around excessive, irrational fear and dread.

Anxiety disorders commonly occur along with other mental or physical illnesses, including alcohol or substance abuse, which may mask anxiety symptoms or make them worse. In some cases, these other illnesses need to be treated before a person will respond to treatment for the anxiety disorder.

Effective therapies for anxiety disorders are available, and research is uncovering new treatments that can help most people with anxiety disorders lead productive, fulfilling lives. If you think you have an anxiety disorder, you should seek information and treatment right away.

Who Is At Risk?

Anxiety disorders affect about 40 million American adults age 18 years and older (about 18%) in a given year, causing them to be filled with fearfulness and uncertainty.

Women are 60% more likely than men to experience an anxiety disorder over their lifetime. Non-Hispanic blacks are 20% less likely, and Hispanics are 30% less likely, than non-Hispanic whites to experience an anxiety disorder during their lifetime.

A large, national survey of adolescent mental health reported that about 8 percent of teens ages 13–18 have an anxiety disorder, with symptoms commonly emerging around age 6. However, of these teens, only 18 percent received mental health care.

Diagnosis

A doctor must conduct a careful diagnostic evaluation to determine whether a person’s symptoms are caused by an anxiety disorder or a physical problem. If an anxiety disorder is diagnosed, the type of disorder or the combination of disorders that are present must be identified, as well as any coexisting conditions, such as depression or substance abuse. Sometimes alcoholism, depression, or other coexisting conditions have such a strong effect on the individual that treating the anxiety disorder must wait until the coexisting conditions are brought under control.

Treatments

In general, anxiety disorders are treated with medication, specific types of psychotherapy, or both. Treatment choices depend on the problem and the person’s preference.

People with anxiety disorders who have already received treatment should tell their current doctor about that treatment in detail. If they received medication, they should tell their doctor what medication was used, what the dosage was at the beginning of treatment, whether the dosage was increased or decreased while they were under treatment, what side effects occurred, and whether the treatment helped them become less anxious. If they received psychotherapy, they should describe the type of therapy, how often they attended sessions, and whether the therapy was useful.

Often people believe that they have “failed” at treatment or that the treatment didn’t work for them when, in fact, it was not given for an adequate length of time or was administered incorrectly. Sometimes people must try several different treatments or combinations of treatment before they find the one that works for them.

Medication

Medication will not cure anxiety disorders, but it can keep them under control while the person receives psychotherapy. Medication must be prescribed by physicians, usually psychiatrists, who can either offer psychotherapy themselves or work as a team with psychologists, social workers, or counselors who provide psychotherapy. The principal medications used for anxiety disorders are antidepressants, anti-anxiety drugs, and beta-blockers to control some of the physical symptoms. With proper treatment, many people with anxiety disorders can lead normal, fulfilling lives.

Antidepressants

Antidepressants were developed to treat depression but are also effective for anxiety disorders. Although these medications begin to alter brain chemistry after the very first dose, their full effect requires a series of changes to occur; it is usually about 4 to 6 weeks before symptoms start to fade. It is important to continue taking these medications long enough to let them work.

SSRIs

Some of the newest antidepressants are called selective serotonin reuptake inhibitors, or SSRIs. SSRIs alter the levels of the neurotransmitter serotonin in the brain, which, like other neurotransmitters, helps brain cells communicate with one another.

Fluoxetine (Prozac®), sertraline (Zoloft®), escitalopram (Lexapro®), paroxetine (Paxil®), and citalopram (Celexa®) are some of the SSRIs commonly prescribed for panic disorder, OCD, PTSD, and social phobia. SSRIs are also used to treat panic disorder when it occurs in combination with OCD, social phobia, or depression. Venlafaxine (Effexor®), a drug closely related to the SSRIs, is used to treat GAD. These medications are started at low doses and gradually increased until they have a beneficial effect.

SSRIs have fewer side effects than older antidepressants, but they sometimes produce slight nausea or jitters when people first start to take them. These symptoms fade with time. Some people also experience sexual dysfunction with SSRIs, which may be helped by adjusting the dosage or switching to another SSRI.

Tricyclics

Tricyclics are older than SSRIs and work as well as SSRIs for anxiety disorders other than OCD. They are also started at low doses that are gradually increased. They sometimes cause dizziness, drowsiness, dry mouth, and weight gain, which can usually be corrected by changing the dosage or switching to another tricyclic medication.

Tricyclics include imipramine (Tofranil®), which is prescribed for panic disorder and GAD, and clomipramine (Anafranil®), which is the only tricyclic antidepressant useful for treating OCD.

MAOIs

Monoamine oxidase inhibitors (MAOIs) are the oldest class of antidepressant medications. The MAOIs most commonly prescribed for anxiety disorders are phenelzine (Nardil®), followed by tranylcypromine (Parnate®), and isocarboxazid (Marplan®), which are useful in treating panic disorder and social phobia. People who take MAOIs cannot eat a variety of foods and beverages (including cheese and red wine) that contain tyramine or take certain medications, including some types of birth control pills, pain relievers (such as Advil®, Motrin®, or Tylenol®), cold and allergy medications, and herbal supplements; these substances can interact with MAOIs to cause dangerous increases in blood pressure. The development of a new MAOI skin patch may help lessen these risks. MAOIs can also react with SSRIs to produce a serious condition called “serotonin syndrome,” which can cause confusion, hallucinations, increased sweating, muscle stiffness, seizures, changes in blood pressure or heart rhythm, and other potentially life-threatening conditions.

Anti-Anxiety Drugs

High-potency benzodiazepines combat anxiety and have few side effects other than drowsiness. Because people can get used to them and may need higher and higher doses to get the same effect, benzodiazepines are generally prescribed for short periods of time, especially for people who have abused drugs or alcohol and who become dependent on medication easily. One exception to this rule is people with panic disorder, who can take benzodiazepines for up to a year without harm.

Clonazepam (Klonopin®) is used for social phobia and GAD, lorazepam (Ativan®) is helpful for panic disorder, and alprazolam (Xanax®) is useful for both panic disorder and GAD.

Some people experience withdrawal symptoms if they stop taking benzodiazepines abruptly instead of tapering off, and anxiety can return once the medication is stopped. These potential problems have led some physicians to shy away from using these drugs or to use them in inadequate doses.

Buspirone (Buspar®), an azapirone, is a newer anti-anxiety medication used to treat GAD. Possible side effects include dizziness, headaches, and nausea. Unlike benzodiazepines, buspirone must be taken consistently for at least 2 weeks to achieve an anti-anxiety effect.

Beta-Blockers

Beta-blockers, such as propranolol (Inderal®), which is used to treat heart conditions, can prevent the physical symptoms that accompany certain anxiety disorders, particularly social phobia. When a feared situation can be predicted (such as giving a speech), a doctor may prescribe a beta-blocker to keep physical symptoms of anxiety under control.

Taking Medications

Before taking medication for an anxiety disorder:

Ask your doctor to tell you about the effects and side effects of the drug.
Tell your doctor about any alternative therapies or over-the-counter medications you are using.
Ask your doctor when and how the medication should be stopped. Some drugs can’t be stopped abruptly but must be tapered off slowly under a doctor’s supervision.
Work with your doctor to determine which medication is right for you and what dosage is best.
Be aware that some medications are effective only if they are taken regularly and that symptoms may recur if the medication is stopped.

Psychotherapy

Psychotherapy involves talking with a trained mental health professional, such as a psychiatrist, psychologist, social worker, or counselor, to discover what caused an anxiety disorder and how to deal with its symptoms.

Cognitive-Behavioral Therapy

Cognitive-behavioral therapy (CBT) is very useful in treating anxiety disorders. The cognitive part helps people change the thinking patterns that support their fears, and the behavioral part helps people change the way they react to anxiety-provoking situations.

For example, CBT can help people with panic disorder learn that their panic attacks are not really heart attacks and help people with social phobia learn how to overcome the belief that others are always watching and judging them. When people are ready to confront their fears, they are shown how to use exposure techniques to desensitize themselves to situations that trigger their anxieties.

People with OCD who fear dirt and germs are encouraged to get their hands dirty and wait increasing amounts of time before washing them. The therapist helps the person cope with the anxiety that waiting produces; after the exercise has been repeated a number of times, the anxiety diminishes. People with social phobia may be encouraged to spend time in feared social situations without giving in to the temptation to flee and to make small social blunders and observe how people respond to them. Since the response is usually far less harsh than the person fears, these anxieties are lessened. People with PTSD may be supported through recalling their traumatic event in a safe situation, which helps reduce the fear it produces. CBT therapists also teach deep breathing and other types of exercises to relieve anxiety and encourage relaxation.

Exposure-based behavioral therapy has been used for many years to treat specific phobias. The person gradually encounters the object or situation that is feared, perhaps at first only through pictures or tapes, then later face-to-face. Often the therapist will accompany the person to a feared situation to provide support and guidance.

CBT is undertaken when people decide they are ready for it and with their permission and cooperation. To be effective, the therapy must be directed at the person’s specific anxieties and must be tailored to his or her needs. There are no side effects other than the discomfort of temporarily increased anxiety.

CBT or behavioral therapy often lasts about 12 weeks. It may be conducted individually or with a group of people who have similar problems. Group therapy is particularly effective for social phobia. Often “homework” is assigned for participants to complete between sessions. There is some evidence that the benefits of CBT last longer than those of medication for people with panic disorder, and the same may be true for OCD, PTSD, and social phobia. If a disorder recurs at a later date, the same therapy can be used to treat it successfully a second time.

Medication can be combined with psychotherapy for specific anxiety disorders, and this is the best treatment approach for many people.

Living With

If you think you have an anxiety disorder, the first person you should see is your family doctor. A physician can determine whether the symptoms that alarm you are due to an anxiety disorder, another medical condition, or both.

If an anxiety disorder is diagnosed, the next step is usually seeing a mental health professional. The practitioners who are most helpful with anxiety disorders are those who have training in cognitive-behavioral therapy and/or behavioral therapy, and who are open to using medication if it is needed.

You should feel comfortable talking with the mental health professional you choose. If you do not, you should seek help elsewhere. Once you find a mental health professional with whom you are comfortable, the two of you should work as a team and make a plan to treat your anxiety disorder together.

Remember that once you start on medication, it is important not to stop taking it abruptly. Certain drugs must be tapered off under the supervision of a doctor or bad reactions can occur. Make sure you talk to the doctor who prescribed your medication before you stop taking it. If you are having trouble with side effects, it’s possible that they can be eliminated by adjusting how much medication you take and when you take it.

Most insurance plans, including health maintenance organizations (HMOs), will cover treatment for anxiety disorders. Check with your insurance company and find out. If you don’t have insurance, the Health and Human Services division of your county government may offer mental health care at a public mental health center that charges people according to how much they are able to pay. If you are on public assistance, you may be able to get care through your state Medicaid plan.

Ways to Make Treatment More Effective

Many people with anxiety disorders benefit from joining a self-help or support group and sharing their problems and achievements with others. Internet chat rooms can also be useful in this regard, but any advice received over the Internet should be used with caution, as Internet acquaintances have usually never seen each other and false identities are common. Talking with a trusted friend or member of the clergy can also provide support, but it is not a substitute for care from a mental health professional.

Stress management techniques and meditation can help people with anxiety disorders calm themselves and may enhance the effects of therapy. There is preliminary evidence that aerobic exercise may have a calming effect. Since caffeine, certain illicit drugs, and even some over-the-counter cold medications can aggravate the symptoms of anxiety disorders, they should be avoided. Check with your physician or pharmacist before taking any additional medications.

The family is very important in the recovery of a person with an anxiety disorder. Ideally, the family should be supportive but not help perpetuate their loved one’s symptoms. Family members should not trivialize the disorder or demand improvement without treatment.

Clinical Trials

NIMH supports research studies on mental health and disorders. See also: A Participant's Guide to Mental Health Clinical Research.

Participate, refer a patient or learn about results of studies in ClinicalTrials.gov , the NIH/National Library of Medicine's registry of federally and privately funded clinical trials for all disease.

Find NIH-funded studies currently recruiting participants in anxiety disorders.

Stress and Anxiety Disorder

Q&A on Stress for Adults: How it affects your health and what you can do about it

Stress — just the word may be enough to set your nerves on edge. Everyone feels stressed from time to time. Some people may cope with stress more effectively or recover from stressful events quicker than others. It's important to know your limits when it comes to stress to avoid more serious health effects.

What is stress?

Stress can be defined as the brain's response to any demand. Many things can trigger this response, including change. Changes can be positive or negative, as well as real or perceived. They may be recurring, short-term, or long-term and may include things like commuting to and from school or work every day, traveling for a yearly vacation, or moving to another home. Changes can be mild and relatively harmless, such as winning a race, watching a scary movie, or riding a rollercoaster. Some changes are major, such as marriage or divorce, serious illness, or a car accident. Other changes are extreme, such as exposure to violence, and can lead to traumatic stress reactions.

How does stress affect the body?

Not all stress is bad. All animals have a stress response, which can be life-saving in some situations. The nerve chemicals and hormones released during such stressful times, prepares the animal to face a threat or flee to safety. When you face a dangerous situation, your pulse quickens, you breathe faster, your muscles tense, your brain uses more oxygen and increases activity—all functions aimed at survival. In the short term, it can even boost the immune system.

However, with chronic stress, those same nerve chemicals that are life-saving in short bursts can suppress functions that aren't needed for immediate survival. Your immunity is lowered and your digestive, excretory, and reproductive systems stop working normally. Once the threat has passed, other body systems act to restore normal functioning. Problems occur if the stress response goes on too long, such as when the source of stress is constant, or if the response continues after the danger has subsided.

How does stress affect your overall health?

There are at least three different types of stress, all of which carry physical and mental health risks:

Routine stress related to the pressures of work, family and other daily responsibilities.
Stress brought about by a sudden negative change, such as losing a job, divorce, or illness.
Traumatic stress, experienced in an event like a major accident, war, assault, or a natural disaster where one may be seriously hurt or in danger of being killed.

The body responds to each type of stress in similar ways. Different people may feel it in different ways. For example, some people experience mainly digestive symptoms, while others may have headaches, sleeplessness, depressed mood, anger and irritability. People under chronic stress are prone to more frequent and severe viral infections, such as the flu or common cold, and vaccines, such as the flu shot, are less effective for them.

Of all the types of stress, changes in health from routine stress may be hardest to notice at first. Because the source of stress tends to be more constant than in cases of acute or traumatic stress, the body gets no clear signal to return to normal functioning. Over time, continued strain on your body from routine stress may lead to serious health problems, such as heart disease, high blood pressure, diabetes, depression, anxiety disorder, and other illnesses.

How can I cope with stress?

The effects of stress tend to build up over time. Taking practical steps to maintain your health and outlook can reduce or prevent these effects. The following are some tips that may help you to cope with stress:

Seek help from a qualified mental health care provider if you are overwhelmed, feel you cannot cope, have suicidal thoughts, or are using drugs or alcohol to cope.
Get proper health care for existing or new health problems.
Stay in touch with people who can provide emotional and other support. Ask for help from friends, family, and community or religious organizations to reduce stress due to work burdens or family issues, such as caring for a loved one.
Recognize signs of your body's response to stress, such as difficulty sleeping, increased alcohol and other substance use, being easily angered, feeling depressed, and having low energy.
Set priorities-decide what must get done and what can wait, and learn to say no to new tasks if they are putting you into overload.
Note what you have accomplished at the end of the day, not what you have been unable to do.
Avoid dwelling on problems. If you can't do this on your own, seek help from a qualified mental health professional who can guide you.
Exercise regularly-just 30 minutes per day of gentle walking can help boost mood and reduce stress.
Schedule regular times for healthy and relaxing activities.
Explore stress coping programs, which may incorporate meditation, yoga, tai chi, or other gentle exercises.

If you or someone you know is overwhelmed by stress, ask for help from a health professional. If you or someone close to you is in crisis, call the toll-free, 24-hour National Suicide Prevention Lifeline at 1-800-273-TALK (1-800-273-8255).

What is Anxiety Disorder?

The following anxiety disorders are discussed on this website:

generalized anxiety disorder (GAD)
obsessive-compulsive disorder (OCD),
panic disorder,
post-traumatic stress disorder (PTSD), and
social phobia (or social anxiety disorder).

Causes

Signs & Symptoms

Who Is At Risk?

Anxiety disorders affect about 40 million American adults age 18 years and older (about 18%) in a given year, causing them to be filled with fearfulness and uncertainty.

Diagnosis

Treatments

In general, anxiety disorders are treated with medication, specific types of psychotherapy, or both. Treatment choices depend on the problem and the person’s preference.

Medication

Antidepressants

SSRIs

Tricyclics

Tricyclics include imipramine (Tofranil®), which is prescribed for panic disorder and GAD, and clomipramine (Anafranil®), which is the only tricyclic antidepressant useful for treating OCD.

MAOIs

Anti-Anxiety Drugs

Clonazepam (Klonopin®) is used for social phobia and GAD, lorazepam (Ativan®) is helpful for panic disorder, and alprazolam (Xanax®) is useful for both panic disorder and GAD.

Beta-Blockers

Taking Medications

Before taking medication for an anxiety disorder:

Ask your doctor to tell you about the effects and side effects of the drug.
Tell your doctor about any alternative therapies or over-the-counter medications you are using.
Ask your doctor when and how the medication should be stopped. Some drugs can’t be stopped abruptly but must be tapered off slowly under a doctor’s supervision.
Work with your doctor to determine which medication is right for you and what dosage is best.
Be aware that some medications are effective only if they are taken regularly and that symptoms may recur if the medication is stopped.

Psychotherapy

Cognitive-Behavioral Therapy

Medication can be combined with psychotherapy for specific anxiety disorders, and this is the best treatment approach for many people.

Living With

Ways to Make Treatment More Effective

Depression

What Is Depression?
Causes
Signs & Symptoms
Who Is At Risk?
Diagnosis
Treatments
Living With
Clinical Trials

What Is Depression?

Everyone occasionally feels blue or sad. But these feelings are usually short-lived and pass within a couple of days. When you have depression, it interferes with daily life and causes pain for both you and those who care about you. Depression is a common but serious illness.

Many people with a depressive illness never seek treatment. But the majority, even those with the most severe depression, can get better with treatment. Medications, psychotherapies, and other methods can effectively treat people with depression.

There are several forms of depressive disorders.

Major depression,—severe symptoms that interfere with your ability to work, sleep, study, eat, and enjoy life. An episode can occur only once in a person’s lifetime, but more often, a person has several episodes.

Persistent depressive disorder—depressed mood that lasts for at least 2 years. A person diagnosed with persistent depressive disorder may have episodes of major depression along with periods of less severe symptoms, but symptoms must last for 2 years.

Some forms of depression are slightly different, or they may develop under unique circumstances. They include:

Psychotic depression, which occurs when a person has severe depression plus some form of psychosis, such as having disturbing false beliefs or a break with reality (delusions), or hearing or seeing upsetting things that others cannot hear or see (hallucinations).
Postpartum depression, which is much more serious than the "baby blues" that many women experience after giving birth, when hormonal and physical changes and the new responsibility of caring for a newborn can be overwhelming. It is estimated that 10 to 15 percent of women experience postpartum depression after giving birth.
Seasonal affective disorder (SAD), which is characterized by the onset of depression during the winter months, when there is less natural sunlight. The depression generally lifts during spring and summer. SAD may be effectively treated with light therapy, but nearly half of those with SAD do not get better with light therapy alone. Antidepressant medication and psychotherapy can reduce SAD symptoms, either alone or in combination with light therapy.

Bipolar disorder, also called manic-depressive illness, is not as common as major depression or persistent depressive disorder. Bipolar disorder is characterized by cycling mood changes—from extreme highs (e.g., mania) to extreme lows (e.g., depression).

Causes

Most likely, depression is caused by a combination of genetic, biological, environmental, and psychological factors.

Depressive illnesses are disorders of the brain. Brain-imaging technologies, such as magnetic resonance imaging (MRI), have shown that the brains of people who have depression look different than those of people without depression. The parts of the brain involved in mood, thinking, sleep, appetite, and behavior appear different. But these images do not reveal why the depression has occurred. They also cannot be used to diagnose depression.

Some types of depression tend to run in families. However, depression can occur in people without family histories of depression too. Scientists are studying certain genes that may make some people more prone to depression. Some genetics research indicates that risk for depression results from the influence of several genes acting together with environmental or other factors. In addition, trauma, loss of a loved one, a difficult relationship, or any stressful situation may trigger a depressive episode. Other depressive episodes may occur with or without an obvious trigger.

Signs & Symptoms

"It was really hard to get out of bed in the morning. I just wanted to hide under the covers and not talk to anyone. I didn't feel much like eating and I lost a lot of weight. Nothing seemed fun anymore. I was tired all the time, and I wasn't sleeping well at night. But I knew I had to keep going because I've got kids and a job. It just felt so impossible, like nothing was going to change or get better."

People with depressive illnesses do not all experience the same symptoms. The severity, frequency, and duration of symptoms vary depending on the individual and his or her particular illness.

Signs and symptoms include:

Persistent sad, anxious, or "empty" feelings
Feelings of hopelessness or pessimism
Feelings of guilt, worthlessness, or helplessness
Irritability, restlessness
Loss of interest in activities or hobbies once pleasurable, including sex
Fatigue and decreased energy
Difficulty concentrating, remembering details, and making decisions
Insomnia, early-morning wakefulness, or excessive sleeping
Overeating, or appetite loss
Thoughts of suicide, suicide attempts
Aches or pains, headaches, cramps, or digestive problems that do not ease even with treatment.

Who Is At Risk?

Major depressive disorder is one of the most common mental disorders in the United States. Each year about 6.7% of U.S adults experience major depressive disorder. Women are 70 % more likely than men to experience depression during their lifetime. Non-Hispanic blacks are 40% less likely than non-Hispanic whites to experience depression during their lifetime. The average age of onset is 32 years old. Additionally, 3.3% of 13 to 18 year olds have experienced a seriously debilitating depressive disorder.

Diagnosis

"I started missing days from work, and a friend noticed that something wasn't right. She talked to me about the time she had been really depressed and had gotten help from her doctor."

Depression, even the most severe cases, can be effectively treated. The earlier that treatment can begin, the more effective it is.

The first step to getting appropriate treatment is to visit a doctor or mental health specialist. Certain medications, and some medical conditions such as viruses or a thyroid disorder, can cause the same symptoms as depression. A doctor can rule out these possibilities by doing a physical exam, interview, and lab tests. If the doctor can find no medical condition that may be causing the depression, the next step is a psychological evaluation.

The doctor may refer you to a mental health professional, who should discuss with you any family history of depression or other mental disorder, and get a complete history of your symptoms. You should discuss when your symptoms started, how long they have lasted, how severe they are, and whether they have occurred before and if so, how they were treated. The mental health professional may also ask if you are using alcohol or drugs, and if you are thinking about death or suicide.

Other illnesses may come on before depression, cause it, or be a consequence of it. But depression and other illnesses interact differently in different people. In any case, co-occurring illnesses need to be diagnosed and treated.

Anxiety disorders, such as post-traumatic stress disorder (PTSD), obsessive-compulsive disorder, panic disorder, social phobia, and generalized anxiety disorder, often accompany depression. PTSD can occur after a person experiences a terrifying event or ordeal, such as a violent assault, a natural disaster, an accident, terrorism or military combat. People experiencing PTSD are especially prone to having co-existing depression.

Alcohol and other substance abuse or dependence may also co-exist with depression. Research shows that mood disorders and substance abuse commonly occur together.

Depression also may occur with other serious medical illnesses such as heart disease, stroke, cancer, HIV/AIDS, diabetes, and Parkinson's disease. People who have depression along with another medical illness tend to have more severe symptoms of both depression and the medical illness, more difficulty adapting to their medical condition, and more medical costs than those who do not have co-existing depression. Treating the depression can also help improve the outcome of treating the co-occurring illness.

Treatments

Once diagnosed, a person with depression can be treated in several ways. The most common treatments are medication and psychotherapy.

Medication

Antidepressants primarily work on brain chemicals called neurotransmitters, especially serotonin and norepinephrine. Other antidepressants work on the neurotransmitter dopamine. Scientists have found that these particular chemicals are involved in regulating mood, but they are unsure of the exact ways that they work. The latest information on medications for treating depression is available on the U.S. Food and Drug Administration (FDA) website .

Popular newer antidepressants

Some of the newest and most popular antidepressants are called selective serotonin reuptake inhibitors (SSRIs). Fluoxetine (Prozac), sertraline (Zoloft), escitalopram (Lexapro), paroxetine (Paxil), and citalopram (Celexa) are some of the most commonly prescribed SSRIs for depression. Most are available in generic versions. Serotonin and norepinephrine reuptake inhibitors (SNRIs) are similar to SSRIs and include venlafaxine (Effexor) and duloxetine (Cymbalta).

SSRIs and SNRIs tend to have fewer side effects than older antidepressants, but they sometimes produce headaches, nausea, jitters, or insomnia when people first start to take them. These symptoms tend to fade with time. Some people also experience sexual problems with SSRIs or SNRIs, which may be helped by adjusting the dosage or switching to another medication.

One popular antidepressant that works on dopamine is bupropion (Wellbutrin). Bupropion tends to have similar side effects as SSRIs and SNRIs, but it is less likely to cause sexual side effects. However, it can increase a person's risk for seizures.

Tricyclics

Tricyclics are older antidepressants. Tricyclics are powerful, but they are not used as much today because their potential side effects are more serious. They may affect the heart in people with heart conditions. They sometimes cause dizziness, especially in older adults. They also may cause drowsiness, dry mouth, and weight gain. These side effects can usually be corrected by changing the dosage or switching to another medication. However, tricyclics may be especially dangerous if taken in overdose. Tricyclics include imipramine and nortriptyline.

MAOIs

Monoamine oxidase inhibitors (MAOIs) are the oldest class of antidepressant medications. They can be especially effective in cases of "atypical" depression, such as when a person experiences increased appetite and the need for more sleep rather than decreased appetite and sleep. They also may help with anxious feelings or panic and other specific symptoms.

However, people who take MAOIs must avoid certain foods and beverages (including cheese and red wine) that contain a substance called tyramine. Certain medications, including some types of birth control pills, prescription pain relievers, cold and allergy medications, and herbal supplements, also should be avoided while taking an MAOI. These substances can interact with MAOIs to cause dangerous increases in blood pressure. The development of a new MAOI skin patch may help reduce these risks. If you are taking an MAOI, your doctor should give you a complete list of foods, medicines, and substances to avoid.

MAOIs can also react with SSRIs to produce a serious condition called "serotonin syndrome," which can cause confusion, hallucinations, increased sweating, muscle stiffness, seizures, changes in blood pressure or heart rhythm, and other potentially life-threatening conditions. MAOIs should not be taken with SSRIs.

How should I take medication?

All antidepressants must be taken for at least 4 to 6 weeks before they have a full effect. You should continue to take the medication, even if you are feeling better, to prevent the depression from returning.

Medication should be stopped only under a doctor's supervision. Some medications need to be gradually stopped to give the body time to adjust. Although antidepressants are not habit-forming or addictive, suddenly ending an antidepressant can cause withdrawal symptoms or lead to a relapse of the depression. Some individuals, such as those with chronic or recurrent depression, may need to stay on the medication indefinitely.

In addition, if one medication does not work, you should consider trying another. NIMH-funded research has shown that people who did not get well after taking a first medication increased their chances of beating the depression after they switched to a different medication or added another medication to their existing one.

Sometimes stimulants, anti-anxiety medications, or other medications are used together with an antidepressant, especially if a person has a co-existing illness. However, neither anti-anxiety medications nor stimulants are effective against depression when taken alone, and both should be taken only under a doctor's close supervision.

Report any unusual side effects to a doctor immediately.

FDA warning on antidepressants

Despite the relative safety and popularity of SSRIs and other antidepressants, studies have suggested that they may have unintentional effects on some people, especially adolescents and young adults. In 2004, the Food and Drug Administration (FDA) conducted a thorough review of published and unpublished controlled clinical trials of antidepressants that involved nearly 4,400 children and adolescents. The review revealed that 4 percent of those taking antidepressants thought about or attempted suicide (although no suicides occurred), compared to 2 percent of those receiving placebos.

This information prompted the FDA, in 2005, to adopt a "black box" warning label on all antidepressant medications to alert the public about the potential increased risk of suicidal thinking or attempts in children and adolescents taking antidepressants. In 2007, the FDA proposed that makers of all antidepressant medications extend the warning to include young adults up through age 24. A "black box" warning is the most serious type of warning on prescription drug labeling.

The warning emphasizes that patients of all ages taking antidepressants should be closely monitored, especially during the initial weeks of treatment. Possible side effects to look for are worsening depression, suicidal thinking or behavior, or any unusual changes in behavior such as sleeplessness, agitation, or withdrawal from normal social situations. The warning adds that families and caregivers should also be told of the need for close monitoring and report any changes to the doctor. The latest information from the FDA can be found on their website .

Results of a comprehensive review of pediatric trials conducted between 1988 and 2006 suggested that the benefits of antidepressant medications likely outweigh their risks to children and adolescents with major depression and anxiety disorders.

What about St. John's wort?

The extract from the herb St. John's wort (Hypericum perforatum) has been used for centuries in many folk and herbal remedies. Today in Europe, it is used extensively to treat mild to moderate depression. However, recent studies have found that St. John’s wort is no more effective than placebo in treating major or minor depression.

In 2000, the FDA issued a Public Health Advisory letter stating that the herb may interfere with certain medications used to treat heart disease, depression, seizures, certain cancers, and those used to prevent organ transplant rejection. The herb also may interfere with the effectiveness of oral contraceptives. Consult with your doctor before taking any herbal supplement.

Psychotherapy

Now I'm seeing the specialist on a regular basis for "talk therapy," which helps me learn ways to deal with this illness in my everyday life, and I'm taking medicine for depression.

Several types of psychotherapy—or "talk therapy"—can help people with depression.

Two main types of psychotherapies—cognitive-behavioral therapy (CBT) and interpersonal therapy (IPT)—are effective in treating depression. CBT helps people with depression restructure negative thought patterns. Doing so helps people interpret their environment and interactions with others in a positive and realistic way. It may also help you recognize things that may be contributing to the depression and help you change behaviors that may be making the depression worse. IPT helps people understand and work through troubled relationships that may cause their depression or make it worse.

For mild to moderate depression, psychotherapy may be the best option. However, for severe depression or for certain people, psychotherapy may not be enough. For example, for teens, a combination of medication and psychotherapy may be the most effective approach to treating major depression and reducing the chances of it coming back. Another study looking at depression treatment among older adults found that people who responded to initial treatment of medication and IPT were less likely to have recurring depression if they continued their combination treatment for at least 2 years.

More information on psychotherapy is available on the NIMH website.

Electroconvulsive therapy and other brain stimulation therapies

For cases in which medication and/or psychotherapy does not help relieve a person's treatment-resistant depression, electroconvulsive therapy (ECT) may be useful. ECT, formerly known as "shock therapy," once had a bad reputation. But in recent years, it has greatly improved and can provide relief for people with severe depression who have not been able to feel better with other treatments.

Before ECT begins, a patient is put under brief anesthesia and given a muscle relaxant. He or she sleeps through the treatment and does not consciously feel the electrical impulses. Within 1 hour after the treatment session, which takes only a few minutes, the patient is awake and alert.

A person typically will undergo ECT several times a week, and often will need to take an antidepressant or other medication along with the ECT treatments. Although some people will need only a few courses of ECT, others may need maintenance ECT—usually once a week at first, then gradually decreasing to monthly treatments. Ongoing NIMH-supported ECT research is aimed at developing personalized maintenance ECT schedules.

ECT may cause some side effects, including confusion, disorientation, and memory loss. Usually these side effects are short-term, but sometimes they can linger. Newer methods of administering the treatment have reduced the memory loss and other cognitive difficulties associated with ECT. Research has found that after 1 year of ECT treatments, most patients showed no adverse cognitive effects.

Other more recently introduced types of brain stimulation therapies used to treat severe depression include vagus nerve stimulation (VNS), and repetitive transcranial magnetic stimulation (rTMS). These methods are not yet commonly used, but research has suggested that they show promise.

More information on ECT, VNS, rTMS and other brain stimulation therapies is available on the NIMH website.

Living With

How do women experience depression?

Depression is more common among women than among men. Biological, life cycle, hormonal, and psychosocial factors that women experience may be linked to women's higher depression rate. Researchers have shown that hormones directly affect the brain chemistry that controls emotions and mood. For example, women are especially vulnerable to developing postpartum depression after giving birth, when hormonal and physical changes and the new responsibility of caring for a newborn can be overwhelming.

Some women may also have a severe form of premenstrual syndrome (PMS) called premenstrual dysphoric disorder (PMDD). PMDD is associated with the hormonal changes that typically occur around ovulation and before menstruation begins.

During the transition into menopause, some women experience an increased risk for depression. In addition, osteoporosis—bone thinning or loss—may be associated with depression. Scientists are exploring all of these potential connections and how the cyclical rise and fall of estrogen and other hormones may affect a woman's brain chemistry.

Finally, many women face the additional stresses of work and home responsibilities, caring for children and aging parents, abuse, poverty, and relationship strains. It is still unclear, though, why some women faced with enormous challenges develop depression, while others with similar challenges do not.

How do men experience depression?

Men often experience depression differently than women. While women with depression are more likely to have feelings of sadness, worthlessness, and excessive guilt, men are more likely to be very tired, irritable, lose interest in once-pleasurable activities, and have difficulty sleeping.

Men may be more likely than women to turn to alcohol or drugs when they are depressed. They also may become frustrated, discouraged, irritable, angry, and sometimes abusive. Some men throw themselves into their work to avoid talking about their depression with family or friends, or behave recklessly. And although more women attempt suicide, many more men die by suicide in the United States.

How do older adults experience depression?

Depression is not a normal part of aging. Studies show that most seniors feel satisfied with their lives, despite having more illnesses or physical problems. However, when older adults do have depression, it may be overlooked because seniors may show different, less obvious symptoms. They may be less likely to experience or admit to feelings of sadness or grief.

Sometimes it can be difficult to distinguish grief from major depression. Grief after loss of a loved one is a normal reaction to the loss and generally does not require professional mental health treatment. However, grief that is complicated and lasts for a very long time following a loss may require treatment. Researchers continue to study the relationship between complicated grief and major depression.

Older adults also may have more medical conditions such as heart disease, stroke, or cancer, which may cause depressive symptoms. Or they may be taking medications with side effects that contribute to depression. Some older adults may experience what doctors call vascular depression, also called arteriosclerotic depression or subcortical ischemic depression. Vascular depression may result when blood vessels become less flexible and harden over time, becoming constricted. Such hardening of vessels prevents normal blood flow to the body's organs, including the brain. Those with vascular depression may have, or be at risk for, co-existing heart disease or stroke.

Although many people assume that the highest rates of suicide are among young people, older white males age 85 and older actually have the highest suicide rate in the United States. Many have a depressive illness that their doctors are not aware of, even though many of these suicide victims visit their doctors within 1 month of their deaths.

Most older adults with depression improve when they receive treatment with an antidepressant, psychotherapy, or a combination of both. Research has shown that medication alone and combination treatment are both effective in reducing depression in older adults. Psychotherapy alone also can be effective in helping older adults stay free of depression, especially among those with minor depression. Psychotherapy is particularly useful for those who are unable or unwilling to take antidepressant medication.

How do children and teens experience depression?

Children who develop depression often continue to have episodes as they enter adulthood. Children who have depression also are more likely to have other more severe illnesses in adulthood.

A child with depression may pretend to be sick, refuse to go to school, cling to a parent, or worry that a parent may die. Older children may sulk, get into trouble at school, be negative and irritable, and feel misunderstood. Because these signs may be viewed as normal mood swings typical of children as they move through developmental stages, it may be difficult to accurately diagnose a young person with depression.

Before puberty, boys and girls are equally likely to develop depression. By age 15, however, girls are twice as likely as boys to have had a major depressive episode.

Depression during the teen years comes at a time of great personal change—when boys and girls are forming an identity apart from their parents, grappling with gender issues and emerging sexuality, and making independent decisions for the first time in their lives. Depression in adolescence frequently co-occurs with other disorders such as anxiety, eating disorders, or substance abuse. It can also lead to increased risk for suicide.

An NIMH-funded clinical trial of 439 adolescents with major depression found that a combination of medication and psychotherapy was the most effective treatment option. Other NIMH-funded researchers are developing and testing ways to prevent suicide in children and adolescents.

Childhood depression often persists, recurs, and continues into adulthood, especially if left untreated.

How can I help a loved one who is depressed?

If you know someone who is depressed, it affects you too. The most important thing you can do is help your friend or relative get a diagnosis and treatment. You may need to make an appointment and go with him or her to see the doctor. Encourage your loved one to stay in treatment, or to seek different treatment if no improvement occurs after 6 to 8 weeks.

To help your friend or relative

Offer emotional support, understanding, patience, and encouragement.
Talk to him or her, and listen carefully.
Never dismiss feelings, but point out realities and offer hope.
Never ignore comments about suicide, and report them to your loved one's therapist or doctor.
Invite your loved one out for walks, outings and other activities. Keep trying if he or she declines, but don't push him or her to take on too much too soon.
Provide assistance in getting to the doctor's appointments.
Remind your loved one that with time and treatment, the depression will lift.

How can I help myself if I am depressed?

If you have depression, you may feel exhausted, helpless, and hopeless. It may be extremely difficult to take any action to help yourself. But as you begin to recognize your depression and begin treatment, you will start to feel better.

To Help Yourself

Do not wait too long to get evaluated or treated. There is research showing the longer one waits, the greater the impairment can be down the road. Try to see a professional as soon as possible.
Try to be active and exercise. Go to a movie, a ballgame, or another event or activity that you once enjoyed.
Set realistic goals for yourself.
Break up large tasks into small ones, set some priorities and do what you can as you can.
Try to spend time with other people and confide in a trusted friend or relative. Try not to isolate yourself, and let others help you.
Expect your mood to improve gradually, not immediately. Do not expect to suddenly "snap out of" your depression. Often during treatment for depression, sleep and appetite will begin to improve before your depressed mood lifts.
Postpone important decisions, such as getting married or divorced or changing jobs, until you feel better. Discuss decisions with others who know you well and have a more objective view of your situation.
Remember that positive thinking will replace negative thoughts as your depression responds to treatment.
Continue to educate yourself about depression.

Clinical Trials

NIMH supports research studies on mental health and disorders. See also: A Participant's Guide to Mental Health Clinical Research.

For More Information on Stress

Information from NIMH is available in multiple formats. You can browse online, download documents in PDF, and order materials through the mail. Check the NIMH website for the latest information on this topic and to order publications. If you do not have Internet access, please contact the NIMH Information Resource Center at the numbers listed below.

National Institute of Mental Health
Science Writing, Press & Dissemination Branch
6001 Executive Boulevard
Room 8184, MSC 9663
Bethesda, MD 20892-9663
Phone: 301-443-4513 or
1-866-615-NIMH (6464) toll-free
TTY: 301-443-8431
TTY: 866-415-8051 toll-free
FAX: 301-443-4279
E-mail: nimhinfo@nih.gov
Website: http://www.nimh.nih.gov

Source: National Institute of Mental Health, NIH, HHS

Bipolar Disorder

What Is Bipolar Disorder?
Causes
Signs & Symptoms
Who Is At Risk?
Diagnosis
Treatments
Living With
Clinical Trials

What Is Bipolar Disorder?

Bipolar disorder, also known as manic-depressive illness, is a brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks. Symptoms of bipolar disorder are severe. They are different from the normal ups and downs that everyone goes through from time to time. Bipolar disorder symptoms can result in damaged relationships, poor job or school performance, and even suicide. But bipolar disorder can be treated, and people with this illness can lead full and productive lives.

Causes

Scientists are studying the possible causes of bipolar disorder. Most scientists agree that there is no single cause. Rather, many factors likely act together to produce the illness or increase risk.

Genetics

Bipolar disorder tends to run in families. Some research has suggested that people with certain genes are more likely to develop bipolar disorder than others. Children with a parent or sibling who has bipolar disorder are much more likely to develop the illness, compared with children who do not have a family history of bipolar disorder. However, most children with a family history of bipolar disorder will not develop the illness.

Technological advances are improving genetic research on bipolar disorder. One example is the launch of the Bipolar Disorder Phenome Database, funded in part by NIMH. Using the database, scientists will be able to link visible signs of the disorder with the genes that may influence them.

Scientists are also studying illnesses with similar symptoms such as depression and schizophrenia to identify genetic differences that may increase a person's risk for developing bipolar disorder. Finding these genetic "hotspots" may also help explain how environmental factors can increase a person's risk.

But genes are not the only risk factor for bipolar disorder. Studies of identical twins have shown that the twin of a person with bipolar illness does not always develop the disorder, despite the fact that identical twins share all of the same genes. Research suggests that factors besides genes are also at work. It is likely that many different genes and environmental factors are involved. However, scientists do not yet fully understand how these factors interact to cause bipolar disorder.

Brain structure and functioning

Brain-imaging tools, such as functional magnetic resonance imaging (fMRI) and positron emission tomography (PET), allow researchers to take pictures of the living brain at work. These tools help scientists study the brain's structure and activity.

Some imaging studies show how the brains of people with bipolar disorder may differ from the brains of healthy people or people with other mental disorders. For example, one study using MRI found that the pattern of brain development in children with bipolar disorder was similar to that in children with "multi-dimensional impairment," a disorder that causes symptoms that overlap somewhat with bipolar disorder and schizophrenia. This suggests that the common pattern of brain development may be linked to general risk for unstable moods.

Another MRI study found that the brain's prefrontal cortex in adults with bipolar disorder tends to be smaller and function less well compared to adults who don't have bipolar disorder. The prefrontal cortex is a brain structure involved in "executive" functions such as solving problems and making decisions. This structure and its connections to other parts of the brain mature during adolescence, suggesting that abnormal development of this brain circuit may account for why the disorder tends to emerge during a person's teen years. Pinpointing brain changes in youth may help us detect illness early or offer targets for early intervention.

The connections between brain regions are important for shaping and coordinating functions such as forming memories, learning, and emotions, but scientists know little about how different parts of the human brain connect. Learning more about these connections, along with information gained from genetic studies, helps scientists better understand bipolar disorder. Scientists are working towards being able to predict which types of treatment will work most effectively.

Signs & Symptoms

People with bipolar disorder experience unusually intense emotional states that occur in distinct periods called "mood episodes." Each mood episode represents a drastic change from a person’s usual mood and behavior. An overly joyful or overexcited state is called a manic episode, and an extremely sad or hopeless state is called a depressive episode. Sometimes, a mood episode includes symptoms of both mania and depression. This is called a mixed state. People with bipolar disorder also may be explosive and irritable during a mood episode.

Extreme changes in energy, activity, sleep, and behavior go along with these changes in mood. Symptoms of bipolar disorder are described below.

Symptoms of mania or a manic episode include:

Symptoms of depression or a depressive episode include:

Mood Changes

A long period of feeling "high," or an overly happy or outgoing mood
Extreme irritability

Behavioral Changes

Talking very fast, jumping from one idea to another, having racing thoughts
Being easily distracted
Increasing activities, such as taking on new projects
Being overly restless
Sleeping little or not being tired
Having an unrealistic belief in one's abilities
Behaving impulsively and engaging in pleasurable, high-risk behaviors

Mood Changes

An overly long period of feeling sad or hopeless
Loss of interest in activities once enjoyed, including sex.

Behavioral Changes

Feeling tired or "slowed down"
Having problems concentrating, remembering, and making decisions
Being restless or irritable
Changing eating, sleeping, or other habits
Thinking of death or suicide, or attempting suicide.

Bipolar disorder can be present even when mood swings are less extreme. For example, some people with bipolar disorder experience hypomania, a less severe form of mania. During a hypomanic episode, you may feel very good, be highly productive, and function well. You may not feel that anything is wrong, but family and friends may recognize the mood swings as possible bipolar disorder. Without proper treatment, people with hypomania may develop severe mania or depression.

Bipolar disorder may also be present in a mixed state, in which you might experience both mania and depression at the same time. During a mixed state, you might feel very agitated, have trouble sleeping, experience major changes in appetite, and have suicidal thoughts. People in a mixed state may feel very sad or hopeless while at the same time feel extremely energized.

Sometimes, a person with severe episodes of mania or depression has psychotic symptoms too, such as hallucinations or delusions. The psychotic symptoms tend to reflect the person's extreme mood. For example, if you are having psychotic symptoms during a manic episode, you may believe you are a famous person, have a lot of money, or have special powers. If you are having psychotic symptoms during a depressive episode, you may believe you are ruined and penniless, or you have committed a crime. As a result, people with bipolar disorder who have psychotic symptoms are sometimes misdiagnosed with schizophrenia.

People with bipolar disorder may also abuse alcohol or substances, have relationship problems, or perform poorly in school or at work. It may be difficult to recognize these problems as signs of a major mental illness.

Bipolar disorder usually lasts a lifetime. Episodes of mania and depression typically come back over time. Between episodes, many people with bipolar disorder are free of symptoms, but some people may have lingering symptoms.

Who Is At Risk?

Bipolar disorder often develops in a person's late teens or early adult years. At least half of all cases start before age 25. Some people have their first symptoms during childhood, while others may develop symptoms late in life.

Diagnosis

Doctors diagnose bipolar disorder using guidelines from the Diagnostic and Statistical Manual of Mental Disorders (DSM). To be diagnosed with bipolar disorder, the symptoms must be a major change from your normal mood or behavior. There are four basic types of bipolar disorder:

Bipolar I Disorder—defined by manic or mixed episodes that last at least seven days, or by manic symptoms that are so severe that the person needs immediate hospital care. Usually, depressive episodes occur as well, typically lasting at least 2 weeks.
Bipolar II Disorder—defined by a pattern of depressive episodes and hypomanic episodes, but no full-blown manic or mixed episodes.
Bipolar Disorder Not Otherwise Specified (BP-NOS)—diagnosed when symptoms of the illness exist but do not meet diagnostic criteria for either bipolar I or II. However, the symptoms are clearly out of the person's normal range of behavior.
Cyclothymic Disorder, or Cyclothymia—a mild form of bipolar disorder. People with cyclothymia have episodes of hypomania as well as mild depression for at least 2 years. However, the symptoms do not meet the diagnostic requirements for any other type of bipolar disorder.

A severe form of the disorder is called Rapid-cycling Bipolar Disorder. Rapid cycling occurs when a person has four or more episodes of major depression, mania, hypomania, or mixed states, all within a year. Rapid cycling seems to be more common in people who have their first bipolar episode at a younger age. One study found that people with rapid cycling had their first episode about 4 years earlier—during the mid to late teen years—than people without rapid cycling bipolar disorder. Rapid cycling affects more women than men. Rapid cycling can come and go.

When getting a diagnosis, a doctor or health care provider should conduct a physical examination, an interview, and lab tests. Currently, bipolar disorder cannot be identified through a blood test or a brain scan, but these tests can help rule out other factors that may contribute to mood problems, such as a stroke, brain tumor, or thyroid condition. If the problems are not caused by other illnesses, your health care provider may conduct a mental health evaluation or provide a referral to a trained mental health professional, such as a psychiatrist, who is experienced in diagnosing and treating bipolar disorder.

The doctor or mental health professional should discuss with you any family history of bipolar disorder or other mental illnesses and get a complete history of symptoms. The doctor or mental health professional should also talk to your close relatives or spouse about your symptoms and family medical history.

People with bipolar disorder are more likely to seek help when they are depressed than when experiencing mania or hypomania. Therefore, a careful medical history is needed to assure that bipolar disorder is not mistakenly diagnosed as major depression. Unlike people with bipolar disorder, people who have depression only (also called unipolar depression) do not experience mania.

Bipolar disorder can worsen if left undiagnosed and untreated. Episodes may become more frequent or more severe over time without treatment. Also, delays in getting the correct diagnosis and treatment can contribute to personal, social, and work-related problems. Proper diagnosis and treatment help people with bipolar disorder lead healthy and productive lives. In most cases, treatment can help reduce the frequency and severity of episodes.

Substance abuse is very common among people with bipolar disorder, but the reasons for this link are unclear. Some people with bipolar disorder may try to treat their symptoms with alcohol or drugs. However, substance abuse may trigger or prolong bipolar symptoms, and the behavioral control problems associated with mania can result in a person drinking too much.

Anxiety disorders, such as post-traumatic stress disorder (PTSD) and social phobia, also co-occur often among people with bipolar disorder. Bipolar disorder also co-occurs with attention deficit hyperactivity disorder (ADHD), which has some symptoms that overlap with bipolar disorder, such as restlessness and being easily distracted.

People with bipolar disorder are also at higher risk for thyroid disease, migraine headaches, heart disease, diabetes, obesity, and other physical illnesses. These illnesses may cause symptoms of mania or depression. They may also result from treatment for bipolar disorder.

Treatments

Bipolar disorder cannot be cured, but it can be treated effectively over the long-term. Proper treatment helps many people with bipolar disorder—even those with the most severe forms of the illness—gain better control of their mood swings and related symptoms. But because it is a lifelong illness, long-term, continuous treatment is needed to control symptoms. However, even with proper treatment, mood changes can occur. In the NIMH-funded Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) study—the largest treatment study ever conducted for bipolar disorder—almost half of those who recovered still had lingering symptoms. Having another mental disorder in addition to bipolar disorder increased one's chances for a relapse. See STEP-BD for more information.

Treatment is more effective if you work closely with a doctor and talk openly about your concerns and choices. An effective maintenance treatment plan usually includes a combination of medication and psychotherapy.

Medications

Different types of medications can help control symptoms of bipolar disorder. Not everyone responds to medications in the same way. You may need to try several different medications before finding ones that work best for you.

Keeping a daily life chart that makes note of your daily mood symptoms, treatments, sleep patterns, and life events can help you and your doctor track and treat your illness most effectively. If your symptoms change or if side effects become intolerable, your doctor may switch or add medications.

The types of medications generally used to treat bipolar disorder include mood stabilizers, atypical antipsychotics, and antidepressants. For the most up-to-date information on medication use and their side effects, contact the U.S. Food and Drug Administration (FDA).

Mood stabilizers are usually the first choice to treat bipolar disorder. In general, people with bipolar disorder continue treatment with mood stabilizers for years. Lithium (also known as Eskalith or Lithobid) is an effective mood stabilizer. It was the first mood stabilizer approved by the FDA in the 1970's for treating both manic and depressive episodes.

Anticonvulsants are also used as mood stabilizers. They were originally developed to treat seizures, but they also help control moods. Anticonvulsants used as mood stabilizers include:

Valproic acid or divalproex sodium (Depakote), approved by the FDA in 1995 for treating mania. It is a popular alternative to lithium. However, young women taking valproic acid face special precautions.
Lamotrigine (Lamictal), FDA-approved for maintenance treatment of bipolar disorder. It is often effective in treating depressive symptoms.
Other anticonvulsant medications, including gabapentin (Neurontin), topiramate (Topamax), and oxcarbazepine (Trileptal).

Valproic acid, lamotrigine, and other anticonvulsant medications have an FDA warning. The warning states that their use may increase the risk of suicidal thoughts and behaviors. People taking anticonvulsant medications for bipolar or other illnesses should be monitored closely for new or worsening symptoms of depression, suicidal thoughts or behavior, or any unusual changes in mood or behavior. If you take any of these medications, do not make any changes to your dosage without talking to your doctor.

What are the side effects of mood stabilizers?

Lithium can cause side effects such as:

Restlessness
Dry mouth
Bloating or indigestion
Acne
Unusual discomfort to cold temperatures
Joint or muscle pain
Brittle nails or hair.

When taking lithium, your doctor should check the levels of lithium in your blood regularly, and will monitor your kidney and thyroid function as well. Lithium treatment may cause low thyroid levels in some people. Low thyroid function, called hypothyroidism, has been associated with rapid cycling in some people with bipolar disorder, especially women.

Because too much or too little thyroid hormone can lead to mood and energy changes, it is important that your doctor check your thyroid levels carefully. You may need to take thyroid medication, in addition to medications for bipolar disorder, to keep thyroid levels balanced.

Common side effects of other mood stabilizing medications include:

Drowsiness
Dizziness
Headache
Diarrhea
Constipation
Heartburn
Mood swings
Stuffed or runny nose, or other cold-like symptoms.

These medications may also be linked with rare but serious side effects. Talk with your doctor or a pharmacist to make sure you understand signs of serious side effects for the medications you're taking. If extremely bothersome or unusual side effects occur, tell your doctor as soon as possible.

Should young women take valproic acid?

Valproic acid may increase levels of testosterone (a male hormone) in teenage girls. It could lead to a condition called polycystic ovary syndrome (PCOS) in women who begin taking the medication before age 20. PCOS can cause obesity, excess body hair, an irregular menstrual cycle, and other serious symptoms. Most of these symptoms will improve after stopping treatment with valproic acid. Young girls and women taking valproic acid should be monitored carefully by a doctor.

Atypical antipsychotics are sometimes used to treat symptoms of bipolar disorder. Often, these medications are taken with other medications, such as antidepressants. Atypical antipsychotics include:

Olanzapine (Zyprexa), which when given with an antidepressant medication, may help relieve symptoms of severe mania or psychosis. Olanzapine can be taken as a pill or a shot. The shot is often used for urgent treatment of agitation associated with a manic or mixed episode. Olanzapine can be used as maintenance treatment as well, even when psychotic symptoms are not currently present.
Aripiprazole (Abilify), which is used to treat manic or mixed episodes. Aripiprazole is also used for maintenance treatment. Like olanzapine, aripiprazole can be taken as a pill or a shot. The shot is often used for urgent treatment of severe symptoms.
Quetiapine (Seroquel), risperidone (Risperdal) and ziprasidone (Geodon) also are prescribed to relieve the symptoms of manic episodes.

What are the side effects of atypical antipsychotics?

If you are taking antipsychotics, you should not drive until you have adjusted to your medication. Side effects of many antipsychotics include:

Drowsiness
Dizziness when changing positions
Blurred vision
Rapid heartbeat
Sensitivity to the sun
Skin rashes
Menstrual problems for women.

Atypical antipsychotic medications can cause major weight gain and changes in your metabolism. This may increase your risk of getting diabetes and high cholesterol. Your doctor should monitor your weight, glucose levels, and lipid levels regularly while you are taking these medications.

In rare cases, long-term use of atypical antipsychotic drugs may lead to a condition called tardive dyskinesia (TD). The condition causes uncontrollable muscle movements, frequently around the mouth. TD can range from mild to severe. Some people with TD recover partially or fully after they stop taking the drug, but others do not.

Antidepressants are sometimes used to treat symptoms of depression in bipolar disorder. Fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), and bupropion (Wellbutrin) are examples of antidepressants that may be prescribed to treat symptoms of bipolar depression.

However, taking only an antidepressant can increase your risk of switching to mania or hypomania, or of developing rapid-cycling symptoms. To prevent this switch, doctors usually require you to take a mood-stabilizing medication at the same time as an antidepressant.

What are the side effects of antidepressants?

Antidepressants can cause:

Headache
Nausea (feeling sick to your stomach)
Agitation (feeling jittery)
Sexual problems, which can affect both men and women. These include reduced sex drive and problems having and enjoying sex.

Report any concerns about side effects to your doctor right away. You may need a change in the dose or a different medication. You should not stop taking a medication without talking to your doctor first. Suddenly stopping a medication may lead to "rebound" or worsening of bipolar disorder symptoms. Other uncomfortable or potentially dangerous withdrawal effects are also possible.

Some antidepressants are more likely to cause certain side effects than other types. Your doctor or pharmacist can answer questions about these medications. Any unusual reactions or side effects should be reported to a doctor immediately.

Should women who are pregnant or may become pregnant take medication for bipolar disorder?

Women with bipolar disorder who are pregnant or may become pregnant face special challenges. Mood stabilizing medications can harm a developing fetus or nursing infant. But stopping medications, either suddenly or gradually, greatly increases the risk that bipolar symptoms will recur during pregnancy.

Lithium is generally the preferred mood-stabilizing medication for pregnant women with bipolar disorder. However, lithium can lead to heart problems in the fetus. In addition, women need to know that most bipolar medications are passed on through breast milk. The FDA has also issued warnings about the potential risks associated with the use of antipsychotic medications during pregnancy. If you are pregnant or nursing, talk to your doctor about the benefits and risks of all available treatments.

FDA Warning on Antidepressants

Antidepressants are safe and popular, but some studies have suggested that they may have unintentional effects on some people, especially in adolescents and young adults. The FDA warning says that patients of all ages taking antidepressants should be watched closely, especially during the first few weeks of treatment. Possible side effects to look for are depression that gets worse, suicidal thinking or behavior, or any unusual changes in behavior such as trouble sleeping, agitation, or withdrawal from normal social situations. For the latest information, see the FDA website .

Psychotherapy

When done in combination with medication, psychotherapy can be an effective treatment for bipolar disorder. It can provide support, education, and guidance to people with bipolar disorder and their families. Some psychotherapy treatments used to treat bipolar disorder include:

Cognitive behavioral therapy (CBT), which helps people with bipolar disorder learn to change harmful or negative thought patterns and behaviors.
Family-focused therapy, which involves family members. It helps enhance family coping strategies, such as recognizing new episodes early and helping their loved one. This therapy also improves communication among family members, as well as problem-solving.
Interpersonal and social rhythm therapy, which helps people with bipolar disorder improve their relationships with others and manage their daily routines. Regular daily routines and sleep schedules may help protect against manic episodes.
Psychoeducation, which teaches people with bipolar disorder about the illness and its treatment. Psychoeducation can help you recognize signs of an impending mood swing so you can seek treatment early, before a full-blown episode occurs. Usually done in a group, psychoeducation may also be helpful for family members and caregivers.

In a STEP-BD study on psychotherapies, researchers compared people in two groups. The first group was treated with collaborative care (three sessions of psychoeducation over 6 weeks). The second group was treated with medication and intensive psychotherapy (30 sessions over 9 months of CBT, interpersonal and social rhythm therapy, or family-focused therapy). Researchers found that the second group had fewer relapses, lower hospitalization rates, and were better able to stick with their treatment plans. They were also more likely to get well faster and stay well longer. Overall, more than half of the study participants recovered over the course of 1 year.

A licensed psychologist, social worker, or counselor typically provides psychotherapy. He or she should work with your psychiatrist to track your progress. The number, frequency, and type of sessions should be based on your individual treatment needs. As with medication, following the doctor's instructions for any psychotherapy will provide the greatest benefit.

Visit the NIMH website for more information on psychotherapy.

Other treatments

Electroconvulsive Therapy (ECT)—For cases in which medication and psychotherapy do not work, electroconvulsive therapy (ECT) may be useful. ECT, formerly known as "shock therapy," once had a bad reputation. But in recent years, it has greatly improved and can provide relief for people with severe bipolar disorder who have not been able to recover with other treatments.

Before ECT is administered, a patient takes a muscle relaxant and is put under brief anesthesia. He or she does not consciously feel the electrical impulse administered in ECT. On average, ECT treatments last from 30–90 seconds. People who have ECT usually recover after 5–15 minutes and are able to go home the same day.

Sometimes ECT is used for bipolar symptoms when other medical conditions, including pregnancy, make the use of medications too risky. ECT is a highly effective treatment for severely depressive, manic, or mixed episodes. But it is generally not used as a first-line treatment.

ECT may cause some short-term side effects, including confusion, disorientation, and memory loss. People with bipolar disorder should discuss possible benefits and risks of ECT with an experienced doctor.

Sleep Medications—People with bipolar disorder who have trouble sleeping usually sleep better after getting treatment for bipolar disorder. However, if sleeplessness does not improve, your doctor may suggest a change in medications. If the problems still continue, your doctor may prescribe sedatives or other sleep medications.

Herbal Supplements—In general, not much research has been conducted on herbal or natural supplements and how they may affect bipolar disorder. An herb called St. John's wort (Hypericum perforatum), often marketed as a natural antidepressant, may cause a switch to mania in some people with bipolar disorder. St. John's wort can also make other medications less effective, including some antidepressant and anticonvulsant medications. Scientists are also researching omega-3 fatty acids (most commonly found in fish oil) to measure their usefulness for long-term treatment of bipolar disorder. Study results have been mixed.

Be sure to tell your doctor about all prescription drugs, over-the-counter medications, or supplements you are taking. Certain medications and supplements taken together may cause unwanted or dangerous effects.

What research is NIMH doing to improve treatments for bipolar disorder?

Scientists are working to identify new targets for improving current medications or developing new treatments for bipolar disorder. In addition, NIMH researchers have made promising advances toward finding fast-acting medication treatment. In a small study of people with bipolar disorder whose symptoms had not responded to prior treatments, a single dose of ketamine—an anesthetic medication—significantly reduced symptoms of depression in as little as 40 minutes. These effects lasted about a week on average.

Ketamine itself is unlikely to become widely available as a treatment because it can cause serious side effects at high doses, such as hallucinations. However, scientists are working to understand how the drug works on the brain in an effort to develop treatments with fewer side effects and that act similarly to ketamine. Such medications could also be used for longer term management of symptoms.

In addition, NIMH is working to better understand bipolar disorder and other mental disorders by spearheading the Research Domain Criteria (RDoC) Project, which is an ongoing effort to map our current understanding of the brain circuitry that is involved in behavioral and cognitive functioning. By essentially breaking down mental disorders into their component pieces—RDoC aims to add to the knowledge we have gained from more traditional research approaches that focus solely on understanding mental disorders based on symptoms. The hope is that by changing the way we approach mental disorders, RDoC will help us open the door to new targets of preventive and treatment interventions.

Living With

If you know someone who has bipolar disorder, it affects you too. The first and most important thing you can do is help him or her get the right diagnosis and treatment. You may need to make the appointment and go with him or her to see the doctor. Encourage your loved one to stay in treatment.

To help a friend or relative, you can:

Offer emotional support, understanding, patience, and encouragement
Learn about bipolar disorder so you can understand what your friend or relative is experiencing
Talk to your friend or relative and listen carefully
Listen to feelings your friend or relative expresses and be understanding about situations that may trigger bipolar symptoms
Invite your friend or relative out for positive distractions, such as walks, outings, and other activities
Remind your friend or relative that, with time and treatment, he or she can get better.

Never ignore comments from your friend or relative about harming himself or herself. Always report such comments to his or her therapist or doctor.

How can caregivers find support?

Like other serious illnesses, bipolar disorder can be difficult for spouses, family members, friends, and other caregivers. Relatives and friends often have to cope with the person's serious behavioral problems, such as wild spending sprees during mania, extreme withdrawal during depression, or poor work or school performance. These behaviors can have lasting consequences.

Caregivers usually take care of the medical needs of their loved ones. But caregivers have to deal with how this affects their own health as well. Caregivers' stress may lead to missed work or lost free time, strained relationships with people who may not understand the situation, and physical and mental exhaustion.

It can be very hard to cope with a loved one's bipolar symptoms. One study shows that if a caregiver is under a lot of stress, his or her loved one has more trouble following the treatment plan, which increases the chance for a major bipolar episode. If you are a caregiver of someone with bipolar disorder, it is important that you also make time to take care of yourself.

How can I help myself if I have bipolar disorder?

It may be very hard to take that first step to help yourself. It may take time, but you can get better with treatment. To help yourself:

Talk to your doctor about treatment options and progress.
Keep a regular routine, such as going to sleep at the same time every night and eating meals at the same time every day.
Try hard to get enough sleep.
Stay on your medication.
Learn about warning signs signaling a shift into depression or mania.
Expect your symptoms to improve gradually, not immediately.

Where can I go for help?

If you are unsure where to go for help, ask your family doctor. Others who can help are listed below.

Mental health specialists, such as psychiatrists, psychologists, social workers, or mental health counselors
Health maintenance organizations
Community mental health centers
Hospital psychiatry departments and outpatient clinics
Mental health programs at universities or medical schools
State hospital outpatient clinics
Family services, social agencies, or clergy
Peer support groups
Private clinics and facilities
Employee assistance programs
Local medical and/or psychiatric societies.

You can also check the phone book under "mental health," "health," "social services," "hotlines," or "physicians" for phone numbers and addresses. An emergency room doctor can also provide temporary help and can tell you where and how to get further help.

What if I or someone I know is in crisis?

If you are thinking about harming yourself, or know someone who is, tell someone who can help immediately.

Call your doctor.
Call 911 or go to a hospital emergency room to get immediate help or ask a friend or family member to help you do these things.
Call the toll-free, 24-hour National Suicide Prevention Lifeline at 1-800-273-TALK (1-800-273-8255); TTY: 1-800-799-4TTY (4889) to talk to a trained counselor.

Make sure you or the suicidal person is not left alone.

Schizophrenia

What Is Schizophrenia?
Causes
Who Is At Risk?
Signs & Symptoms
Treatments
Living With

What Is Schizophrenia?

Schizophrenia is a chronic, severe, and disabling brain disorder that has affected people throughout history.

People with the disorder may hear voices other people don't hear. They may believe other people are reading their minds, controlling their thoughts, or plotting to harm them. This can terrify people with the illness and make them withdrawn or extremely agitated.

People with schizophrenia may not make sense when they talk. They may sit for hours without moving or talking. Sometimes people with schizophrenia seem perfectly fine until they talk about what they are really thinking.

Families and society are affected by schizophrenia too. Many people with schizophrenia have difficulty holding a job or caring for themselves, so they rely on others for help.

Treatment helps relieve many symptoms of schizophrenia, but most people who have the disorder cope with symptoms throughout their lives. However, many people with schizophrenia can lead rewarding and meaningful lives in their communities. Researchers are developing more effective medications and using new research tools to understand the causes of schizophrenia. In the years to come, this work may help prevent and better treat the illness.

Causes

Experts think schizophrenia is caused by several factors.

Genes and environment. Scientists have long known that schizophrenia runs in families. The illness occurs in 1 percent of the general population, but it occurs in 10 percent of people who have a first-degree relative with the disorder, such as a parent, brother, or sister. People who have second-degree relatives (aunts, uncles, grandparents, or cousins) with the disease also develop schizophrenia more often than the general population. The risk is highest for an identical twin of a person with schizophrenia. He or she has a 40 to 65 percent chance of developing the disorder.

We inherit our genes from both parents. Scientists believe several genes are associated with an increased risk of schizophrenia, but that no gene causes the disease by itself. In fact, recent research has found that people with schizophrenia tend to have higher rates of rare genetic mutations. These genetic differences involve hundreds of different genes and probably disrupt brain development.

Other recent studies suggest that schizophrenia may result in part when a certain gene that is key to making important brain chemicals malfunctions. This problem may affect the part of the brain involved in developing higher functioning skills. Research into this gene is ongoing, so it is not yet possible to use the genetic information to predict who will develop the disease.

Despite this, tests that scan a person's genes can be bought without a prescription or a health professional's advice. Ads for the tests suggest that with a saliva sample, a company can determine if a client is at risk for developing specific diseases, including schizophrenia. However, scientists don't yet know all of the gene variations that contribute to schizophrenia. Those that are known raise the risk only by very small amounts. Therefore, these "genome scans" are unlikely to provide a complete picture of a person's risk for developing a mental disorder like schizophrenia.

In addition, it probably takes more than genes to cause the disorder. Scientists think interactions between genes and the environment are necessary for schizophrenia to develop. Many environmental factors may be involved, such as exposure to viruses or malnutrition before birth, problems during birth, and other not yet known psychosocial factors.

Different brain chemistry and structure. Scientists think that an imbalance in the complex, interrelated chemical reactions of the brain involving the neurotransmitters dopamine and glutamate, and possibly others, plays a role in schizophrenia. Neurotransmitters are substances that allow brain cells to communicate with each other. Scientists are learning more about brain chemistry and its link to schizophrenia.

Also, in small ways the brains of people with schizophrenia look different than those of healthy people. For example, fluid-filled cavities at the center of the brain, called ventricles, are larger in some people with schizophrenia. The brains of people with the illness also tend to have less gray matter, and some areas of the brain may have less or more activity.

Studies of brain tissue after death also have revealed differences in the brains of people with schizophrenia. Scientists found small changes in the distribution or characteristics of brain cells that likely occurred before birth. Some experts think problems during brain development before birth may lead to faulty connections. The problem may not show up in a person until puberty. The brain undergoes major changes during puberty, and these changes could trigger psychotic symptoms. Scientists have learned a lot about schizophrenia, but more research is needed to help explain how it develops.

Who Is At Risk?

About 1% of Americans have this illness.

Schizophrenia affects men and women equally. It occurs at similar rates in all ethnic groups around the world. Symptoms such as hallucinations and delusions usually start between ages 16 and 30. Men tend to experience symptoms a little earlier than women. Most of the time, people do not get schizophrenia after age 45. Schizophrenia rarely occurs in children, but awareness of childhood-onset schizophrenia is increasing.

It can be difficult to diagnose schizophrenia in teens. This is because the first signs can include a change of friends, a drop in grades, sleep problems, and irritability—behaviors that are common among teens. A combination of factors can predict schizophrenia in up to 80% of youth who are at high risk of developing the illness. These factors include isolating oneself and withdrawing from others, an increase in unusual thoughts and suspicions, and a family history of psychosis. In young people who develop the disease, this stage of the disorder is called the "prodromal" period.

Signs & Symptoms

The symptoms of schizophrenia fall into three broad categories: positive symptoms, negative symptoms, and cognitive symptoms.

Positive symptoms

Positive symptoms are psychotic behaviors not seen in healthy people. People with positive symptoms often "lose touch" with reality. These symptoms can come and go. Sometimes they are severe and at other times hardly noticeable, depending on whether the individual is receiving treatment. They include the following:

Hallucinations are things a person sees, hears, smells, or feels that no one else can see, hear, smell, or feel. "Voices" are the most common type of hallucination in schizophrenia. Many people with the disorder hear voices. The voices may talk to the person about his or her behavior, order the person to do things, or warn the person of danger. Sometimes the voices talk to each other. People with schizophrenia may hear voices for a long time before family and friends notice the problem.

Other types of hallucinations include seeing people or objects that are not there, smelling odors that no one else detects, and feeling things like invisible fingers touching their bodies when no one is near.

Delusions are false beliefs that are not part of the person's culture and do not change. The person believes delusions even after other people prove that the beliefs are not true or logical. People with schizophrenia can have delusions that seem bizarre, such as believing that neighbors can control their behavior with magnetic waves. They may also believe that people on television are directing special messages to them, or that radio stations are broadcasting their thoughts aloud to others. Sometimes they believe they are someone else, such as a famous historical figure. They may have paranoid delusions and believe that others are trying to harm them, such as by cheating, harassing, poisoning, spying on, or plotting against them or the people they care about. These beliefs are called "delusions of persecution."

Thought disorders are unusual or dysfunctional ways of thinking. One form of thought disorder is called "disorganized thinking." This is when a person has trouble organizing his or her thoughts or connecting them logically. They may talk in a garbled way that is hard to understand. Another form is called "thought blocking." This is when a person stops speaking abruptly in the middle of a thought. When asked why he or she stopped talking, the person may say that it felt as if the thought had been taken out of his or her head. Finally, a person with a thought disorder might make up meaningless words, or "neologisms."

Movement disorders may appear as agitated body movements. A person with a movement disorder may repeat certain motions over and over. In the other extreme, a person may become catatonic. Catatonia is a state in which a person does not move and does not respond to others. Catatonia is rare today, but it was more common when treatment for schizophrenia was not available.

Negative symptoms

Negative symptoms are associated with disruptions to normal emotions and behaviors. These symptoms are harder to recognize as part of the disorder and can be mistaken for depression or other conditions. These symptoms include the following:

"Flat affect" (a person's face does not move or he or she talks in a dull or monotonous voice)
Lack of pleasure in everyday life
Lack of ability to begin and sustain planned activities
Speaking little, even when forced to interact.

People with negative symptoms need help with everyday tasks. They often neglect basic personal hygiene. This may make them seem lazy or unwilling to help themselves, but the problems are symptoms caused by the schizophrenia.

Cognitive symptoms

Cognitive symptoms are subtle. Like negative symptoms, cognitive symptoms may be difficult to recognize as part of the disorder. Often, they are detected only when other tests are performed. Cognitive symptoms include the following:

Poor "executive functioning" (the ability to understand information and use it to make decisions)
Trouble focusing or paying attention
Problems with "working memory" (the ability to use information immediately after learning it)

Cognitive symptoms often make it hard to lead a normal life and earn a living. They can cause great emotional distress.

Treatments

Because the causes of schizophrenia are still unknown, treatments focus on eliminating the symptoms of the disease. Treatments include antipsychotic medications and various psychosocial treatments.

Antipsychotic medications

Antipsychotic medications have been available since the mid-1950's. The older types are called conventional or "typical" antipsychotics. Some of the more commonly used typical medications include:

Chlorpromazine (Thorazine)
Haloperidol (Haldol)
Perphenazine (Etrafon, Trilafon)
Fluphenazine (Prolixin).

In the 1990's, new antipsychotic medications were developed. These new medications are called second generation, or "atypical" antipsychotics.

One of these medications, clozapine (Clozaril) is an effective medication that treats psychotic symptoms, hallucinations, and breaks with reality. But clozapine can sometimes cause a serious problem called agranulocytosis, which is a loss of the white blood cells that help a person fight infection. People who take clozapine must get their white blood cell counts checked every week or two. This problem and the cost of blood tests make treatment with clozapine difficult for many people. But clozapine is potentially helpful for people who do not respond to other antipsychotic medications.

Other atypical antipsychotics were also developed. None cause agranulocytosis. Examples include:

Risperidone (Risperdal)
Olanzapine (Zyprexa)
Quetiapine (Seroquel)
Ziprasidone (Geodon)
Aripiprazole (Abilify)
Paliperidone (Invega).

What are the side effects?

Some people have side effects when they start taking these medications. Most side effects go away after a few days and often can be managed successfully. People who are taking antipsychotics should not drive until they adjust to their new medication. Side effects of many antipsychotics include:

Drowsiness
Dizziness when changing positions
Blurred vision
Rapid heartbeat
Sensitivity to the sun
Skin rashes
Menstrual problems for women.

Atypical antipsychotic medications can cause major weight gain and changes in a person's metabolism. This may increase a person's risk of getting diabetes and high cholesterol. A person's weight, glucose levels, and lipid levels should be monitored regularly by a doctor while taking an atypical antipsychotic medication.

Typical antipsychotic medications can cause side effects related to physical movement, such as:

Rigidity
Persistent muscle spasms
Tremors
Restlessness.

Long-term use of typical antipsychotic medications may lead to a condition called tardive dyskinesia (TD). TD causes muscle movements a person can't control. The movements commonly happen around the mouth. TD can range from mild to severe, and in some people the problem cannot be cured. Sometimes people with TD recover partially or fully after they stop taking the medication.

TD happens to fewer people who take the atypical antipsychotics, but some people may still get TD. People who think that they might have TD should check with their doctor before stopping their medication.

How are antipsychotics taken and how do people respond to them?

Antipsychotics are usually in pill or liquid form. Some anti-psychotics are shots that are given once or twice a month.

Symptoms of schizophrenia, such as feeling agitated and having hallucinations, usually go away within days. Symptoms like delusions usually go away within a few weeks. After about six weeks, many people will see a lot of improvement.

However, people respond in different ways to antipsychotic medications, and no one can tell beforehand how a person will respond. Sometimes a person needs to try several medications before finding the right one. Doctors and patients can work together to find the best medication or medication combination, as well as the right dose.

Some people may have a relapse-their symptoms come back or get worse. Usually, relapses happen when people stop taking their medication, or when they only take it sometimes. Some people stop taking the medication because they feel better or they may feel they don't need it anymore. But no one should stop taking an antipsychotic medication without talking to his or her doctor. When a doctor says it is okay to stop taking a medication, it should be gradually tapered off, never stopped suddenly.

How do antipsychotics interact with other medications?

Antipsychotics can produce unpleasant or dangerous side effects when taken with certain medications. For this reason, all doctors treating a patient need to be aware of all the medications that person is taking. Doctors need to know about prescription and over-the-counter medicine, vitamins, minerals, and herbal supplements. People also need to discuss any alcohol or other drug use with their doctor.

To find out more about how antipsychotics work, the National Institute of Mental Health (NIMH) funded a study called CATIE (Clinical Antipsychotic Trials of Intervention Effectiveness). This study compared the effectiveness and side effects of five antipsychotics used to treat people with schizophrenia. In general, the study found that the older typical antipsychotic perphenazine (Trilafon) worked as well as the newer, atypical medications. But because people respond differently to different medications, it is important that treatments be designed carefully for each person. More information about CATIE is on the NIMH website.

Psychosocial treatments

Psychosocial treatments can help people with schizophrenia who are already stabilized on antipsychotic medication. Psychosocial treatments help these patients deal with the everyday challenges of the illness, such as difficulty with communication, self-care, work, and forming and keeping relationships. Learning and using coping mechanisms to address these problems allow people with schizophrenia to socialize and attend school and work.

Patients who receive regular psychosocial treatment also are more likely to keep taking their medication, and they are less likely to have relapses or be hospitalized. A therapist can help patients better understand and adjust to living with schizophrenia. The therapist can provide education about the disorder, common symptoms or problems patients may experience, and the importance of staying on medications. For more information on psychosocial treatments, see the psychotherapies section on the NIMH website.

Illness management skills. People with schizophrenia can take an active role in managing their own illness. Once patients learn basic facts about schizophrenia and its treatment, they can make informed decisions about their care. If they know how to watch for the early warning signs of relapse and make a plan to respond, patients can learn to prevent relapses. Patients can also use coping skills to deal with persistent symptoms.

Integrated treatment for co-occurring substance abuse. Substance abuse is the most common co-occurring disorder in people with schizophrenia. But ordinary substance abuse treatment programs usually do not address this population's special needs. When schizophrenia treatment programs and drug treatment programs are used together, patients get better results.

Rehabilitation. Rehabilitation emphasizes social and vocational training to help people with schizophrenia function better in their communities. Because schizophrenia usually develops in people during the critical career-forming years of life (ages 18 to 35), and because the disease makes normal thinking and functioning difficult, most patients do not receive training in the skills needed for a job.

Rehabilitation programs can include job counseling and training, money management counseling, help in learning to use public transportation, and opportunities to practice communication skills. Rehabilitation programs work well when they include both job training and specific therapy designed to improve cognitive or thinking skills. Programs like this help patients hold jobs, remember important details, and improve their functioning.

Family education. People with schizophrenia are often discharged from the hospital into the care of their families. So it is important that family members know as much as possible about the disease. With the help of a therapist, family members can learn coping strategies and problem-solving skills. In this way the family can help make sure their loved one sticks with treatment and stays on his or her medication. Families should learn where to find outpatient and family services.

Cognitive behavioral therapy. Cognitive behavioral therapy (CBT) is a type of psychotherapy that focuses on thinking and behavior. CBT helps patients with symptoms that do not go away even when they take medication. The therapist teaches people with schizophrenia how to test the reality of their thoughts and perceptions, how to "not listen" to their voices, and how to manage their symptoms overall. CBT can help reduce the severity of symptoms and reduce the risk of relapse.

Self-help groups. Self-help groups for people with schizophrenia and their families are becoming more common. Professional therapists usually are not involved, but group members support and comfort each other. People in self-help groups know that others are facing the same problems, which can help everyone feel less isolated. The networking that takes place in self-help groups can also prompt families to work together to advocate for research and more hospital and community treatment programs. Also, groups may be able to draw public attention to the discrimination many people with mental illnesses face.

Living With

How can you help a person with schizophrenia?

People with schizophrenia can get help from professional case managers and caregivers at residential or day programs. However, family members usually are a patient's primary caregivers.

People with schizophrenia often resist treatment. They may not think they need help because they believe their delusions or hallucinations are real. In these cases, family and friends may need to take action to keep their loved one safe. Laws vary from state to state, and it can be difficult to force a person with a mental disorder into treatment or hospitalization. But when a person becomes dangerous to himself or herself, or to others, family members or friends may have to call the police to take their loved one to the hospital.

Treatment at the hospital. In the emergency room, a mental health professional will assess the patient and determine whether a voluntary or involuntary admission is needed. For a person to be admitted involuntarily, the law states that the professional must witness psychotic behavior and hear the person voice delusional thoughts. Family and friends can provide needed information to help a mental health professional make a decision.

After a loved one leaves the hospital. Family and friends can help their loved ones get treatment and take their medication once they go home. If patients stop taking their medication or stop going to follow-up appointments, their symptoms likely will return. Sometimes symptoms become severe for people who stop their medication and treatment. This is dangerous, since they may become unable to care for themselves. Some people end up on the street or in jail, where they rarely receive the kind of help they need.

Family and friends can also help patients set realistic goals and learn to function in the world. Each step toward these goals should be small and taken one at a time. The patient will need support during this time. When people with a mental illness are pressured and criticized, they usually do not get well. Often, their symptoms may get worse. Telling them when they are doing something right is the best way to help them move forward.

It can be difficult to know how to respond to someone with schizophrenia who makes strange or clearly false statements. Remember that these beliefs or hallucinations seem very real to the person. It is not helpful to say they are wrong or imaginary. But going along with the delusions is not helpful, either. Instead, calmly say that you see things differently. Tell them that you acknowledge that everyone has the right to see things his or her own way. In addition, it is important to understand that schizophrenia is a biological illness. Being respectful, supportive, and kind without tolerating dangerous or inappropriate behavior is the best way to approach people with this disorder.

Are people with schizophrenia violent?

People with schizophrenia are not usually violent. In fact, most violent crimes are not committed by people with schizophrenia. However, some symptoms are associated with violence, such as delusions of persecution. Substance abuse may also increase the chance a person will become violent. If a person with schizophrenia becomes violent, the violence is usually directed at family members and tends to take place at home.

The risk of violence among people with schizophrenia is small. But people with the illness attempt suicide much more often than others. About 10 percent (especially young adult males) die by suicide. It is hard to predict which people with schizophrenia are prone to suicide. If you know someone who talks about or attempts suicide, help him or her find professional help right away.

What about substance abuse?

Some people who abuse drugs show symptoms similar to those of schizophrenia. Therefore, people with schizophrenia may be mistaken for people who are affected by drugs. Most researchers do not believe that substance abuse causes schizophrenia. However, people who have schizophrenia are much more likely to have a substance or alcohol abuse problem than the general population.

Substance abuse can make treatment for schizophrenia less effective. Some drugs, like marijuana and stimulants such as amphetamines or cocaine, may make symptoms worse. In fact, research has found increasing evidence of a link between marijuana and schizophrenia symptoms. In addition, people who abuse drugs are less likely to follow their treatment plan.

Schizophrenia and smoking

Addiction to nicotine is the most common form of substance abuse in people with schizophrenia. They are addicted to nicotine at three times the rate of the general population (75 to 90 percent vs. 25 to 30 percent).

The relationship between smoking and schizophrenia is complex. People with schizophrenia seem to be driven to smoke, and researchers are exploring whether there is a biological basis for this need. In addition to its known health hazards, several studies have found that smoking may make antipsychotic drugs less effective.

Quitting smoking may be very difficult for people with schizophrenia because nicotine withdrawal may cause their psychotic symptoms to get worse for a while. Quitting strategies that include nicotine replacement methods may be easier for patients to handle. Doctors who treat people with schizophrenia should watch their patients' response to antipsychotic medication carefully if the patient decides to start or stop smoking.

Source: National Institute of Mental Health, NIH

Borderline Personality Disorder

What is Borderline Personality Disorder?
Causes
Signs & Symptoms
Who Is At Risk?
Diagnosis
Treatments
Living With
Clinical Trials

What is Borderline Personality Disorder?

Borderline personality disorder (BPD) is a serious mental illness marked by unstable moods, behavior, and relationships. In 1980, the Diagnostic and Statistical Manual for Mental Disorders, Third Edition (DSM-III) listed BPD as a diagnosable illness for the first time. Most psychiatrists and other mental health professionals use the DSM to diagnose mental illnesses.

Because some people with severe BPD have brief psychotic episodes, experts originally thought of this illness as atypical, or borderline, versions of other mental disorders. While mental health experts now generally agree that the name "borderline personality disorder" is misleading, a more accurate term does not exist yet.

Most people who have BPD suffer from:

Problems with regulating emotions and thoughts
Impulsive and reckless behavior
Unstable relationships with other people.

People with this disorder also have high rates of co-occurring disorders, such as depression, anxiety disorders, substance abuse, and eating disorders, along with self-harm, suicidal behaviors, and completed suicides.

Causes

Research on the possible causes and risk factors for BPD is still at a very early stage. However, scientists generally agree that genetic and environmental factors are likely to be involved.

Studies on twins with BPD suggest that the illness is strongly inherited. Another study shows that a person can inherit his or her temperament and specific personality traits, particularly impulsiveness and aggression. Scientists are studying genes that help regulate emotions and impulse control for possible links to the disorder.

Social or cultural factors may increase the risk for BPD. For example, being part of a community or culture in which unstable family relationships are common may increase a person's risk for the disorder. Impulsiveness, poor judgment in lifestyle choices, and other consequences of BPD may lead individuals to risky situations. Adults with borderline personality disorder are considerably more likely to be the victim of violence, including rape and other crimes.

Signs & Symptoms

According to the DSM, Fourth Edition, Text Revision (DSM-IV-TR), to be diagnosed with borderline personality disorder, a person must show an enduring pattern of behavior that includes at least five of the following symptoms:

Extreme reactions—including panic, depression, rage, or frantic actions—to abandonment, whether real or perceived
A pattern of intense and stormy relationships with family, friends, and loved ones, often veering from extreme closeness and love (idealization) to extreme dislike or anger (devaluation)
Distorted and unstable self-image or sense of self, which can result in sudden changes in feelings, opinions, values, or plans and goals for the future (such as school or career choices)
Impulsive and often dangerous behaviors, such as spending sprees, unsafe sex, substance abuse, reckless driving, and binge eating
Recurring suicidal behaviors or threats or self-harming behavior, such as cutting
Intense and highly changeable moods, with each episode lasting from a few hours to a few days
Chronic feelings of emptiness and/or boredom
Inappropriate, intense anger or problems controlling anger
Having stress-related paranoid thoughts or severe dissociative symptoms, such as feeling cut off from oneself, observing oneself from outside the body, or losing touch with reality.

Seemingly mundane events may trigger symptoms. For example, people with BPD may feel angry and distressed over minor separations—such as vacations, business trips, or sudden changes of plans—from people to whom they feel close. Studies show that people with this disorder may see anger in an emotionally neutral face and have a stronger reaction to words with negative meanings than people who do not have the disorder.

Suicide and Self-harm

Self-injurious behavior includes suicide and suicide attempts, as well as self-harming behaviors, described below. As many as 80 percent of people with BPD have suicidal behaviors, and about 4 to 9 percent commit suicide.

Suicide is one of the most tragic outcomes of any mental illness. Some treatments can help reduce suicidal behaviors in people with BPD. For example, one study showed that dialectical behavior therapy (DBT) reduced suicide attempts in women by half compared with other types of psychotherapy, or talk therapy. DBT also reduced use of emergency room and inpatient services and retained more participants in therapy, compared to other approaches to treatment.

Unlike suicide attempts, self-harming behaviors do not stem from a desire to die. However, some self-harming behaviors may be life threatening. Self-harming behaviors linked with BPD include cutting, burning, hitting, head banging, hair pulling, and other harmful acts. People with BPD may self-harm to help regulate their emotions, to punish themselves, or to express their pain. They do not always see these behaviors as harmful.

Who Is At Risk?

According to data from a subsample of participants in a national survey on mental disorders, about 1.6 percent of adults in the United States have BPD in a given year. BPD usually begins during adolescence or early adulthood. Some studies suggest that early symptoms of the illness may occur during childhood.

Diagnosis

Unfortunately, BPD is often underdiagnosed or misdiagnosed.

A mental health professional experienced in diagnosing and treating mental disorders—such as a psychiatrist, psychologist, clinical social worker, or psychiatric nurse—can detect BPD based on a thorough interview and a discussion about symptoms. A careful and thorough medical exam can help rule out other possible causes of symptoms.

The mental health professional may ask about symptoms and personal and family medical histories, including any history of mental illnesses. This information can help the mental health professional decide on the best treatment. In some cases, co-occurring mental illnesses may have symptoms that overlap with BPD, making it difficult to distinguish borderline personality disorder from other mental illnesses. For example, a person may describe feelings of depression but may not bring other symptoms to the mental health professional's attention.

Women with BPD are more likely to have co-occurring disorders such as major depression, anxiety disorders, or eating disorders. In men, BPD is more likely to co-occur with disorders such as substance abuse or antisocial personality disorder. According to the NIMH-funded National Comorbidity Survey Replication—the largest national study to date of mental disorders in U.S. adults—about 85 percent of people with BPD also meet the diagnostic criteria for another mental illness. Other illnesses that often occur with BPD include diabetes, high blood pressure, chronic back pain, arthritis, and fibromyalgia. These conditions are associated with obesity, which is a common side effect of the medications prescribed to treat BPD and other mental disorders.

No single test can diagnose BPD. Scientists funded by NIMH are looking for ways to improve diagnosis of this disorder. One study found that adults with BPD showed excessive emotional reactions when looking at words with unpleasant meanings, compared with healthy people. People with more severe BPD showed a more intense emotional response than people who had less severe BPD.

Treatments

BPD is often viewed as difficult to treat. However, recent research shows that BPD can be treated effectively, and that many people with this illness improve over time.

BPD can be treated with psychotherapy, or "talk" therapy. In some cases, a mental health professional may also recommend medications to treat specific symptoms. When a person is under more than one professional's care, it is essential for the professionals to coordinate with one another on the treatment plan.

The treatments described below are just some of the options that may be available to a person with BPD. However, the research on treatments is still in very early stages. More studies are needed to determine the effectiveness of these treatments, who may benefit the most, and how best to deliver treatments.

Psychotherapy

Psychotherapy is usually the first treatment for people with BPD. Current research suggests psychotherapy can relieve some symptoms, but further studies are needed to better understand how well psychotherapy works.

It is important that people in therapy get along with and trust their therapist. The very nature of BPD can make it difficult for people with this disorder to maintain this type of bond with their therapist.

Types of psychotherapy used to treat BPD include the following: Cognitive behavioral therapy (CBT). CBT can help people with BPD identify and change core beliefs and/or behaviors that underlie inaccurate perceptions of themselves and others and problems interacting with others. CBT may help reduce a range of mood and anxiety symptoms and reduce the number of suicidal or self-harming behaviors.

Dialectical behavior therapy (DBT). This type of therapy focuses on the concept of mindfulness, or being aware of and attentive to the current situation. DBT teaches skills to control intense emotions, reduces self-destructive behaviors, and improves relationships. This therapy differs from CBT in that it seeks a balance between changing and accepting beliefs and behaviors.
Schema-focused therapy. This type of therapy combines elements of CBT with other forms of psychotherapy that focus on reframing schemas, or the ways people view themselves. This approach is based on the idea that BPD stems from a dysfunctional self-image—possibly brought on by negative childhood experiences—that affects how people react to their environment, interact with others, and cope with problems or stress.

Therapy can be provided one-on-one between the therapist and the patient or in a group setting. Therapist-led group sessions may help teach people with BPD how to interact with others and how to express themselves effectively.

One type of group therapy, Systems Training for Emotional Predictability and Problem Solving (STEPPS), is designed as a relatively brief treatment consisting of 20 two-hour sessions led by an experienced social worker. Scientists funded by NIMH reported that STEPPS, when used with other types of treatment (medications or individual psychotherapy), can help reduce symptoms and problem behaviors of BPD, relieve symptoms of depression, and improve quality of life. The effectiveness of this type of therapy has not been extensively studied.

Families of people with BPD may also benefit from therapy. The challenges of dealing with an ill relative on a daily basis can be very stressful, and family members may unknowingly act in ways that worsen their relative's symptoms.

Some therapies, such as DBT-family skills training (DBT-FST), include family members in treatment sessions. These types of programs help families develop skills to better understand and support a relative with BPD. Other therapies, such as Family Connections, focus on the needs of family members. More research is needed to determine the effectiveness of family therapy in BPD. Studies with other mental disorders suggest that including family members can help in a person's treatment.

Other types of therapy not listed in this booklet may be helpful for some people with BPD. Therapists often adapt psychotherapy to better meet a person's needs. Therapists may switch from one type of therapy to another, mix techniques from different therapies, or use a combination therapy. For more information see the NIMH website section on psychotherapy.

Some symptoms of BPD may come and go, but the core symptoms of highly changeable moods, intense anger, and impulsiveness tend to be more persistent. People whose symptoms improve may continue to face issues related to co-occurring disorders, such as depression or post-traumatic stress disorder. However, encouraging research suggests that relapse, or the recurrence of full-blown symptoms after remission, is rare. In one study, 6 percent of people with BPD had a relapse after remission.

Medications

No medications have been approved by the U.S. Food and Drug Administration to treat BPD. Only a few studies show that medications are necessary or effective for people with this illness. However, many people with BPD are treated with medications in addition to psychotherapy. While medications do not cure BPD, some medications may be helpful in managing specific symptoms. For some people, medications can help reduce symptoms such as anxiety, depression, or aggression. Often, people are treated with several medications at the same time, but there is little evidence that this practice is necessary or effective.

Medications can cause different side effects in different people. People who have BPD should talk with their prescribing doctor about what to expect from a particular medication.

Other Treatments

Omega-3 fatty acids. One study done on 30 women with BPD showed that omega-3 fatty acids may help reduce symptoms of aggression and depression. The treatment seemed to be as well tolerated as commonly prescribed mood stabilizers and had few side effects. Fewer women who took omega-3 fatty acids dropped out of the study, compared to women who took a placebo (sugar pill).

With proper treatment, many people experience fewer or less severe symptoms. However, many factors affect the amount of time it takes for symptoms to improve, so it is important for people with BPD to be patient and to receive appropriate support during treatment.

Living With

Some people with BPD experience severe symptoms and require intensive, often inpatient, care. Others may use some outpatient treatments but never need hospitalization or emergency care. Some people who develop this disorder may improve without any treatment.

How can I help a friend or relative who has BPD?

If you know someone who has BPD, it affects you too. The first and most important thing you can do is help your friend or relative get the right diagnosis and treatment. You may need to make an appointment and go with your friend or relative to see the doctor. Encourage him or her to stay in treatment or to seek different treatment if symptoms do not appear to improve with the current treatment.

To help a friend or relative you can:

Offer emotional support, understanding, patience, and encouragement—change can be difficult and frightening to people with BPD, but it is possible for them to get better over time

Learn about mental disorders, including BPD, so you can understand what your friend or relative is experiencing
With permission from your friend or relative, talk with his or her therapist to learn about therapies that may involve family members, such as DBT-FST.

Never ignore comments about someone's intent or plan to harm himself or herself or someone else. Report such comments to the person's therapist or doctor. In urgent or potentially life-threatening situations, you may need to call the police.

How can I help myself if I have BPD?

Taking that first step to help yourself may be hard. It is important to realize that, although it may take some time, you can get better with treatment.

To help yourself:

Talk to your doctor about treatment options and stick with treatment
Try to maintain a stable schedule of meals and sleep times
Engage in mild activity or exercise to help reduce stress
Set realistic goals for yourself
Break up large tasks into small ones, set some priorities, and do what you can, as you can
Try to spend time with other people and confide in a trusted friend or family member
Tell others about events or situations that may trigger symptoms
Expect your symptoms to improve gradually, not immediately
Identify and seek out comforting situations, places, and people
Continue to educate yourself about this disorder.

Source: National Institute of Mental Health, NIH, HHS

Post-Traumatic Stress Disorder (PTSD)

What is Post-traumatic Stress Disorder (PTSD)?
Causes
Signs & Symptoms
Who Is At Risk?
Diagnosis
Treatments
Living With
Clinical Trials

What is Post-traumatic Stress Disorder (PTSD)?

When in danger, it’s natural to feel afraid. This fear triggers many split-second changes in the body to prepare to defend against the danger or to avoid it. This “fight-or-flight” response is a healthy reaction meant to protect a person from harm. But in post-traumatic stress disorder (PTSD), this reaction is changed or damaged. People who have PTSD may feel stressed or frightened even when they’re no longer in danger.

PTSD develops after a terrifying ordeal that involved physical harm or the threat of physical harm. The person who develops PTSD may have been the one who was harmed, the harm may have happened to a loved one, or the person may have witnessed a harmful event that happened to loved ones or strangers.

PTSD was first brought to public attention in relation to war veterans, but it can result from a variety of traumatic incidents, such as mugging, rape, torture, being kidnapped or held captive, child abuse, car accidents, train wrecks, plane crashes, bombings, or natural disasters such as floods or earthquakes.

Causes

Genes. Currently, many scientists are focusing on genes that play a role in creating fear memories. Understanding how fear memories are created may help to refine or find new interventions for reducing the symptoms of PTSD. For example, PTSD researchers have pinpointed genes that make:

Stathmin, a protein needed to form fear memories. In one study, mice that did not make stathmin were less likely than normal mice to “freeze,” a natural, protective response to danger, after being exposed to a fearful experience. They also showed less innate fear by exploring open spaces more willingly than normal mice.

GRP (gastrin-releasing peptide), a signaling chemical in the brain released during emotional events. In mice, GRP seems to help control the fear response, and lack of GRP may lead to the creation of greater and more lasting memories of fear.

Researchers have also found a version of the 5-HTTLPR gene, which controls levels of serotonin — a brain chemical related to mood-that appears to fuel the fear response. Like other mental disorders, it is likely that many genes with small effects are at work in PTSD.

Brain Areas. Studying parts of the brain involved in dealing with fear and stress also helps researchers to better understand possible causes of PTSD. One such brain structure is the amygdala, known for its role in emotion, learning, and memory. The amygdala appears to be active in fear acquisition, or learning to fear an event (such as touching a hot stove), as well as in the early stages of fear extinction, or learning not to fear.

Storing extinction memories and dampening the original fear response appears to involve the prefrontal cortex (PFC) area of the brain, involved in tasks such as decision-making, problem-solving, and judgment. Certain areas of the PFC play slightly different roles. For example, when it deems a source of stress controllable, the medial PFC suppresses the amygdala an alarm center deep in the brainstem and controls the stress response.5The ventromedial PFC helps sustain long-term extinction of fearful memories, and the size of this brain area may affect its ability to do so.

Individual differences in these genes or brain areas may only set the stage for PTSD without actually causing symptoms. Environmental factors, such as childhood trauma, head injury, or a history of mental illness, may further increase a person's risk by affecting the early growth of the brain. Also, personality and cognitive factors, such as optimism and the tendency to view challenges in a positive or negative way, as well as social factors, such as the availability and use of social support, appear to influence how people adjust to trauma. More research may show what combinations of these or perhaps other factors could be used someday to predict who will develop PTSD following a traumatic event.

The Next Steps for PTSD Research

In the last decade, rapid progress in research on the mental and biological foundations of PTSD has lead scientists to focus on prevention as a realistic and important goal.

For example, NIMH-funded researchers are exploring new and orphan medications thought to target underlying causes of PTSD in an effort to prevent the disorder. Other research is attempting to enhance cognitive, personality, and social protective factors and to minimize risk factors to ward off full-blown PTSD after trauma. Still other research is attempting to identify what factors determine whether someone with PTSD will respond well to one type of intervention or another, aiming to develop more personalized, effective and efficient treatments.

As gene research and brain imaging technologies continue to improve, scientists are more likely to be able to pinpoint when and where in the brain PTSD begins. This understanding may then lead to better targeted treatments to suit each person's own needs or even prevent the disorder before it causes harm.

Signs & Symptoms

PTSD can cause many symptoms. These symptoms can be grouped into three categories:

1. Re-experiencing symptoms

Flashbacks—reliving the trauma over and over, including physical symptoms like a racing heart or sweating
Bad dreams
Frightening thoughts.

Re-experiencing symptoms may cause problems in a person’s everyday routine. They can start from the person’s own thoughts and feelings. Words, objects, or situations that are reminders of the event can also trigger re-experiencing.

2. Avoidance symptoms

Staying away from places, events, or objects that are reminders of the experience
Feeling emotionally numb
Feeling strong guilt, depression, or worry
Losing interest in activities that were enjoyable in the past
Having trouble remembering the dangerous event.

Things that remind a person of the traumatic event can trigger avoidance symptoms. These symptoms may cause a person to change his or her personal routine. For example, after a bad car accident, a person who usually drives may avoid driving or riding in a car.

3. Hyperarousal symptoms

Being easily startled
Feeling tense or “on edge”
Having difficulty sleeping, and/or having angry outbursts.

Hyperarousal symptoms are usually constant, instead of being triggered by things that remind one of the traumatic event. They can make the person feel stressed and angry. These symptoms may make it hard to do daily tasks, such as sleeping, eating, or concentrating.

It’s natural to have some of these symptoms after a dangerous event. Sometimes people have very serious symptoms that go away after a few weeks. This is called acute stress disorder, or ASD. When the symptoms last more than a few weeks and become an ongoing problem, they might be PTSD. Some people with PTSD don’t show any symptoms for weeks or months.

Do children react differently than adults?

Children and teens can have extreme reactions to trauma, but their symptoms may not be the same as adults. In very young children, these symptoms can include:

Bedwetting, when they’d learned how to use the toilet before
Forgetting how or being unable to talk
Acting out the scary event during playtime
Being unusually clingy with a parent or other adult.

Older children and teens usually show symptoms more like those seen in adults. They may also develop disruptive, disrespectful, or destructive behaviors. Older children and teens may feel guilty for not preventing injury or deaths. They may also have thoughts of revenge. For more information, see the NIMH booklets on helping children cope with violence and disasters. (from Post-Traumatic Stress Disorder (PTSD) )

Who Is At Risk?

PTSD can occur at any age, including childhood. Women are more likely to develop PTSD than men, and there is some evidence that susceptibility to the disorder may run in families.

Anyone can get PTSD at any age. This includes war veterans and survivors of physical and sexual assault, abuse, accidents, disasters, and many other serious events.

Not everyone with PTSD has been through a dangerous event. Some people get PTSD after a friend or family member experiences danger or is harmed. The sudden, unexpected death of a loved one can also cause PTSD.

Why do some people get PTSD and other people do not?

It is important to remember that not everyone who lives through a dangerous event gets PTSD. In fact, most will not get the disorder.

Many factors play a part in whether a person will get PTSD. Some of these are risk factors that make a person more likely to get PTSD. Other factors, called resilience factors, can help reduce the risk of the disorder. Some of these risk and resilience factors are present before the trauma and others become important during and after a traumatic event.

Risk factors for PTSD include:

Living through dangerous events and traumas
Having a history of mental illness
Getting hurt
Seeing people hurt or killed
Feeling horror, helplessness, or extreme fear
Having little or no social support after the event
Dealing with extra stress after the event, such as loss of a loved one, pain and injury, or loss of a job or home.

Resilience factors that may reduce the risk of PTSD include:

Seeking out support from other people, such as friends and family
Finding a support group after a traumatic event
Feeling good about one’s own actions in the face of danger
Having a coping strategy, or a way of getting through the bad event and learning from it
Being able to act and respond effectively despite feeling fear.

Researchers are studying the importance of various risk and resilience factors. With more study, it may be possible someday to predict who is likely to get PTSD and prevent it.

Diagnosis

Not every traumatized person develops full-blown or even minor PTSD. Symptoms usually begin within 3 months of the incident but occasionally emerge years afterward. They must last more than a month to be considered PTSD. The course of the illness varies. Some people recover within 6 months, while others have symptoms that last much longer. In some people, the condition becomes chronic.

A doctor who has experience helping people with mental illnesses, such as a psychiatrist or psychologist, can diagnose PTSD. The diagnosis is made after the doctor talks with the person who has symptoms of PTSD.

To be diagnosed with PTSD, a person must have all of the following for at least 1 month:

At least one re-experiencing symptom
At least three avoidance symptoms
At least two hyperarousal symptoms

Symptoms that make it hard to go about daily life, go to school or work, be with friends, and take care of important tasks.

PTSD is often accompanied by depression, substance abuse, or one or more of the other anxiety disorders.

Treatments

The main treatments for people with PTSD are psychotherapy (“talk” therapy), medications, or both. Everyone is different, so a treatment that works for one person may not work for another. It is important for anyone with PTSD to be treated by a mental health care provider who is experienced with PTSD. Some people with PTSD need to try different treatments to find what works for their symptoms.

If someone with PTSD is going through an ongoing trauma, such as being in an abusive relationship, both of the problems need to be treated. Other ongoing problems can include panic disorder, depression, substance abuse, and feeling suicidal.

Psychotherapy

Psychotherapy is “talk” therapy. It involves talking with a mental health professional to treat a mental illness. Psychotherapy can occur one-on-one or in a group. Talk therapy treatment for PTSD usually lasts 6 to 12 weeks, but can take more time. Research shows that support from family and friends can be an important part of therapy.

Many types of psychotherapy can help people with PTSD. Some types target the symptoms of PTSD directly. Other therapies focus on social, family, or job-related problems. The doctor or therapist may combine different therapies depending on each person’s needs.

One helpful therapy is called cognitive behavioral therapy, or CBT. There are several parts to CBT, including:

Exposure therapy. This therapy helps people face and control their fear. It exposes them to the trauma they experienced in a safe way. It uses mental imagery, writing, or visits to the place where the event happened. The therapist uses these tools to help people with PTSD cope with their feelings.
Cognitive restructuring. This therapy helps people make sense of the bad memories. Sometimes people remember the event differently than how it happened. They may feel guilt or shame about what is not their fault. The therapist helps people with PTSD look at what happened in a realistic way.
Stress inoculation training. This therapy tries to reduce PTSD symptoms by teaching a person how to reduce anxiety. Like cognitive restructuring, this treatment helps people look at their memories in a healthy way.

Other types of treatment can also help people with PTSD. People with PTSD should talk about all treatment options with their therapist.

How Talk Therapies Help People Overcome PTSD

Talk therapies teach people helpful ways to react to frightening events that trigger their PTSD symptoms. Based on this general goal, different types of therapy may:

Teach about trauma and its effects.
Use relaxation and anger control skills.
Provide tips for better sleep, diet, and exercise habits.
Help people identify and deal with guilt, shame, and other feelings about the event.
Focus on changing how people react to their PTSD symptoms. For example, therapy helps people visit places and people that are reminders of the trauma.

Medications

The U.S. Food and Drug Administration (FDA) has approved two medications for treating adults with PTSD:

sertraline (Zoloft)
paroxetine (Paxil)

Both of these medications are antidepressants, which are also used to treat depression. They may help control PTSD symptoms such as sadness, worry, anger, and feeling numb inside. Taking these medications may make it easier to go through psychotherapy.

Sometimes people taking these medications have side effects. The effects can be annoying, but they usually go away. However, medications affect everyone differently. Any side effects or unusual reactions should be reported to a doctor immediately.

The most common side effects of antidepressants like sertraline and paroxetine are:

Headache, which usually goes away within a few days.
Nausea (feeling sick to your stomach), which usually goes away within a few days.
Sleeplessness or drowsiness, which may occur during the first few weeks but then goes away.
Agitation (feeling jittery).
Sexual problems, which can affect both men and women, including reduced sex drive, and problems having and enjoying sex.

Sometimes the medication dose needs to be reduced or the time of day it is taken needs to be adjusted to help lessen these side effects.

FDA Warning on Antidepressants

Despite the relative safety and popularity of SSRIs and other antidepressants, some studies have suggested that they may have unintentional effects on some people, especially adolescents and young adults. In 2004, the U.S. Food and Drug Administration (FDA) conducted a thorough review of published and unpublished controlled clinical trials of antidepressants that involved nearly 4,400 children and adolescents. The review revealed that 4 percent of those taking antidepressants thought about or attempted suicide (although no suicides occurred), compared to 2 percent of those receiving placebos.

This information prompted the FDA, in 2005, to adopt a “black box” warning label on all antidepressant medications to alert the public about the potential increased risk of suicidal thinking or attempts in children and adolescents taking antidepressants. In 2007, the FDA proposed that makers of all antidepressant medications extend the warning to include young adults up through age 24. A “black box” warning is the most serious type of warning on prescription drug labeling.

The warning emphasizes that patients of all ages taking antidepressants should be closely monitored, especially during the initial weeks of treatment. Possible side effects to look for are worsening depression, suicidal thinking or behavior, or any unusual changes in behavior such as sleeplessness, agitation, or withdrawal from normal social situations. The warning adds that families and caregivers should also be told of the need for close monitoring and report any changes to the physician. The latest information can be found on the FDA website.

Other Medications

Doctors may also prescribe other types of medications, such as the ones listed below. There is little information on how well these work for people with PTSD.

Benzodiazepines. These medications may be given to help people relax and sleep. People who take benzodiazepines may have memory problems or become dependent on the medication.
Antipsychotics. These medications are usually given to people with other mental disorders, like schizophrenia. People who take antipsychotics may gain weight and have a higher chance of getting heart disease and diabetes.
Other antidepressants. Like sertraline and paroxetine, the antidepressants fluoxetine (Prozac) and citalopram (Celexa) can help people with PTSD feel less tense or sad. For people with PTSD who also have other anxiety disorders or depression, antidepressants may be useful in reducing symptoms of these co-occurring illnesses.

Treatment After Mass Trauma

Sometimes large numbers of people are affected by the same event. For example, a lot of people needed help after Hurricane Katrina in 2005 and the terrorist attacks of September 11, 2001. Most people will have some PTSD symptoms in the first few weeks after events like these. This is a normal and expected response to serious trauma, and for most people, symptoms generally lessen with time. Most people can be helped with basic support, such as:

Getting to a safe place
Seeing a doctor if injured
Getting food and water
Contacting loved ones or friends
Learning what is being done to help.

But some people do not get better on their own. A study of Hurricane Katrina survivors found that, over time, more people were having problems with PTSD, depression, and related mental disorders. This pattern is unlike the recovery from other natural disasters, where the number of people who have mental health problems gradually lessens. As communities try to rebuild after a mass trauma, people may experience ongoing stress from loss of jobs and schools, and trouble paying bills, finding housing, and getting health care. This delay in community recovery may in turn delay recovery from PTSD.

In the first couple weeks after a mass trauma, brief versions of CBT may be helpful to some people who are having severe distress. Sometimes other treatments are used, but their effectiveness is not known. For example, there is growing interest in an approach called psychological first aid. The goal of this approach is to make people feel safe and secure, connect people to health care and other resources, and reduce stress reactions. There are guides for carrying out the treatment, but experts do not know yet if it helps prevent or treat PTSD.

In single-session psychological debriefing, another type of mass trauma treatment, survivors talk about the event and express their feelings one-on-one or in a group. Studies show that it is not likely to reduce distress or the risk for PTSD, and may actually increase distress and risk.

Mass Trauma Affects Hospitals and Other Providers

Hospitals, health care systems, and health care providers are also affected by a mass trauma. The number of people who need immediate physical and psychological help may be too much for health systems to handle. Some patients may not find help when they need it because hospitals do not have enough staff or supplies. In some cases, health care providers themselves may be struggling to recover as well.

NIMH scientists are working on this problem. For example, researchers are testing how to give CBT and other treatments using the phone and the Internet. In one study, people with PTSD met with a therapist to learn about the disorder, made a list of things that trigger their symptoms, and learned basic ways to reduce stress. After this meeting, the participants could visit a website with more information about PTSD. Participants could keep a log of their symptoms and practice coping skills. Overall, the researchers found the Internet-based treatment helped reduce symptoms of PTSD and depression. These effects lasted after treatment ended.

Researchers will carry out more studies to find out if other such approaches to therapy can be helpful after mass trauma.

Living With

“I was raped when I was 25 years old. For a long time, I spoke about the rape as though it was something that happened to someone else. I was very aware that it had happened to me, but there was just no feeling.”

“Then I started having flashbacks. They kind of came over me like a splash of water. I would be terrified. Suddenly I was reliving the rape. Every instant was startling. I wasn’t aware of anything around me, I was in a bubble, just kind of floating. And it was scary. Having a flashback can wring you out.”

“The rape happened the week before Thanksgiving, and I can’t believe the anxiety and fear I feel every year around the anniversary date. It’s as though I’ve seen a werewolf. I can’t relax, can’t sleep, don’t want to be with anyone. I wonder whether I’ll ever be free of this terrible problem.”

Source: National Institute of Mental Health, NIH, HHS

Panic Disorder

What is Panic Disorder?
Causes
Signs & Symptoms
Who Is At Risk?
Diagnosis
Treatments
Living With
Clinical Trials

What is Panic Disorder?

People with panic disorder have sudden and repeated attacks of fear that last for several minutes. Sometimes symptoms may last longer. These are called panic attacks. Panic attacks are characterized by a fear of disaster or of losing control even when there is no real danger. A person may also have a strong physical reaction during a panic attack. It may feel like having a heart attack. Panic attacks can occur at any time, and many people with panic disorder worry about and dread the possibility of having another attack.

A person with panic disorder may become discouraged and feel ashamed because he or she cannot carry out normal routines like going to the grocery store or driving. Having panic disorder can also interfere with school or work.

Causes

Panic disorder sometimes runs in families, but no one knows for sure why some people have it while others don't. Researchers have found that several parts of the brain are involved in fear and anxiety. By learning more about fear and anxiety in the brain, scientists may be able to create better treatments. Researchers are also looking for ways in which stress and environmental factors may play a role.

Signs & Symptoms

People with panic disorder may have:

Sudden and repeated attacks of fear
A feeling of being out of control during a panic attack
An intense worry about when the next attack will happen
A fear or avoidance of places where panic attacks have occurred in the past
Physical symptoms during an attack, such as a pounding or racing heart, sweating, breathing problems, weakness or dizziness, feeling hot or a cold chill, tingly or numb hands, chest pain, or stomach pain.

Who Is At Risk?

Panic disorder affects about 6 million American adults and is twice as common in women as men. Panic attacks often begin in late adolescence or early adulthood, but not everyone who experiences panic attacks will develop panic disorder. Many people have just one attack and never have another. The tendency to develop panic attacks appears to be inherited.

Diagnosis

Panic attacks can occur at any time, even during sleep. An attack usually peaks within 10 minutes, but some symptoms may last much longer.

People who have full-blown, repeated panic attacks can become very disabled by their condition and should seek treatment before they start to avoid places or situations where panic attacks have occurred. For example, if a panic attack happened in an elevator, someone with panic disorder may develop a fear of elevators that could affect the choice of a job or an apartment, and restrict where that person can seek medical attention or enjoy entertainment.

Some people’s lives become so restricted that they avoid normal activities, such as grocery shopping or driving. About one-third become housebound or are able to confront a feared situation only when accompanied by a spouse or other trusted person. When the condition progresses this far, it is called agoraphobia, or fear of open spaces.

Early treatment can often prevent agoraphobia, but people with panic disorder may sometimes go from doctor to doctor for years and visit the emergency room repeatedly before someone correctly diagnoses their condition. This is unfortunate, because panic disorder is one of the most treatable of all the anxiety disorders, responding in most cases to certain kinds of medication or certain kinds of cognitive psychotherapy, which help change thinking patterns that lead to fear and anxiety.

Panic disorder is often accompanied by other serious problems, such as depression, drug abuse, or alcoholism.These conditions need to be treated separately. Symptoms of depression include feelings of sadness or hopelessness, changes in appetite or sleep patterns, low energy, and difficulty concentrating. Most people with depression can be effectively treated with antidepressant medications, certain types of psychotherapy, or a combination of the two.

First, talk to your doctor about your symptoms. Your doctor should do an exam to make sure that another physical problem isn't causing the symptoms. The doctor may refer you to a mental health specialist.

Treatments

Panic disorder is generally treated with psychotherapy, medication, or both.

Psychotherapy. A type of psychotherapy called cognitive behavior therapy is especially useful for treating panic disorder. It teaches a person different ways of thinking, behaving, and reacting to situations that help him or her feel less anxious and fearful.

Medication. Doctors also may prescribe medication to help treat panic disorder. The most commonly prescribed medications for panic disorder are anti-anxiety medications and antidepressants. Anti-anxiety medications are powerful and there are different types. Many types begin working right away, but they generally should not be taken for long periods.

Antidepressants are used to treat depression, but they also are helpful for panic disorder. They may take several weeks to start working. Some of these medications may cause side effects such as headache, nausea, or difficulty sleeping. These side effects are usually not a problem for most people, especially if the dose starts off low and is increased slowly over time. Talk to your doctor about any side effects you may have.

It's important to know that although antidepressants can be safe and effective for many people, they may be risky for some, especially children, teens, and young adults. A "black box"—the most serious type of warning that a prescription drug can have—has been added to the labels of antidepressant medications. These labels warn people that antidepressants may cause some people to have suicidal thoughts or make suicide attempts. Anyone taking antidepressants should be monitored closely, especially when they first start treatment with medications.

Another type of medication called beta-blockers can help control some of the physical symptoms of panic disorder such as excessive sweating, a pounding heart, or dizziness. Although beta blockers are not commonly prescribed, they may be helpful in certain situations that bring on a panic attack.

Some people do better with cognitive behavior therapy, while others do better with medication. Still others do best with a combination of the two. Talk with your doctor about the best treatment for you.

Living With

"One day, without any warning or reason, I felt terrified. I was so afraid, I thought I was going to die. My heart was pounding and my head was spinning. I would get these feelings every couple of weeks. I thought I was losing my mind."

"The more attacks I had, the more afraid I got. I was always living in fear. I didn't know when I might have another attack. I became so afraid that I didn't want to leave my house."

"My friend saw how afraid I was and told me to call my doctor for help. My doctor told me I was physically healthy but that I have panic disorder. My doctor gave me medicine that helps me feel less afraid. I've also been working with a counselor learning ways to cope with my fear. I had to work hard, but after a few months of medicine and therapy, I'm starting to feel like myself again."

Clinical Trials

NIMH supports research studies on mental health and disorders. See also: A Participant's Guide to Mental Health Clinical Research.

Find NIH-funded studies currently recruiting participants with panic disorder .

Source: National Institute of Mental Health, NIH, HHS

Obsessive-Compulsive Disorder, OCD

What is Obsessive-Compulsive Disorder (OCD)?
Causes
Signs & Symptoms
Who Is At Risk?
Diagnosis
Treatments
Living With
Clinical Trials

What is Obsessive-Compulsive Disorder (OCD)?

Everyone double checks things sometimes. For example, you might double check to make sure the stove or iron is turned off before leaving the house. But people with obsessive-compulsive disorder (OCD) feel the need to check things repeatedly, or have certain thoughts or perform routines and rituals over and over. The thoughts and rituals associated with OCD cause distress and get in the way of daily life.

The frequent upsetting thoughts are called obsessions. To try to control them, a person will feel an overwhelming urge to repeat certain rituals or behaviors called compulsions. People with OCD can't control these obsessions and compulsions. Most of the time, the rituals end up controlling them.

For example, if people are obsessed with germs or dirt, they may develop a compulsion to wash their hands over and over again. If they develop an obsession with intruders, they may lock and relock their doors many times before going to bed. Being afraid of social embarrassment may prompt people with OCD to comb their hair compulsively in front of a mirror-sometimes they get “caught” in the mirror and can’t move away from it. Performing such rituals is not pleasurable. At best, it produces temporary relief from the anxiety created by obsessive thoughts.

Other common rituals are a need to repeatedly check things, touch things (especially in a particular sequence), or count things. Some common obsessions include having frequent thoughts of violence and harming loved ones, persistently thinking about performing sexual acts the person dislikes, or having thoughts that are prohibited by religious beliefs. People with OCD may also be preoccupied with order and symmetry, have difficulty throwing things out (so they accumulate), or hoard unneeded items.

Healthy people also have rituals, such as checking to see if the stove is off several times before leaving the house. The difference is that people with OCD perform their rituals even though doing so interferes with daily life and they find the repetition distressing. Although most adults with OCD recognize that what they are doing is senseless, some adults and most children may not realize that their behavior is out of the ordinary.

Causes

OCD sometimes runs in families, but no one knows for sure why some people have it while others don't. Researchers have found that several parts of the brain are involved in fear and anxiety. By learning more about fear and anxiety in the brain, scientists may be able to create better treatments. Researchers are also looking for ways in which stress and environmental factors may play a role.

Signs & Symptoms

People with OCD generally:

Have repeated thoughts or images about many different things, such as fear of germs, dirt, or intruders; acts of violence; hurting loved ones; sexual acts; conflicts with religious beliefs; or being overly tidy
Do the same rituals over and over such as washing hands, locking and unlocking doors, counting, keeping unneeded items, or repeating the same steps again and again
Can't control the unwanted thoughts and behaviors
Don't get pleasure when performing the behaviors or rituals, but get brief relief from the anxiety the thoughts cause
Spend at least 1 hour a day on the thoughts and rituals, which cause distress and get in the way of daily life.

Who Is At Risk?

For many people, OCD starts during childhood or the teen years. Most people are diagnosed by about age 19. Symptoms of OCD may come and go and be better or worse at different times.

OCD affects about 2.2 million American adults. It strikes men and women in roughly equal numbers and usually appears in childhood, adolescence, or early adulthood. One-third of adults with OCD develop symptoms as children, and research indicates that OCD might run in families.

Diagnosis

The course of the disease is quite varied. Symptoms may come and go, ease over time, or get worse. If OCD becomes severe, it can keep a person from working or carrying out normal responsibilities at home. People with OCD may try to help themselves by avoiding situations that trigger their obsessions, or they may use alcohol or drugs to calm themselves.

OCD can be accompanied by eating disorders, other anxiety disorders, or depression.

Treatments

OCD is generally treated with psychotherapy, medication, or both.

Psychotherapy. A type of psychotherapy called cognitive behavior therapy is especially useful for treating OCD. It teaches a person different ways of thinking, behaving, and reacting to situations that help him or her feel less anxious or fearful without having obsessive thoughts or acting compulsively. One type of therapy called exposure and response prevention is especially helpful in reducing compulsive behaviors in OCD.

Medication. Doctors also may prescribe medication to help treat OCD. The most commonly prescribed medications for OCD are anti-anxiety medications and antidepressants. Anti-anxiety medications are powerful and there are different types. Many types begin working right away, but they generally should not be taken for long periods.

Antidepressants are used to treat depression, but they are also particularly helpful for OCD, probably more so than anti-anxiety medications. They may take several weeks—10 to 12 weeks for some—to start working. Some of these medications may cause side effects such as headache, nausea, or difficulty sleeping. These side effects are usually not a problem for most people, especially if the dose starts off low and is increased slowly over time. Talk to your doctor about any side effects you may have.

Some people with OCD do better with cognitive behavior therapy, especially exposure and response prevention. Others do better with medication. Still others do best with a combination of the two. Talk with your doctor about the best treatment for you.

OCD usually responds well to treatment with certain medications and/or exposure-based psychotherapy, in which people face situations that cause fear or anxiety and become less sensitive (desensitized) to them. NIMH is supporting research into new treatment approaches for people whose OCD does not respond well to the usual therapies. These approaches include combination and augmentation (add-on) treatments, as well as modern techniques such as deep brain stimulation.

Living With

"I couldn't do anything without rituals. They invaded every aspect of my life. Counting really bogged me down. I would wash my hair three times as opposed to once because three was a good luck number and one wasn't. It took me longer to read because I'd count the lines in a paragraph. When I set my alarm at night, I had to set it to a number that wouldn't add up to a 'bad' number."

"Getting dressed in the morning was tough, because I had a routine, and if I didn't follow the routine, I'd get anxious and would have to get dressed again. I always worried that if I didn't do something, my parents were going to die. I'd have these terrible thoughts of harming my parents. I knew that was completely irrational, but the thoughts triggered more anxiety and more senseless behavior. Because of the time I spent on rituals, I was unable to do a lot of things that were important to me."

"I knew the rituals didn't make sense, and I was deeply ashamed of them, but I couldn't seem to overcome them until I got treatment." (from Obsessive-Compulsive Disorder: When Unwanted Thoughts Take Over: What is it like having OCD? )

Source: National Institute of Mental Health, NIH, HHS

Social Phobia (Social Anxiety Disorder)

What is Social Phobia (Social Anxiety Disorder)

Social phobia is a strong fear of being judged by others and of being embarrassed. This fear can be so strong that it gets in the way of going to work or school or doing other everyday things.

Everyone has felt anxious or embarrassed at one time or another. For example, meeting new people or giving a public speech can make anyone nervous. But people with social phobia worry about these and other things for weeks before they happen.

People with social phobia are afraid of doing common things in front of other people. For example, they might be afraid to sign a check in front of a cashier at the grocery store, or they might be afraid to eat or drink in front of other people, or use a public restroom. Most people who have social phobia know that they shouldn't be as afraid as they are, but they can't control their fear. Sometimes, they end up staying away from places or events where they think they might have to do something that will embarrass them. For some people, social phobia is a problem only in certain situations, while others have symptoms in almost any social situation.

Causes

Social phobia sometimes runs in families, but no one knows for sure why some people have it while others don't. Researchers have found that several parts of the brain are involved in fear and anxiety. By learning more about fear and anxiety in the brain, scientists may be able to create better treatments. Researchers are also looking for ways in which stress and environmental factors may play a role.

Signs & Symptoms

People with social phobia tend to:

Be very anxious about being with other people and have a hard time talking to them, even though they wish they could
Be very self-conscious in front of other people and feel embarrassed
Be very afraid that other people will judge them
Worry for days or weeks before an event where other people will be
Stay away from places where there are other people
Have a hard time making friends and keeping friends
Blush, sweat, or tremble around other people
Feel nauseous or sick to their stomach when with other people.

Who Is At Risk?

Social phobia affects about 15 million American adults. Women and men are equally likely to develop the disorder, which usually begins in childhood or early adolescence. There is some evidence that genetic factors are involved. Social phobia is often accompanied by other anxiety disorders or depression. Substance abuse may develop if people try to self-medicate their anxiety.

Diagnosis

Social phobia usually starts during youth. A doctor can tell that a person has social phobia if the person has had symptoms for at least 6 months. Without treatment, social phobia can last for many years or a lifetime.

Social phobia can be limited to one situation (such as talking to people, eating or drinking, or writing on a blackboard in front of others) or may be so broad (such as in generalized social phobia) that the person experiences anxiety around almost anyone other than the family.

Treatments

Social phobia is generally treated with psychotherapy, medication, or both.

Psychotherapy. A type of psychotherapy called Cognitive behavior therapy (cbt) is especially useful for treating social phobia. It teaches a person different ways of thinking, behaving, and reacting to situations that help him or her feel less anxious and fearful. It can also help people learn and practice social skills.

Medication. Doctors also may prescribe medication to help treat social phobia. The most commonly prescribed medications for social phobia are anti-anxiety medications and antidepressants. Anti-anxiety medications are powerful and there are different types. Many types begin working right away, but they generally should not be taken for long periods.

Antidepressants are used to treat depression, but they are also helpful for social phobia. They are probably more commonly prescribed for social phobia than anti-anxiety medications. Antidepressants may take several weeks to start working. Some may cause side effects such as headache, nausea, or difficulty sleeping. These side effects are usually not a problem for most people, especially if the dose starts off low and is increased slowly over time. Talk to your doctor about any side effects you may have.

A type of antidepressant called monoamine oxidase inhibitors (MAOIs) are especially effective in treating social phobia. However, they are rarely used as a first line of treatment because when MAOIs are combined with certain foods or other medicines, dangerous side effects can occur.

Anyone taking antidepressants should be monitored closely, especially when they first start treatment with medications.

Another type of medication called beta-blockers can help control some of the physical symptoms of social phobia such as excessive sweating, shaking, or a racing heart. They are most commonly prescribed when the symptoms of social phobia occur in specific situations, such as "stage fright."

Living With

"In school I was always afraid of being called on, even when I knew the answers. When I got a job, I hated to meet with my boss. I couldn't eat lunch with my co-workers. I worried about being stared at or judged, and worried that I would make a fool of myself. My heart would pound and I would start to sweat when I thought about meetings. The feelings got worse as the time of the event got closer. Sometimes I couldn't sleep or eat for days before a staff meeting.”

“In any social situation, I felt fear. I would be anxious before I even left the house, and it would escalate as I got closer to a college class, a party, or whatever. I would feel sick in my stomach—it almost felt like I had the flu. My heart would pound, my palms would get sweaty, and I would get this feeling of being removed from myself and from everybody else.”

“When I would walk into a room full of people, I’d turn red and it would feel like everybody’s eyes were on me. I was embarrassed to stand off in a corner by myself, but I couldn’t think of anything to say to anybody. It was humiliating. I felt so clumsy, I couldn’t wait to get out.”

Clinical Trials

NIMH supports research studies on mental health and disorders. See also: A Participant's Guide to Mental Health Clinical Research.

Find NIH-funded studies currently recruiting participants with social phobia.

Source: National Institute of Mental Health, NIH

MENTAL HEALTH TREATMENT

Psychotherapies

What is psychotherapy?

Psychotherapy, or "talk therapy", is a way to treat people with a mental disorder by helping them understand their illness. It teaches people strategies and gives them tools to deal with stress and unhealthy thoughts and behaviors. Psychotherapy helps patients manage their symptoms better and function at their best in everyday life.

Sometimes psychotherapy alone may be the best treatment for a person, depending on the illness and its severity. Other times, psychotherapy is combined with medications. Therapists work with an individual or families to devise an appropriate treatment plan.

What are the different types of psychotherapy?

Many kinds of psychotherapy exist. There is no "one-size-fits-all" approach. In addition, some therapies have been scientifically tested more than others. Some people may have a treatment plan that includes only one type of psychotherapy. Others receive treatment that includes elements of several different types. The kind of psychotherapy a person receives depends on his or her needs.

This section explains several of the most commonly used psychotherapies. However, it does not cover every detail about psychotherapy. Patients should talk to their doctor or a psychotherapist about planning treatment that meets their needs.

Cognitive Behavioral Therapy

Cognitive behavioral therapy (CBT) is a blend of two therapies: cognitive therapy (CT) and behavioral therapy. CT was developed by psychotherapist Aaron Beck, M.D., in the 1960's. CT focuses on a person's thoughts and beliefs, and how they influence a person's mood and actions, and aims to change a person's thinking to be more adaptive and healthy. Behavioral therapy focuses on a person's actions and aims to change unhealthy behavior patterns.

CBT helps a person focus on his or her current problems and how to solve them. Both patient and therapist need to be actively involved in this process. The therapist helps the patient learn how to identify distorted or unhelpful thinking patterns, recognize and change inaccurate beliefs, relate to others in more positive ways, and change behaviors accordingly.

CBT can be applied and adapted to treat many specific mental disorders.

CBT for depression

Many studies have shown that CBT is a particularly effective treatment for depression, especially minor or moderate depression. Some people with depression may be successfully treated with CBT only. Others may need both CBT and medication. CBT helps people with depression restructure negative thought patterns. Doing so helps people interpret their environment and interactions with others in a positive and realistic way. It may also help a person recognize things that may be contributing to the depression and help him or her change behaviors that may be making the depression worse.

CBT for anxiety disorders

CBT for anxiety disorders aims to help a person develop a more adaptive response to a fear. A CBT therapist may use "exposure" therapy to treat certain anxiety disorders, such as a specific phobia, post traumatic stress disorder, or obsessive compulsive disorder. Exposure therapy has been found to be effective in treating anxiety-related disorders.¹ It works by helping a person confront a specific fear or memory while in a safe and supportive environment. The main goals of exposure therapy are to help the patient learn that anxiety can lessen over time and give him or her the tools to cope with fear or traumatic memories.

A recent study sponsored by the Centers for Disease Control and Prevention concluded that CBT is effective in treating trauma-related disorders in children and teens.

CBT for bipolar disorder

People with bipolar disorder usually need to take medication, such as a mood stabilizer. But CBT is often used as an added treatment. The medication can help stabilize a person's mood so that he or she is receptive to psychotherapy and can get the most out of it. CBT can help a person cope with bipolar symptoms and learn to recognize when a mood shift is about to occur. CBT also helps a person with bipolar disorder stick with a treatment plan to reduce the chances of relapse (e.g., when symptoms return).

CBT for eating disorders

Eating disorders can be very difficult to treat. However, some small studies have found that CBT can help reduce the risk of relapse in adults with anorexia who have restored their weight. CBT may also reduce some symptoms of bulimia, and it may also help some people reduce binge-eating behavior.

CBT for schizophrenia

Treating schizophrenia with CBT is challenging. The disorder usually requires medication first. But research has shown that CBT, as an add-on to medication, can help a patient cope with schizophrenia. CBT helps patients learn more adaptive and realistic interpretations of events. Patients are also taught various coping techniques for dealing with "voices" or other hallucinations. They learn how to identify what triggers episodes of the illness, which can prevent or reduce the chances of relapse.

CBT for schizophrenia also stresses skill-oriented therapies. Patients learn skills to cope with life's challenges. The therapist teaches social, daily functioning, and problem-solving skills. This can help patients with schizophrenia minimize the types of stress that can lead to outbursts and hospitalizations.

Dialectical Behavior Therapy

Dialectical behavior therapy (DBT), a form of CBT, was developed by Marsha Linehan, Ph.D. At first, it was developed to treat people with suicidal thoughts and actions. It is now also used to treat people with borderline personality disorder (BPD). BPD is an illness in which suicidal thinking and actions are more common.

The term "dialectical" refers to a philosophic exercise in which two opposing views are discussed until a logical blending or balance of the two extremes—the middle way—is found. In keeping with that philosophy, the therapist assures the patient that the patient's behavior and feelings are valid and understandable. At the same time, the therapist coaches the patient to understand that it is his or her personal responsibility to change unhealthy or disruptive behavior.

DBT emphasizes the value of a strong and equal relationship between patient and therapist. The therapist consistently reminds the patient when his or her behavior is unhealthy or disruptive—when boundaries are overstepped—and then teaches the skills needed to better deal with future similar situations. DBT involves both individual and group therapy. Individual sessions are used to teach new skills, while group sessions provide the opportunity to practice these skills.

Research suggests that DBT is an effective treatment for people with BPD. A recent NIMH-funded study found that DBT reduced suicide attempts by half compared to other types of treatment for patients with BPD.

Interpersonal Therapy

Interpersonal therapy (IPT) is most often used on a one-on-one basis to treat depression or dysthymia (a more persistent but less severe form of depression). The current manual-based form of IPT used today was developed in the 1980's by Gerald Klerman, M.D., and Myrna Weissman, M.D.

IPT is based on the idea that improving communication patterns and the ways people relate to others will effectively treat depression. IPT helps identify how a person interacts with other people. When a behavior is causing problems, IPT guides the person to change the behavior. IPT explores major issues that may add to a person's depression, such as grief, or times of upheaval or transition. Sometimes IPT is used along with antidepressant medications.

IPT varies depending on the needs of the patient and the relationship between the therapist and patient. Basically, a therapist using IPT helps the patient identify troubling emotions and their triggers. The therapist helps the patient learn to express appropriate emotions in a healthy way. The patient may also examine relationships in his or her past that may have been affected by distorted mood and behavior. Doing so can help the patient learn to be more objective about current relationships.

Studies vary as to the effectiveness of IPT. It may depend on the patient, the disorder, the severity of the disorder, and other variables. In general, however, IPT is found to be effective in treating depression.

A variation of IPT called interpersonal and social rhythm therapy (IPSRT) was developed to treat bipolar disorder. IPSRT combines the basic principles of IPT with behavioral psychoeducation designed to help patients adopt regular daily routines and sleep/wake cycles, stick with medication treatment, and improve relationships. Research has found that when IPSRT is combined with medication, it is an effective treatment for bipolar disorder. IPSRT is as effective as other types of psychotherapy combined with medication in helping to prevent a relapse of bipolar symptoms.

Family-focused Therapy

Family-focused therapy (FFT) was developed by David Miklowitz, Ph.D., and Michael Goldstein, Ph.D., for treating bipolar disorder. It was designed with the assumption that a patient's relationship with his or her family is vital to the success of managing the illness. FFT includes family members in therapy sessions to improve family relationships, which may support better treatment results.

Therapists trained in FFT work to identify difficulties and conflicts among family members that may be worsening the patient's illness. Therapy is meant to help members find more effective ways to resolve those difficulties. The therapist educates family members about their loved one's disorder, its symptoms and course, and how to help their relative manage it more effectively. When families learn about the disorder, they may be able to spot early signs of a relapse and create an action plan that involves all family members. During therapy, the therapist will help family members recognize when they express unhelpful criticism or hostility toward their relative with bipolar disorder. The therapist will teach family members how to communicate negative emotions in a better way. Several studies have found FFT to be effective in helping a patient become stabilized and preventing relapses.

FFT also focuses on the stress family members feel when they care for a relative with bipolar disorder. The therapy aims to prevent family members from "burning out" or disengaging from the effort. The therapist helps the family accept how bipolar disorder can limit their relative. At the same time, the therapist holds the patient responsible for his or her own well being and actions to a level that is appropriate for the person's age.

Generally, the family and patient attend sessions together. The needs of each patient and family are different, and those needs determine the exact course of treatment. However, the main components of a structured FFT usually include:

Family education on bipolar disorder
Building communication skills to better deal with stress, and
Solving problems together as a family.

It is important to acknowledge and address the needs of family members. Research has shown that primary caregivers of people with bipolar disorder are at increased risk for illness themselves. For example, a 2007 study based on results from the NIMH-funded Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) trial found that primary caregivers of participants were at high risk for developing sleep problems and chronic conditions, such as high blood pressure. However, the caregivers were less likely to see a doctor for their own health issues.¹² In addition, a 2005 study found that 33 percent of caregivers of bipolar patients had clinically significant levels of depression.

Are psychotherapies different for children and adolescents?

Psychotherapies can be adapted to the needs of children and adolescents, depending on the mental disorder. For example, the NIMH-funded Treatment of Adolescents with Depression Study (TADS) found that CBT, when combined with antidepressant medication, was the most effective treatment over the short term for teens with major depression.¹⁴ CBT by itself was also an effective treatment, especially over the long term. Studies have found that individual and group-based CBT are effective treatments for child and adolescent anxiety disorders.¹⁵ Other studies have found that IPT is an effective treatment for child and adolescent depression.^16,17

Psychosocial treatments that involve a child's parents and family also have been shown to be effective, especially for disruptive disorders such as conduct disorder or oppositional defiant disorder. Some effective treatments are designed to reduce the child's problem behaviors and improve parent-child interactions. Focusing on behavioral parent management training, parents are taught the skills they need to encourage and reward positive behaviors in their children.¹⁸ Similar training helps parents manage their child's attention deficit/hyperactivity disorder (ADHD). This approach, which has been shown to be effective, can be combined with approaches directed at children to help them learn problem-solving, anger management and social interaction skills.

Family-based therapy may also be used to treat adolescents with eating disorders. One type is called the Maudsley approach, named after the Maudsley Hospital in London, where the approach was developed. This type of outpatient family therapy is used to treat anorexia nervosa in adolescents. It considers the active participation of parents to be essential in the recovery of their teen. The Maudsley approach proceeds through three phases:

Weight restoration. Parents become fully responsible for ensuring that their teen eats. A therapist helps parents better understand their teen's disease. Parents learn how to avoid criticizing their teen, but they also learn to make sure that their teen eats.
Returning control over eating to the teen. Once the teen accepts the control parents have over his or her eating habits, parents may begin giving up that control. Parents are encouraged to help their teen take more control over eating again.
Establishing healthy adolescent identity. When the teen has reached and maintained a healthy weight, the therapist helps him or her begin developing a healthy sense of identity and autonomy.

Several studies have found the Maudsley approach to be successful in treating teens with anorexia. Currently a large-scale, NIMH-funded study on the approach is under way.

What other types of therapies are used?

In addition to the therapies listed above, many more approaches exist. Some types have been scientifically tested more than others. Also, some of these therapies are constantly evolving. They are often combined with more established psychotherapies. A few examples of other therapies are described here.

Psychodynamic therapy. Historically, psychodynamic therapy was tied to the principles of psychoanalytic theory, which asserts that a person's behavior is affected by his or her unconscious mind and past experiences. Now therapists who use psychodynamic therapy rarely include psychoanalytic methods. Rather, psychodynamic therapy helps people gain greater self-awareness and understanding about their own actions. It helps patients identify and explore how their nonconscious emotions and motivations can influence their behavior. Sometimes ideas from psychodynamic therapy are interwoven with other types of therapy, like CBT or IPT, to treat various types of mental disorders. Research on psychodynamic therapy is mixed. However, a review of 23 clinical trials involving psychodynamic therapy found it to be as effective as other established psychotherapies.

Light therapy. Light therapy is used to treat seasonal affective disorder (SAD), a form of depression that usually occurs during the autumn and winter months, when the amount of natural sunlight decreases. Scientists think SAD occurs in some people when their bodies' daily rhythms are upset by short days and long nights. Research has found that the hormone melatonin is affected by this seasonal change. Melatonin normally works to regulate the body's rhythms and responses to light and dark. During light therapy, a person sits in front of a "light box" for periods of time, usually in the morning. The box emits a full spectrum light, and sitting in front of it appears to help reset the body's daily rhythms. Also, some research indicates that a low dose of melatonin, taken at specific times of the day, can also help treat SAD.²³

Other types of therapies sometimes used in conjunction with the more established therapies include:

Expressive or creative arts therapy. Expressive or creative arts therapy is based on the idea that people can help heal themselves through art, music, dance, writing, or other expressive acts. One study has found that expressive writing can reduce depression symptoms among women who were victims of domestic violence.²⁴ It also helps college students at risk for depression.
Animal-assisted therapy. Working with animals, such as horses, dogs, or cats, may help some people cope with trauma, develop empathy, and encourage better communication. Companion animals are sometimes introduced in hospitals, psychiatric wards, nursing homes, and other places where they may bring comfort and have a mild therapeutic effect. Animal-assisted therapy has also been used as an added therapy for children with mental disorders. Research on the approach is limited, but a recent study found it to be moderately effective in easing behavioral problems and promoting emotional well-being.²⁶
Play therapy. This therapy is used with children. It involves the use of toys and games to help a child identify and talk about his or her feelings, as well as establish communication with a therapist. A therapist can sometimes better understand a child's problems by watching how he or she plays. Research in play therapy is minimal.

What research is underway to improve psychotherapies?

Researchers are continually studying ways to better treat mental disorders with psychotherapy, and many NIMH-funded studies are underway. For more information about NIMH-funded clinical trials involving psychotherapies, see the NIMH Clinical Trials page.

How do I find a psychotherapist?

Your family doctor can help you find a psychotherapist. Other resources for locating services are available here.

Brain Stimulation Therapies

What are brain stimulation therapies?

Brain stimulation therapies involve activating or touching the brain directly with electricity, magnets, or implants to treat depression and other disorders. Electroconvulsive therapy is the most researched stimulation therapy and has the longest history of use. Other stimulation therapies discussed here — vagus nerve stimulation, repetitive transcranial magnetic stimulation, magnetic seizure therapy, and deep brain stimulation—are newer, more experimental methods.

Electroconvulsive therapy

First developed in 1938, electroconvulsive therapy (ECT) for years had a poor reputation with many negative depictions in popular culture. However, the procedure has improved significantly since its initial use and is safe and effective. People who undergo ECT do not feel any pain or discomfort during the procedure.

ECT is usually considered only after a patient's illness has not improved after other treatment options, such as antidepressant medication or psychotherapy, are tried. It is most often used to treat severe, treatment-resistant depression, but occasionally it is used to treat other mental disorders, such as bipolar disorder or schizophrenia. It also may be used in life-threatening circumstances, such as when a patient is unable to move or respond to the outside world (e.g., catatonia), is suicidal, or is malnourished as a result of severe depression. One study, the Consortium for Research in ECT study, found an 86 percent remission rate for those with severe major depression.¹ The same study found it to be effective in reducing chances of relapse when the patients underwent follow-up treatments.²

How does it work?

Before ECT is administered, a person is sedated with general anesthesia and given a medication called a muscle relaxant to prevent movement during the procedure. An anesthesiologist monitors breathing, heart rate and blood pressure during the entire procedure, which is conducted by a trained physician. Electrodes are placed at precise locations on the head. Through the electrodes, an electric current passes through the brain, causing a seizure that lasts generally less than one minute.

Scientists are unsure how the treatment works to relieve depression, but it appears to produce many changes in the chemistry and functioning of the brain. Because the patient is under anesthesia and has taken a muscle relaxant, the patient's body shows no signs of seizure, nor does he or she feel any pain, other than the discomfort associated with inserting an IV.

Five to ten minutes after the procedure ends, the patient awakens. He or she may feel groggy at first as the anesthesia wears off. But after about an hour, the patient usually is alert and can resume normal activities.

A typical course of ECT is administered about three times a week until the patient's depression lifts (usually within six to 12 treatments). After that, maintenance ECT treatment is sometimes needed to reduce the chance that symptoms will return. ECT maintenance treatment varies depending on the needs of the individual, and may range from one session per week to one session every few months. Frequently, a person who underwent ECT will take antidepressant medication or a mood stabilizing medication as well.

What are the side effects?

The most common side effects associated with ECT are headache, upset stomach, and muscle aches. Some people may experience memory problems, especially of memories around the time of the treatment. People may also have trouble remembering information learned shortly after the procedure, but this difficulty usually disappears over the days and weeks following the end of an ECT course. It is possible that a person may have gaps in memory over the weeks during which he or she receives treatment.³

Research has found that memory problems seem to be more associated with the traditional type of ECT called bilateral ECT, in which the electrodes are placed on both sides of the head. Unilateral ECT, in which the electrodes are placed on just one side of the head—typically the right side because it is opposite the brain's learning and memory areas—appears less likely to cause memory problems and therefore is preferred by many doctors. In the past, a "sine wave" was used to administer electricity in a constant, high dose. However, studies have found that a "brief pulse" of electricity administered in several short bursts is less likely to cause memory loss, and therefore is most commonly used today.⁴

Vagus nerve stimulation

Vagus nerve stimulation (VNS) works through a device implanted under the skin that sends electrical pulses through the left vagus nerve, half of a prominent pair of nerves that run from the brainstem through the neck and down to each side of the chest and abdomen. The vagus nerves carry messages from the brain to the body's major organs like the heart, lungs and intestines, and to areas of the brain that control mood, sleep, and other functions.

VNS was originally developed as a treatment for epilepsy. However, it became evident that it also had effects on mood, especially depressive symptoms. Using brain scans, scientists found that the device affected areas of the brain that are also involved in mood regulation. The pulses also appeared to alter certain neurotransmitters (brain chemicals) associated with mood, including serotonin, norepinephrine, GABA and glutamate.⁵

In 2005, the U.S. Food and Drug Administration (FDA) approved VNS for use in treating major depression in certain circumstances—if the illness has lasted two years or more, if it is severe or recurrent, and if the depression has not eased after trying at least four other treatments. Despite FDA approval, VNS remains a controversial treatment for depression because results of studies testing its effectiveness in treating major depression have been mixed.

How does it work?

A device called a pulse generator, about the size of a stopwatch, is surgically implanted in the upper left side of the chest. Connected to the pulse generator is a lead wire, which is guided under the skin up to the neck, where it is attached to the left-side vagus nerve.

Typically, electrical pulses that last about 30 seconds are sent about every five minutes from the generator to the vagus nerve. The duration and frequency of the pulses may vary depending on how the generator is programmed. The vagus nerve, in turn, delivers those signals to the brain. The pulse generator, which operates continuously, is powered by a battery that lasts around 10 years, after which it must be replaced. Normally, a person does not feel any sensation in the body as the device works, but it may cause coughing or the voice may become hoarse while the nerve is being stimulated.

The device also can be temporarily deactivated by placing a magnet over the chest where the pulse generator is implanted. A person may want to deactivate it if side effects become intolerable, or before engaging in strenuous activity or exercise because it may interfere with breathing. The device reactivates when the magnet is removed.

What are the side effects?

VNS is not without risk. There may be complications such as infection from the implant surgery, or the device may come loose, move around or malfunction, which may require additional surgery to correct. Long-term side effects are unknown.

Other potential side effects include:

Voice changes or hoarseness
Cough or sore throat
Neck pain
Discomfort or tingling in the area where the device is implanted
Breathing problems, especially during exercise
Difficulty swallowing

Repetitive transcranial magnetic stimulation

Repetitive transcranial magnetic stimulation (rTMS) uses a magnet instead of an electrical current to activate the brain. First developed in 1985, rTMS has been studied as a possible treatment for depression, psychosis and other disorders since the mid-1990's.

Clinical trials studying the effectiveness of rTMS reveal mixed results. When compared to a placebo or inactive (sham) treatment, some studies have found that rTMS is more effective in treating patients with major depression.⁶ But other studies have found no difference in response compared to inactive treatment.⁷

In October 2008, rTMS was approved for use by the FDA as a treatment for major depression for patients who have not responded to at least one antidepressant medication. It is also used in countries such as in Canada and Israel as a treatment for depression for patients who have not responded to medications and who might otherwise be considered for ECT.

How does it work?

Unlike ECT, in which electrical stimulation is more generalized, rTMS can be targeted to a specific site in the brain. Scientists believe that focusing on a specific spot in the brain reduces the chance for the type of side effects that are associated with ECT. But opinions vary as to what spot is best.

A typical rTMS session lasts 30 to 60 minutes and does not require anesthesia. An electromagnetic coil is held against the forehead near an area of the brain that is thought to be involved in mood regulation. Then, short electromagnetic pulses are administered through the coil. The magnetic pulse easily passes through the skull, and causes small electrical currents that stimulate nerve cells in the targeted brain region. And because this type of pulse generally does not reach further than two inches into the brain, scientists can select which parts of the brain will be affected and which will not be. The magnetic field is about the same strength as that of a magnetic resonance imaging (MRI) scan. Generally, the person will feel a slight knocking or tapping on the head as the pulses are administered.

Not all scientists agree on the best way to position the magnet on the patient's head or give the electromagnetic pulses. They also do not yet know if rTMS works best when given as a single treatment or combined with medication. More research, including a large NIMH-funded trial, is underway to determine the safest and most effective use of rTMS.

What are the side effects?

Sometimes a person may have discomfort at the site on the head where the magnet is placed. The muscles of the scalp, jaw or face may contract or tingle during the procedure. Mild headache or brief lightheadedness may result. It is also possible that the procedure could cause a seizure, although documented incidences of this are uncommon. A recent large-scale study on the safety of rTMS found that most side effects, such as headaches or scalp discomfort, were mild or moderate, and no seizures occurred.⁸ Because the treatment is new, however, long-term side effects are unknown.

Magnetic seizure therapy

Magnetic seizure therapy (MST) borrows certain aspects from both ECT and rTMS. Like rTMS, it uses a magnetic pulse instead of electricity to stimulate a precise target in the brain. However, unlike rTMS, MST aims to induce a seizure like ECT. So the pulse is given at a higher frequency than that used in rTMS. Therefore, like ECT, the patient must be anesthetized and given a muscle relaxant to prevent movement. The goal of MST is to retain the effectiveness of ECT while reducing the cognitive side effects usually associated with it.

MST is currently in the early stages of testing, but initial results are promising. Studies on both animals and humans have found that MST produces fewer memory side effects, shorter seizures, and allows for a shorter recovery time than ECT.^9,10 However, its effect on treatment-resistant depression is not yet established. Studies are underway to determine its antidepressant effects.

Deep brain stimulation

Deep brain stimulation (DBS) was first developed as a treatment for Parkinson's disease to reduce tremor, stiffness, walking problems and uncontrollable movements. In DBS, a pair of electrodes is implanted in the brain and controlled by a generator that is implanted in the chest. Stimulation is continuous and its frequency and level is customized to the individual.

DBS has only recently been studied as a treatment for depression or obsessive compulsive disorder (OCD). Currently, it is available on an experimental basis only. So far, very little research has been conducted to test DBS for depression treatment, but the few studies that have been conducted show that the treatment may be promising. One small trial involving people with severe, treatment-resistant depression found that four out of six participants showed marked improvement in their symptoms either immediately after the procedure, or soon after.¹¹ Another study involving 10 people with OCD found continued improvement among the majority three years after the surgery.¹²

How does it work?

DBS requires brain surgery. The head is shaved and then attached with screws to a sturdy frame that prevents the head from moving during the surgery. Scans of the head and brain using MRI are taken. The surgeon uses these images as guides during the surgery. Patients are awake during the procedure to provide the surgeon with feedback, but they feel no pain because the head is numbed with a local anesthetic.

Once ready for surgery, two holes are drilled into the head. From there, the surgeon threads a slender tube down into the brain to place electrodes on each side of a specific part of the brain. In the case of depression, the part of the brain targeted is called Area 25. This area has been found to be overactive in depression and other mood disorders.¹¹ In the case of OCD, the electrodes are placed in a different part of the brain believed to be associated with the disorder.

After the electrodes are implanted and the patient provides feedback about the placement of the electrodes, the patient is put under general anesthesia. The electrodes are then attached to wires that are run inside the body from the head down to the chest, where a pair of battery-operated generators are implanted. From here, electrical pulses are continuously delivered over the wires to the electrodes in the brain. Although it is unclear exactly how the device works to reduce depression or OCD, scientists believe that the pulses help to "reset" the area of the brain that is malfunctioning so that it works normally again.

What are the side effects?

DBS carries risks associated with any type of brain surgery. For example, the procedure may lead to:

Bleeding in the brain or stroke
Infection
Disorientation or confusion
Unwanted mood changes
Movement disorders
Lightheadedness
Trouble sleeping

Because the procedure is still experimental, other side effects that are not yet identified may be possible. Long-term benefits and side effects are unknown.

What research is underway on brain stimulation therapies?

Brain stimulation therapies hold promise for treating certain mental disorders that do not respond to more conventional treatments. Therefore, they are of high interest and are the subject of many studies. For example, researchers continue to look for ways to reduce the side effects of ECT while retaining the benefits. Studies on rTMS are ongoing .

Other researchers are studying how the brain responds to VNS by using imaging techniques such as PET scans. Finally, although DBS as a depression treatment is still very new, researchers are beginning to conduct studies with people to determine its effectiveness and safety in treating depression, OCD and other mental disorders.

Source: National Institute of Mental Health, NIH, HHS

MEDICATIONS FOR TREATING MENTAL HEALTH

Antipsychotic Medicines for Treating Schizophrenia and Bipolar Disorder: A Review of the Research for Adults and Caregivers

Medications for Treating Mental Health Conditions
A Review of the Research for Adults and Caregivers

Table of Contents

Is This Information Right for Me?
Understanding Your Condition
Understanding Antipsychotics
Making a Decision
Source

Is This Information Right for Me?

Yes, this information is right for you if:

A doctor has told you that you or someone you care for has schizophrenia or bipolar disorder.
A doctor has suggested one of the medicines listed below.* These medicines are called “antipsychotics” because they were made to treat severe mental illnesses such as psychosis. Antipsychotics are now used for many mental health conditions and symptoms, not just psychosis. There are two generations of antipsychotics—older and newer.

Older Antipsychotics:You are age 18 or older. The information in this summary is from research on adults.

- Chlorpromazine (Thorazine^®)
- Fluphenazine (Prolixin^®)
- Haloperidol (Haldol^®)
- Perphenazine (Trilafon^®)
- Thioridazine (Mellaril^®)
- Trifluoperazine (Stelazine^®)

Newer Antipsychotics:

- Aripiprazole (Abilify^®)
- Asenapine (Saphris^®)
- Clozapine (Clozaril^®, FazaClo^®)
- Olanzapine (Zyprexa^®)
- Quetiapine (Seroquel^®)
- Risperidone (Risperdal^®)
- Ziprasidone (Geodon^®)

* There are other antipsychotic medicines than those listed here. These are the ones that were studied in the research for this summary.

What will this summary tell me?

This summary talks about one type of medicine—antipsychotics— used to treat schizophrenia and bipolar disorder. It will tell you what research says about how older and newer antipsychotics compare for treating schizophrenia and bipolar disorder in adults. Please note that the research on antipsychotics as treatment for bipolar disorder is limited, and more research is needed. This summary will also tell you about the possible side effects of antipsychotics. It can help you talk with your doctor about whether or not one of these antipsychotic medicines might be right for you.

This summary does not talk about medicines other than antipsychotics for schizophrenia or bipolar disorder, such as mood stabilizers or antidepressants. This summary also does not discuss nonmedicine treatments, such as psychotherapy.

Where does the information come from?

Researchers funded by the Agency for Healthcare Research and Quality (AHRQ), a Federal Government research agency, reviewed 114 studies of antipsychotics for schizophrenia and 12 studied of antipsychotics for bipolar disorder published up to July 2011. The report was reviewed by clinicians, researchers, experts, and the public. You can read the report at www.effectivehealthcare.ahrq.gov/antipsychotics-adult.cfm.

Understanding Your Condition

What is schizophrenia?

Schizophrenia is a severe brain disorder in which people may hear voices or see things that are not real. Scientists are not sure what causes schizophrenia, but the disorder may be passed down in families. A person’s brain structure or chemistry and the environment they live in may also play a role in developing schizophrenia. Out of 100 people in the United States, about 1 person has schizophrenia.

Although symptoms can vary from person to person, common symptoms of schizophrenia include:

Hallucinations: Seeing or hearing things that are not there
Delusions: Believing things that are irrational or not trueTrouble communicating and saying things that do not make sense
- Examples of delusions include thinking others can read your mind, believing others are trying to control your mind, or constantly worrying that others are trying to hurt you.
Movement problems: Repeating motions over and over or not moving at all
Trouble showing emotions: Talking with a flat voice and not showing any facial expressions, like a smile or a frown
Trouble interacting with other people
Trouble paying attention and making decisions
Thoughts of suicide

How is schizophrenia treated?

Schizophrenia can be treated with medicine and psychotherapy (talking with a trained therapist). Antipsychotic medicines are often used to treat the symptoms of schizophrenia. These medicines do not cure schizophrenia, but they can help improve your ability to function and your quality of life. Each person responds differently to different antipsychotic medicines. You may need to try several medicines before finding the one that works best for you.
Your doctor may also suggest other nonmedicine treatments that can help you cope with your illness and symptoms. Such treatments can include counseling, self-help groups, and programs to learn how to manage your illness.
Sometimes, doctors may suggest staying in a hospital to help people with schizophrenia get their symptoms under control.

Note: This summary only discusses antipsychotic medicines used to treat schizophrenia. It does not discuss nonmedicine treatments or hospital stays.

What is bipolar disorder?

Bipolar disorder, also known as manic-depressive illness, is a severe brain disorder that causes intense mood swings. People with bipolar disorder go from feeling very happy and full of energy to feeling very depressed and hopeless and back again. These ups (called “mania,” pronounced MAY-nee-uh) and downs (called depression) are much more intense than the normal ups and downs that everyone feels from time to time. Scientists think bipolar disorder may be passed down in families. A person’s brain structure may also play a role in developing bipolar disorder.

Out of 100 people in the United States, less than 1 to as many as 3 have bipolar disorder.

Although symptoms vary from person to person, common examples of mania and depression symptoms are listed below.

Symptoms of mania include:

Feeling “up” or “high”
Feeling jittery, agitated, or irritable
Feeling invincible—like nothing can hurt you
Easily flying into a rage
Being overactive
Talking fast and switching between topics quickly
Feeling little need for sleep
Acting reckless or taking risks (for example, taking drugs, having unprotected sex, or spending a lot of money)

Symptoms of depression include:

Feeling “down” or sad
Feeling very worried, hopeless, or worthless
Having trouble concentrating and remembering things
No longer being interested in activities you usually enjoy
Feeling tired and becoming much less active
Eating a lot more or a lot less than usual
Having trouble sleeping
Thinking about death often or considering suicide

How is bipolar disorder treated?

Bipolar disorder can be treated with medicine and psychotherapy (talking with a trained therapist). Medicines to treat bipolar disorder include mood stabilizers (such as lithium), antipsychotic medicines, and antidepressant medicines. Each person responds differently to different antipsychotic medicines. You may need to try several medicines or combinations of medicines before finding what works best for you.
Your doctor may also suggest other nonmedicine treatments that can help you cope with your illness and symptoms. Such treatments can include counseling or support groups.
Sometimes, doctors may suggest a stay in the hospital to help people with bipolar disorder stabilize their mood.

Note: This summary only discusses antipsychotic medicines to treat bipolar disorder. It does not discuss other medicines, nonmedicine treatments, or hospital stays

Understanding Antipsychotics

What are antipsychotic medicines?

Antipsychotic medicines were made to help people who have serious mental illnesses such as psychosis. Antipsychotic medicines are now used for many mental health conditions and symptoms, not just psychosis. They work by affecting the way certain chemicals act in the brain. Antipsychotic medicines do not cure mental illnesses, but they are used to help improve symptoms and quality of life.

Antipsychotic medicines are divided into two “generations.” Doctors often refer to these as “older” (also called “typical”) antipsychotics and “newer” (also called “atypical”) antipsychotics. Antipsychotic medicines come as pills you take every day. Some antipsychotics also come as a shot that you get at the doctor’s office or the hospital.

Antipsychotic Medicines
Brand Name	Drug Name	Generic Available
* These medicines were not studied in the research for this summary.
Older Antipsychotic Medicines
Haldol^®	Haloperidol	Yes
Mellaril^®	Thioridazine	Yes
Navane^®*	Thiothixene*	Yes
Prolixin^®	Fluphenazine	Yes
Stelazine^®	Trifluoperazine	Yes
Thorazine^®	Chlorpromazine	Yes
Trilafon^®	Perphenazine	Yes
Newer Antipsychotic Medicines
Abilify^®	Aripiprazole	No
Clozaril^®; FazaClo^®	Clozapine	Yes
Fanapt^®*	Iloperidone*	No
Geodon^®	Ziprasidone	Yes
Invega^®*	Paliperidone*	No
Latuda^®*	Lurasidone*	No
Risperdal^®	Risperidone	Yes
Saphris^®	Asenapine	No
Seroquel^®	Quetiapine	Yes
Zyprexa^®	Olanzapine	Yes

What does research say about how older and newer antipsychotic medicines compare with each other?

Older and newer antipsychotics both work to treat symptoms of schizophrenia and bipolar disorder. However, research studies that compared newer antipsychotic medicines with the older antipsychotic haloperidol (Haldol^®)* only found a few differences in benefits.

Schizophrenia

For treating the schizophrenia symptoms of hallucinations, delusions, trouble communicating, and movement problems:

The newer antipsychotic olanzapine (Zyprexa^®) works about the same as the older antipsychotic haloperidol (Haldol^®).

For treating the schizophrenia symptoms of trouble showing emotion and trouble interacting with others:

The newer antipsychotics aripiprazole (Abilify^®), olanzapine (Zyprexa^®), and risperidone (Risperdal^®) work better than the older antipsychotic haloperidol (Haldol^®).

For treating general mental health symptoms (such as anxiety, guilt, tension, poor attention, and poor judgment) in people with schizophrenia:??

The newer antipsychotic olanzapine (Zyprexa^®) works better than the older antipsychotic haloperidol (Haldol^®).

Bipolar Disorder

For treating mania symptoms of bipolar disorder:

The newer antipsychotics aripiprazole (Abilify^®), olanzapine (Zyprexa^®), and risperidone (Risperdal^®) appear to work the same as the older antipsychotic haloperidol (Haldol^®), but more research is needed to know this for certain.

* Haloperidol (Haldol^®) may not be representative of all older antipsychotics. There is not enough research to know for certain how other older antipsychotics compare with newer antipsychotics.

What are the possible side effects of antipsychotic medicines?

The U.S. Food and Drug Administration (FDA) lists the following possible side effects of antipsychotic medicines.*

Both older and newer antipsychotic medicines can cause:

Uncontrollable movements, such as tics and tremors (the risk is higher with older antipsychotic medicines)
Drowsiness
Dizziness
Restlessness
Weight gain (the risk is higher with newer antipsychotic medicines)
Dry mouth
Constipation
Nausea
Vomiting
Blurred vision
Low blood pressure
Seizures
A low number of white blood cells (the cells in your body that fight infection)

All the antipsychotic medicines in this summary, except for aripiprazole (Abilify^®) and clozapine (Clozaril^® or FazaClo^®), can cause an increased amount of a hormone in the body called prolactin. Increased prolactin can cause problems with sexual function and enlarged breasts in both men and women.

* For information on how likely certain side effects are for various newer antipsychotic medicines, see the consumer research summary Medicines for Treating Mental Health Conditions, A Review of the Research for Adults and Caregivers. For a free copy, call 800-358-9295 and ask for AHRQ Publication No. 11(12)-EHC087-A, or download and print a copy at www.effectivehealthcare.ahrq.gov/mental-health-medicines.cfm.

Possible Serious Side Effects of Antipsychotic Medicines

Both older and newer antipsychotics can cause a condition that causes uncontrollable muscle movements. Sometimes the condition goes away after stopping the medicine, but sometimes it is permanent. Older antipsychotics may be associated with a higher risk of developing this condition than newer antipsychotics.
Both older and newer antipsychotics can cause a possibly life-threatening reaction called “neuroleptic malignant syndrome,” although this is rare. Symptoms include a high fever, sweating, wide changes in blood pressure, and muscle stiffness.
The newer antipsychotic clozapine (Clozaril^® or FazaClo^®) can cause a serious blood condition involving a severely lowered white blood cell count in some people. Your doctor will need to take blood tests often to monitor for this condition. Clozapine can also cause the heart muscle to become inflamed.
Researchers do not known if taking antipsychotics while pregnant can harm the unborn baby. If you are pregnant or are planning to become pregnant, talk with your doctor before taking an antipsychotic medicine.

Making a Decision

What should I think about when deciding?

There are several things to consider when deciding if an antipsychotic medicine is right for you or someone you care for. Only you and your doctor can decide whether any medicine’s ability to help is worth the risk of a serious side effect. Each person responds differently to different antipsychotic medicines. The doctor may try several medicines before finding the right one. The most important thing is to find the medicine that works best for you.

You and your doctor should discuss:

The possible benefits of taking an antipsychotic medicine
Which antipsychotic medicine might work best for you or someone you care for
The possible side effects from taking an antipsychotic medicine and what they mean to you
The risk for a serious side effect
Ways to help you notice side effects so they can be treated or so the medicine can be changed
Which treatment best fits your values and preferences
The cost of each medicine

What are the costs of the medicines?

The wholesale prices of prescription antipsychotic medicines are listed below. Wholesale prices are the prices paid by pharmacies. These prices are given here so you can compare the costs of different medicines to see which are more expensive and which are less expensive. The cost to you for each medicine depends on your health insurance, the dose (amount) of medicine you need, and whether the medicine comes in a generic form.

Wholesale Prices of Prescription Antipsychotics
Brand Name	Daily Dose	Form	Price per Month for Brand Name*	Drug Name	Price per Month for Generic*
* Prices are the average wholesale prices from RED BOOK Online^® rounded to the nearest $5. Generic prices are the middle value in the range of prices listed from different manufacturers. The actual prices of the medicines may be higher or lower than the prices listed here, depending on the manufacturer used by your pharmacy. NA = not available; NB = brand name no longer manufactured; NG = no generic form
Older Antipsychotics
Haldol^®	1–30 mg	Tablet	NB	Haloperidol	NA
Mellaril^®	200–800 mg	Tablet	NB	Thioridazine	NA
Prolixin^®	1–5 mg	Tablet	NB	Fluphenazine	$6–$12
Stelazine^®	10–20 mg	Tablet	NB	Trifluoperazine	$65–$95
Thorazine^®	50–800 mg	Tablet	NB	Chlorpromazine	$60–$350
Trilafon^®	8–32 mg	Tablet	NB	Perphenazine	NA
Newer Antipsychotics
Abilify^®	10–15 mg	Tablet	$760	Aripiprazole	NG
Clozaril^®; FazaClo^®	300–600 mg	Tablet	$975–$1,950; $645–$1,290	Clozapine	$300–$595
Geodon^®	40–160 mg	Capsule	$600–$725	Ziprasidone	$530–$645
Risperdal^®	1–6 mg	Tablet	$210–$835	Risperidone	$140–$270
Saphris^®	10–20 mg	Sublingual Tablet	$750	Asenapine	NG
Seroquel^®	150–300 mg	Tablet	$690–$720	Quetiapine	$590–$620
Zyprexa^®	10–15 mg	Tablet	$665–$995	Olanzapine	$600–$900

Ask your doctor

Which antipsychotic medicine are you considering for me or for someone I care for? Why?
How long will it take for the medicine to start working?
How long will I need to keep taking the medicine?
Which symptoms might the medicine improve?
What serious side effects should I look for, and when should I call you about them?
How much weight might I gain from taking an antipsychotic medicine? When should I call you about my weight gain?
Am I at risk for having high cholesterol or getting diabetes if I take a newer antipsychotic medicine?
What will we do if the medicine does not work? What if the medicine stops working after a while and my symptoms come back?
Will an antipsychotic medicine interact with other medicines I may be taking?
Are there other medicines or nonmedicine treatments that might help me?

Source

The information in this summary comes from the report First-Generation Versus Second-Generation Antipsychotics in Adults: Comparative Effectiveness. The report was produced by the University of Alberta Evidence-based Practice Center through funding by the Agency for Healthcare Research and Quality (AHRQ).

Additional information came from the MedlinePlus^® Web site, a service of the National Library of Medicine and the National Institutes of Health. This site is available at www.nlm.nih.gov/medlineplus.

This summary was prepared by the John M. Eisenberg Center for Clinical Decisions and Communications Science at Baylor College of Medicine, Houston, TX. It was written by Amelia Williamson Smith, M.S., John Coverdale, M.D., and Michael Fordis, M.D. Patients with schizophrenia or bipolar disorder or their caregivers reviewed this summary.

Mental Health Medications

Overview
How are medications used to treat mental disorders?
What medications are used to treat schizophrenia?
What medications are used to treat depression?
What medications are used to treat bipolar disorder?
What medications are used to treat anxiety disorders?
What medications are used to treat ADHD?
Which groups have special needs when taking psychiatric medications?
What should I ask my doctor if I am prescribed a psychiatric medication?
For More Information on Medication

Overview

Medications are used to treat the symptoms of mental disorders such as schizophrenia, depression, bipolar disorder (sometimes called manic-depressive illness), anxiety disorders, and attention deficit-hyperactivity disorder (ADHD). Sometimes medications are used with other treatments such as psychotherapy. Psychotherapy alone may be the best treatment for a person, depending on the illness and its severity. Other times, psychotherapy is combined with medications.

This health topic includes general information on:

Types of medications used to treat mental disorders
Side effects of medications
Warnings about medications from the U.S. Food and Drug Administration (FDA).

This health topic page does not provide information about diagnosing mental disorders. It is intended for general informational purposes only and should not be considered a comprehensive source for all medications available to treat mental health disorders nor should it be considered a guide for making medical decisions. Choosing the right medication, medication dose, and treatment plan should be based on a person's individual needs and medical situation, and under a doctor's care.

Please note: Information about medications changes frequently. Check the FDA website for the latest news and information on warnings, patient medication guides, or newly approved medications. Throughout this document you will only see the generic names for medications. Because information on medications is frequently updated, brand names are not referenced. If you prefer to search by both generic and brand name or require additional information on side effects, dosages, special precautions, and more, please visit the FDA website . You may also be interested in the MedlinePlus Drugs Information page.

How are medications used to treat mental disorders?

Psychiatric medications treat the symptoms of mental disorders. Sometimes called psychotropic or psychotherapeutic medications, they have changed the lives of people with mental disorders for the better. Many people with mental disorders live fulfilling lives with the help of these medications. Without them, people with mental disorders might suffer serious and disabling symptoms.

Medications work differently for different people. Some people get great results from medications and only need them for a short time. For example, a person with depression may feel much better after taking a medication for a few months, and may never need it again. People with disorders like schizophrenia or bipolar disorder, or people who have long-term or severe depression or anxiety may need to take medication for a much longer time.

Some people get side effects from medications and other people don't. Doses can be small or large, depending on the medication and the person. Factors that can affect how medications work in people include:

Type of mental disorder, such as depression, anxiety, bipolar disorder, and schizophrenia
Age, sex, and body size
Physical illnesses
Habits like smoking and drinking
Liver and kidney function
Genetics
Other medications and herbal/vitamin supplements
Diet
Whether medications are taken as prescribed.

What medications are used to treat schizophrenia?

Antipsychotic medications are used to treat schizophrenia and schizophrenia-related disorders.

Some of these medications have been available since the mid-1950s. These first-generation medications are also called conventional "typical" antipsychotics. Some of the more commonly used medications include:

Chlorpromazine
Haloperidol
Perphenazine
Fluphenazine,

In the 1990s, new antipsychotic medications were developed. These newer medications are called second generation, or "atypical" antipsychotics.

One of these medications was clozapine. It is a very effective medication that treats psychotic symptoms, hallucinations, and breaks with reality, such as when a person believes he or she is the president. But clozapine can sometimes cause a serious problem called agranulocytosis, which is a loss of the white blood cells that help a person fight infection. Therefore, people who take clozapine must get their white blood cell counts checked every week or two. This problem and the cost of blood tests make treatment with clozapine difficult for many people. Still, clozapine is potentially helpful for people who do not respond to other antipsychotic medications.

Other atypical antipsychotics were developed. All of them are effective. Agranulocytosis is less likely to occur with these medications than with clozapine, but it has been reported. These include:

Risperidone
Olanzapine
Quetiapine
Ziprasidone
Aripiprazole
Paliperidone
Lurasidone

The antipsychotics listed here are some of the medications used to treat symptoms of schizophrenia. To find additional antipsychotics and other medications used for schizophrenia as well as current warnings and advisories, please visit the FDA website .

Note: The FDA issued a Public Health Advisory for atypical antipsychotic medications. The FDA determined that death rates are higher for elderly people with dementia when taking this medication. A review of data has found a risk with conventional antipsychotics as well. Antipsychotic medications are not FDA-approved for the treatment of behavioral disorders in patients with dementia.

What are the side effects?

Drowsiness
Dizziness when changing positions
Blurred vision
Rapid heartbeat
Sensitivity to the sun
Skin rashes
Menstrual problems for women.

Typical antipsychotic medications can cause side effects related to physical movement, such as:

Rigidity
Persistent muscle spasms
Tremors
Restlessness.

Every year, an estimated 5 percent of people taking typical antipsychotics get TD. The condition happens to fewer people who take the new, atypical antipsychotics, but some people may still get TD. People who think that they might have TD should check with their doctor before stopping their medication.

How are antipsychotics taken and how do people respond to them?

Antipsychotics are usually pills that people swallow, or liquid they can drink. Some antipsychotics are shots that are given once or twice a month.

Some people may have a relapse—their symptoms come back or get worse. Usually, relapses happen when people stop taking their medication, or when they only take it sometimes. Some people stop taking the medication because they feel better or they may feel they don't need it anymore. But no one should stop taking an antipsychotic medication without talking to his or her doctor. When a doctor says it is okay to stop taking a medication, it should be gradually tapered off, never stopped suddenly.

How do antipsychotics interact with other medications?

What medications are used to treat depression?

Depression is commonly treated with antidepressant medications. Antidepressants work to balance some of the natural chemicals in our brains. These chemicals are called neurotransmitters, and they affect our mood and emotional responses. Antidepressants work on neurotransmitters such as serotonin, norepinephrine, and dopamine.

The most popular types of antidepressants are called selective serotonin reuptake inhibitors (SSRIs). These include:

Fluoxetine
Citalopram
Sertraline
Paroxetine
Escitalopram

Other types of antidepressants are serotonin and norepinephrine reuptake inhibitors (SNRIs). SNRIs are similar to SSRIs and include venlafaxine and duloxetine. Another antidepressant that is commonly used is bupropion. Bupropion, which works on the neurotransmitter dopamine, is unique in that it does not fit into any specific drug type.

SSRIs and SNRIs are popular because they do not cause as many side effects as older classes of antidepressants. Older antidepressant medications include tricyclics, tetracyclics, and monoamine oxidase inhibitors (MAOIs). For some people, tricyclics, tetracyclics, or MAOIs may be the best medications.

What are the side effects?

Antidepressants may cause mild side effects that usually do not last long. Any unusual reactions or side effects should be reported to a doctor immediately.

The most common side effects associated with SSRIs and SNRIs include:

Headache, which usually goes away within a few days.
Nausea (feeling sick to your stomach), which usually goes away within a few days.
Sleeplessness or drowsiness, which may happen during the first few weeks but then goes away. Sometimes the medication dose needs to be reduced or the time of day it is taken needs to be adjusted to help lessen these side effects.
Agitation (feeling jittery).
Sexual problems, which can affect both men and women and may include reduced sex drive, and problems having and enjoying sex.

Tricyclic antidepressants can cause side effects, including:

Dry mouth.
Constipation.
Bladder problems. It may be hard to empty the bladder, or the urine stream may not be as strong as usual. Older men with enlarged prostate conditions may be more affected.
Sexual problems, which can affect both men and women and may include reduced sex drive, and problems having and enjoying sex.
Blurred vision, which usually goes away quickly.
Drowsiness. Usually, antidepressants that make you drowsy are taken at bedtime.

People taking MAOIs need to be careful about the foods they eat and the medicines they take. Foods and medicines that contain high levels of a chemical called tyramine are dangerous for people taking MAOIs. Tyramine is found in some cheeses, wines, and pickles. The chemical is also in some medications, including decongestants and over-the-counter cold medicine.

Mixing MAOIs and tyramine can cause a sharp increase in blood pressure, which can lead to stroke. People taking MAOIs should ask their doctors for a complete list of foods, medicines, and other substances to avoid. An MAOI skin patch has recently been developed and may help reduce some of these risks. A doctor can help a person figure out if a patch or a pill will work for him or her.

How should antidepressants be taken?

People taking antidepressants need to follow their doctors' directions. The medication should be taken in the right dose for the right amount of time. It can take three or four weeks until the medicine takes effect. Some people take the medications for a short time, and some people take them for much longer periods. People with long-term or severe depression may need to take medication for a long time.

Once a person is taking antidepressants, it is important not to stop taking them without the help of a doctor. Sometimes people taking antidepressants feel better and stop taking the medication too soon, and the depression may return. When it is time to stop the medication, the doctor will help the person slowly and safely decrease the dose. It's important to give the body time to adjust to the change. People don't get addicted, or "hooked," on the medications, but stopping them abruptly can cause withdrawal symptoms.

If a medication does not work, it is helpful to be open to trying another one. A study funded by NIMH found that if a person with difficult-to-treat depression did not get better with a first medication, chances of getting better increased when the person tried a new one or added a second medication to his or her treatment. The study was called STAR*D (Sequenced Treatment Alternatives to Relieve Depression).

Are herbal medicines used to treat depression?

The herbal medicine St. John's wort has been used for centuries in many folk and herbal remedies. Today in Europe, it is used widely to treat mild-to-moderate depression. In the United States, it is one of the top-selling botanical products. However, FDA has not approved its use as an over-the-counter or prescription medicine for depression. and there are serious concerns about its safety and effectiveness (For more information: NCCIH: St. John’s wort).

Research has shown that St. John's wort can dangerously interact with other prescription medications, including those used to control HIV. On February 10, 2000, the FDA issued a Public Health Advisory letter stating that the herb appears to interfere with certain medications used to treat heart disease, depression, seizures, certain cancers, and organ transplant rejection. Also, St. John’s wort may interfere with oral contraceptives.

Because St. John's wort may not mix well with other medications, people should always talk with their doctors before taking it or any herbal supplement.

FDA warning on antidepressants

Antidepressants are safe and popular, but some studies have suggested that they may have unintentional effects, especially in young people. In 2004, the FDA looked at published and unpublished data on trials of antidepressants that involved nearly 4,400 children and adolescents. They found that 4 percent of those taking antidepressants thought about or tried suicide (although no suicides occurred), compared to 2 percent of those receiving placebos (sugar pill).

The FDA adopted a "black box" warning label—the most serious type of warning—on all antidepressant medications. The warning says there is an increased risk of suicidal thinking or attempts in children, adolescents, and young adults up through age 24.

The warning also says that patients of all ages taking antidepressants should be watched closely, especially during the first few weeks of treatment. Possible side effects to look for are depression that gets worse, suicidal thinking or behavior, or any unusual changes in behavior such as trouble sleeping, agitation, or withdrawal from normal social situations. Families and caregivers should report any changes to the doctor. To find the latest information visit the FDA website .

Finally, the FDA has warned that combining the newer SSRI or SNRI antidepressants with one of the commonly-used "triptan" medications used to treat migraine headaches could cause a life-threatening illness called "serotonin syndrome." A person with serotonin syndrome may be agitated, have hallucinations (see or hear things that are not real), have a high temperature, or have unusual blood pressure changes. Serotonin syndrome is usually associated with the older antidepressants called MAOIs, but it can happen with the newer antidepressants as well, if they are mixed with the wrong medications. For more information, please see the FDA Medication Guide on Antidepressant Medicines

What medications are used to treat bipolar disorder?

Bipolar disorder, also called manic-depressive illness, is commonly treated with mood stabilizers. Sometimes, antipsychotics and antidepressants are used along with a mood stabilizer.

Mood stabilizers

People with bipolar disorder usually try mood stabilizers first. In general, people continue treatment with mood stabilizers for years. Lithium is a very effective mood stabilizer. It was the first mood stabilizer approved by the FDA in the 1970's for treating both manic and depressive episodes.

Anticonvulsant medications also are used as mood stabilizers. They were originally developed to treat seizures, but they were found to help control moods as well. One anticonvulsant commonly used as a mood stabilizer is valproic acid, also called divalproex sodium. For some people, it may work better than lithium. Other anticonvulsants used as mood stabilizers are carbamazepine, lamotrigine and oxcarbazepine.

Atypical antipsychotics

Atypical antipsychotic medications are sometimes used to treat symptoms of bipolar disorder. Often, antipsychotics are used along with other medications.

Antipsychotics used to treat people with bipolar disorder include:

Olanzapine, which helps people with severe or psychotic depression, which often is accompanied by a break with reality, hallucinations, or delusions
Aripiprazole, which can be taken as a pill or as a shot
Risperidone
Ziprasidone
Clozapine, which is often used for people who do not respond to lithium or anticonvulsants.
Lurasidone

Antidepressants

Antidepressants are sometimes used to treat symptoms of depression in bipolar disorder. Fluoxetine, paroxetine, or sertraline are a few that are used. However, people with bipolar disorder should not take an antidepressant on its own. Doing so can cause the person to rapidly switch from depression to mania, which can be dangerous. To prevent this problem, doctors give patients a mood stabilizer or an antipsychotic along with an antidepressant.

Research on whether antidepressants help people with bipolar depression is mixed. An NIMH-funded study found that antidepressants were no more effective than a placebo to help treat depression in people with bipolar disorder. The people were taking mood stabilizers along with the antidepressants. You can find out more about this study, called STEP-BD (Systematic Treatment Enhancement Program for Bipolar Disorder), here.

What are the side effects?

Treatments for bipolar disorder have improved over the last 10 years. But everyone responds differently to medications. If you have any side effects, tell your doctor right away. He or she may change the dose or prescribe a different medication.

Different medications for treating bipolar disorder may cause different side effects. Some medications used for treating bipolar disorder have been linked to unique and serious symptoms, which are described below.

Lithium can cause several side effects, and some of them may become serious. They include:

Loss of coordination
Excessive thirst
Frequent urination
Blackouts
Seizures
Slurred speech
Fast, slow, irregular, or pounding heartbeat
Hallucinations (seeing things or hearing voices that do not exist)
Changes in vision
Itching, rash
Swelling of the eyes, face, lips, tongue, throat, hands, feet, ankles, or lower legs.

If a person with bipolar disorder is being treated with lithium, he or she should visit the doctor regularly to check the levels of lithium in the blood, and make sure the kidneys and the thyroid are working normally.

Some possible side effects linked with valproic acid/divalproex sodium include:

Changes in weight
Nausea
Stomach pain
Vomiting
Anorexia
Loss of appetite.

Valproic acid may cause damage to the liver or pancreas, so people taking it should see their doctors regularly.

Valproic acid may affect young girls and women in unique ways. Sometimes, valproic acid may increase testosterone (a male hormone) levels in teenage girls and lead to a condition called polycystic ovarian syndrome (PCOS) . PCOS is a disease that can affect fertility and make the menstrual cycle become irregular, but symptoms tend to go away after valproic acid is stopped. It also may cause birth defects in women who are pregnant.

Lamotrigine can cause a rare but serious skin rash that needs to be treated in a hospital. In some cases, this rash can cause permanent disability or be life-threatening.

In addition, valproic acid, lamotrigine, carbamazepine, oxcarbazepine and other anticonvulsant medications (listed in the chart at the end of this document) have an FDA warning. The warning states that their use may increase the risk of suicidal thoughts and behaviors. People taking anticonvulsant medications for bipolar or other illnesses should be closely monitored for new or worsening symptoms of depression, suicidal thoughts or behavior, or any unusual changes in mood or behavior. People taking these medications should not make any changes without talking to their health care professional.

Other medications for bipolar disorder may also be linked with rare but serious side effects. Always talk with the doctor or pharmacist about any potential side effects before taking the medication.

For information on side effects of antipsychotics, see the section on medications for treating schizophrenia. .

For information on side effects and FDA warnings of antidepressants, see the section on medications for treating depression. .

How should medications for bipolar disorder be taken?

Medications should be taken as directed by a doctor. Sometimes a person's treatment plan needs to be changed. When changes in medicine are needed, the doctor will guide the change. A person should never stop taking a medication without asking a doctor for help.

There is no cure for bipolar disorder, but treatment works for many people. Treatment works best when it is continuous, rather than on and off. However, mood changes can happen even when there are no breaks in treatment. Patients should be open with their doctors about treatment. Talking about how treatment is working can help it be more effective.

It may be helpful for people or their family members to keep a daily chart of mood symptoms, treatments, sleep patterns, and life events. This chart can help patients and doctors track the illness. Doctors can use the chart to treat the illness most effectively.

Because medications for bipolar disorder can have serious side effects, it is important for anyone taking them to see the doctor regularly to check for possibly dangerous changes in the body.

What medications are used to treat anxiety disorders?

Antidepressants, anti-anxiety medications, and beta-blockers are the most common medications used for anxiety disorders.

Anxiety disorders include:

Obsessive compulsive disorder (OCD)
Post-traumatic stress disorder (PTSD)
Generalized anxiety disorder (GAD)
Panic disorder
Social anxiety disorder.

Antidepressants

Antidepressants were developed to treat depression, but they also help people with anxiety disorders. SSRIs such as fluoxetine, sertraline, escitalopram, paroxetine, and citalopram are commonly prescribed for panic disorder, OCD, PTSD, and social anxiety disorder. The SNRI venlafaxine is commonly used to treat GAD. The antidepressant bupropion is also sometimes used. When treating anxiety disorders, antidepressants generally are started at low doses and increased over time.

Some tricyclic antidepressants work well for anxiety. For example, imipramine is prescribed for panic disorder and GAD. Clomipramine is used to treat OCD. Tricyclics are also started at low doses and increased over time.

MAOIs are also used for anxiety disorders. Doctors sometimes prescribe phenelzine, tranylcypromine, and isocarboxazid. People who take MAOIs must avoid certain food and medicines that can interact with their medicine and cause dangerous increases in blood pressure. For more information, see the section on medications for treating depression. .

Benzodiazepines (anti-anxiety medications)

The anti-anxiety medications called benzodiazepines can start working more quickly than antidepressants. The ones used to treat anxiety disorders include:

Clonazepam, which is used for social phobia and GAD
Lorazepam, which is used for panic disorder
Alprazolam, which is used for panic disorder and GAD.

People can build a tolerance to benzodiazepines if they are taken over a long period of time and may need higher and higher doses to get the same effect. Some people may become dependent on them. To avoid these problems, doctors usually prescribe the medication for short periods, a practice that is especially helpful for people who have substance abuse problems or who become dependent on medication easily. If people suddenly stop taking benzodiazepines, they may get withdrawal symptoms, or their anxiety may return. Therefore, they should be tapered off slowly.

Buspirone is an anti-anxiety medication used to treat GAD. Unlike benzodiazepines, however, it takes at least two weeks for buspirone to begin working.

Clonazepam, listed above, is an anticonvulsant medication. See FDA warning on anticonvulsants under the bipolar disorder section. .

Beta-blockers

Beta-blockers control some of the physical symptoms of anxiety, such as trembling and sweating. Propranolol is a beta-blocker usually used to treat heart conditions and high blood pressure. The medicine also helps people who have physical problems related to anxiety. For example, when a person with social phobia must face a stressful situation, such as giving a speech, or attending an important meeting, a doctor may prescribe a beta-blocker. Taking the medicine for a short period of time can help the person keep physical symptoms under control.

What are the side effects?

See the section on antidepressants for a discussion on side effects. The most common side effects for benzodiazepines are drowsiness and dizziness. Other possible side effects include:

Upset stomach
Blurred vision
Headache
Confusion
Grogginess
Nightmares.

As noted above, long-term use of benzodiazepines can lead to tolerance (needing more of the medication to get the same effect) and dependence. To avoid these problems, doctors usually prescribe the medication for short periods. Recent research has found that benzodiazepines are prescribed especially frequently for older people. See the section on older adults for information on medication use in this age group.

Possible side effects from buspirone include:

Dizziness
Headaches
Nausea
Nervousness
Lightheadedness
Excitement
Trouble sleeping.

Common side effects from beta-blockers include:

Fatigue
Cold hands
Dizziness
Weakness.

In addition, beta-blockers generally are not recommended for people with asthma or diabetes because they may worsen symptoms.

Like benzodiazepines, buspirone and beta-blockers are usually taken on a short-term basis for anxiety. Both should be tapered off slowly. Talk to the doctor before stopping any anti-anxiety medication.

What medications are used to treat ADHD?

Attention deficit/hyperactivity disorder (ADHD) occurs in both children and adults. ADHD is commonly treated with stimulants, such as:

Methylphenidate
Amphetamine
Dextroamphetamine Lisdexamfetamine Dimesylate

In 2002, the FDA approved the nonstimulant medication atomoxetine for use as a treatment for ADHD.

What are the side effects?

Most side effects are minor and disappear when dosage levels are lowered. The most common side effects include:

Decreased appetite. Children seem to be less hungry during the middle of the day, but they are often hungry by dinnertime as the medication wears off.
Sleep problems. If a child cannot fall asleep, the doctor may prescribe a lower dose. The doctor might also suggest that parents give the medication to their child earlier in the day, or stop the afternoon or evening dose. To help ease sleeping problems, a doctor may add a prescription for a low dose of an antidepressant or a medication called clonidine.
Stomachaches and headaches.
Less common side effects. A few children develop sudden, repetitive movements or sounds called tics. These tics may or may not be noticeable. Changing the medication dosage may make tics go away. Some children also may appear to have a personality change, such as appearing "flat" or without emotion. Talk with your child's doctor if you see any of these side effects.

How are ADHD medications taken?

Stimulant medications can be short-acting or long-acting, and can be taken in different forms such as a pill, patch, or powder. Long-acting, sustained and extended release forms allow children to take the medication just once a day before school. Parents and doctors should decide together which medication is best for the child and whether the child needs medication only for school hours or for evenings and weekends too.

ADHD medications help many children and adults who are hyperactive and impulsive. They help people focus, work, and learn. Stimulant medication also may improve physical coordination. However, different people respond differently to medications, so children taking ADHD medications should be watched closely.

Are ADHD medications safe?

Stimulant medications are safe when given under a doctor's supervision. Some children taking them may feel slightly different or "funny."

Some parents worry that stimulant medications may lead to drug abuse or dependence, but there is little evidence of this. Research shows that teens with ADHD who took stimulant medications were less likely to abuse drugs than those who did not take stimulant medications.

FDA warning on possible rare side effects

In 2007, the FDA required that all makers of ADHD medications develop Patient Medication Guides (View the available guides on the FDA website ). The guides must alert patients to possible heart and psychiatric problems related to ADHD medicine. The FDA required the Patient Medication Guides because a review of data found that ADHD patients with heart conditions had a slightly higher risk of strokes, heart attacks, and sudden death when taking the medications. The review also found a slightly higher risk (about 1 in 1,000) for medication-related psychiatric problems, such as hearing voices, having hallucinations, becoming suspicious for no reason, or becoming manic. This happened to patients who had no history of psychiatric problems.

The FDA recommends that any treatment plan for ADHD include an initial health and family history examination. This exam should look for existing heart and psychiatric problems.

The non-stimulant ADHD medication called atomoxetine carries another warning. Studies show that children and teenagers with ADHD who take atomoxetine are more likely to have suicidal thoughts than children and teenagers with ADHD who do not take atomoxetine. If your child is taking atomoxetine, watch his or her behavior carefully. A child may develop serious symptoms suddenly, so it is important to pay attention to your child's behavior every day. Ask other people who spend a lot of time with your child, such as brothers, sisters, and teachers, to tell you if they notice changes in your child's behavior. Call a doctor right away if your child shows any of the following symptoms:

Acting more subdued or withdrawn than usual
Feeling helpless, hopeless, or worthless
New or worsening depression
Thinking or talking about hurting himself or herself
Extreme worry
Agitation
Panic attacks
Trouble sleeping
Irritability
Aggressive or violent behavior
Acting without thinking
Extreme increase in activity or talking
Frenzied, abnormal excitement
Any sudden or unusual changes in behavior.

While taking atomoxetine, your child should see a doctor often, especially at the beginning of treatment. Be sure that your child keeps all appointments with his or her doctor.

Which groups have special needs when taking psychiatric medications?

Psychiatric medications are taken by all types of people, but some groups have special needs, including:

Children and adolescents
Older adults
Women who are pregnant or may become pregnant.

Children and adolescents

Most medications used to treat young people with mental illness are safe and effective. However, many medications have not been studied or approved for use with children. Researchers are not sure how these medications affect a child's growing body. Still, a doctor can give a young person an FDA-approved medication on an "off-label" basis. This means that the doctor prescribes the medication to help the patient even though the medicine is not approved for the specific mental disorder or age.

For these reasons, it is important to watch young people who take these medications. Young people may have different reactions and side effects than adults. Also, some medications, including antidepressants and ADHD medications, carry FDA warnings about potentially dangerous side effects for young people. See the sections on antidepressants and ADHD medications for more information about these warnings. More research is needed on how these medications affect children and adolescents.

In addition to medications, other treatments for young people with mental disorders should be considered. Psychotherapy, family therapy, educational courses, and behavior management techniques can help everyone involved cope with the disorder. Read more about child and adolescent mental health research.

Older adults

Because older people often have more medical problems than other groups, they tend to take more medications than younger people, including prescribed, over-the-counter, and herbal medications. As a result, older people have a higher risk for experiencing bad drug interactions, missing doses, or overdosing.

Older people also tend to be more sensitive to medications. Even healthy older people react to medications differently than younger people because their bodies process it more slowly. Therefore, lower or less frequent doses may be needed. Before starting a medication, older people and their family members should talk carefully with a physician about whether a medication can affect alertness, memory, or coordination, and how to help ensure that prescribed medications will not increase the risk of falls.

Sometimes memory problems affect older people who take medications for mental disorders. An older adult may forget his or her regular dose and take too much or not enough. A good way to keep track of medicine is to use a seven-day pill box, which can be bought at any pharmacy. At the beginning of each week, older adults and their caregivers fill the box so that it is easy to remember what medicine to take. Many pharmacies also have pillboxes with sections for medications that must be taken more than once a day.

For more information and practical tips to help older people take their medicines safely, please see National Institute on Aging’s Safe Use of Medicines booklet and Taking Medicines on NIHSeniorHealth.gov.

Women who are pregnant or may become pregnant

The research on the use of psychiatric medications during pregnancy is limited. The risks are different depending on what medication is taken, and at what point during the pregnancy the medication is taken. Research has shown that antidepressants, especially SSRIs, are safe during pregnancy. Birth defects or other problems are possible, but they are very rare.

However, antidepressant medications do cross the placental barrier and may reach the fetus. Some research suggests the use of SSRIs during pregnancy is associated with miscarriage or birth defects, but other studies do not support this. Studies have also found that fetuses exposed to SSRIs during the third trimester may be born with "withdrawal" symptoms such as breathing problems, jitteriness, irritability, trouble feeding, or hypoglycemia (low blood sugar).

Most studies have found that these symptoms in babies are generally mild and short-lived, and no deaths have been reported. On the flip side, women who stop taking their antidepressant medication during pregnancy may get depression again and may put both themselves and their infant at risk.

In 2004, the FDA issued a warning against the use of certain antidepressants in the late third trimester. The warning said that doctors may want to gradually taper pregnant women off antidepressants in the third trimester so that the baby is not affected. After a woman delivers, she should consult with her doctor to decide whether to return to a full dose during the period when she is most vulnerable to postpartum depression.

Some medications should not be taken during pregnancy. Benzodiazepines may cause birth defects or other infant problems, especially if taken during the first trimester. Mood stabilizers are known to cause birth defects. Benzodiazepines and lithium have been shown to cause "floppy baby syndrome," which is when a baby is drowsy and limp, and cannot breathe or feed well.

Research suggests that taking antipsychotic medications during pregnancy can lead to birth defects, especially if they are taken during the first trimester. But results vary widely depending on the type of antipsychotic. The conventional antipsychotic haloperidol has been studied more than others, and has been found not to cause birth defects.

After the baby is born, women and their doctors should watch for postpartum depression, especially if they stopped taking their medication during pregnancy. In addition, women who nurse while taking psychiatric medications should know that a small amount of the medication passes into the breast milk. However, the medication may or may not affect the baby. It depends on the medication and when it is taken. Women taking psychiatric medications and who intend to breastfeed should discuss the potential risks and benefits with their doctors.

Decisions on medication should be based on each woman's needs and circumstances. Medications should be selected based on available scientific research, and they should be taken at the lowest possible dose. Pregnant women should be watched closely throughout their pregnancy and after delivery.

What should I ask my doctor if I am prescribed a psychiatric medication?

You and your family can help your doctor find the right medications for you. The doctor needs to know your medical history; family history; information about allergies; other medications, supplements or herbal remedies you take; and other details about your overall health. You or a family member should ask the following questions when a medication is prescribed:

What is the name of the medication?
What is the medication supposed to do?
How and when should I take it?
How much should I take?
What should I do if I miss a dose?
When and how should I stop taking it?
Will it interact with other medications I take?
Do I need to avoid any types of food or drink while taking the medication? What should I avoid?
Should it be taken with or without food?
Is it safe to drink alcohol while taking this medication?
What are the side effects? What should I do if I experience them?
Is the Patient Package Insert for the medication available?

After taking the medication for a short time, tell your doctor how you feel, if you are having side effects, and any concerns you have about the medicine.

Source: National Institute of Mental Health, NIH