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Definition Obsessive-compulsive disorder (OCD) is a potentially disabling anxiety disorder. The person afflicted with OCD becomes trapped in a pattern of repetitive senseless thoughts and behaviors that are very difficult to overcome. A person's level of OCD can be anywhere from mild to severe, but if severe and left untreated, it can destroy a person's capacity to function at work, at school or even to lead a comfortable existence in the home. For many years, mental health professionals thought of OCD as a rare disease because only a small minority of their patients admitted to having the condition. The disorder often went unrecognized because many of those afflicted with OCD, ashamed of their repetitive thoughts and behaviors, failed to seek treatment. This led to underestimates of the number of people with the illness. However, a survey conducted in the early 1980s by the National Institute of Mental Health (NIMH) provided new knowledge about the prevalence of OCD. The NIMH survey showed that OCD affects more than 2 percent of the population, meaning that OCD is more common than such severe mental illnesses as schizophrenia, bipolar disorder or panic disorder. OCD strikes people of all ethnic groups. Males and females are equally affected. Although OCD symptoms typically begin during the teen years or early adulthood, research shows that some children may even develop the illness during preschool. Studies indicate that at least one-third of cases of adult OCD began in childhood. Suffering from OCD during early stages of a child's development can cause severe problems for the child. It is important that the child receive evaluation and treatment as soon as possible to prevent the child from missing important opportunities because of this disorder.   Symptoms Obsessions Unwanted repetitive ideas or impulses frequently well up in the mind of the person with OCD. Persistent paranoid fears, an unreasonable concern with becoming contaminated or an excessive need to do things perfectly, are common. Again and again, the individual experiences a disturbing thought, such as, "This bowl is not clean enough. I must keep washing it." "I may have left the door unlocked." Or "I know I forgot to put a stamp on that letter." These thoughts are intrusive, unpleasant and produce a high degree of anxiety. Compulsions In response to their obsessions, most people with OCD resort to repetitive behaviors called compulsions. The most common of these are checking and washing. Other compulsive behaviors include repeating, hoarding, rearranging, counting (often while performing another compulsive action such as lock-checking). Mentally repeating phrases, checking or list making are also common. These behaviors generally are intended to ward off harm to the person with OCD or others. Some people with OCD have regimented rituals: Performing things the same way each time may give the person with OCD some relief from anxiety, but it is only temporary. People with OCD show a range of insight into the uselessness of their obsessions. They can sometimes recognize that their obsessions and compulsions are unrealistic. At other times they may be unsure about their fears or even believe strongly in their validity. Most people with OCD struggle to banish their unwanted thoughts and compulsive behaviors. Many are able to keep their obsessive-compulsive symptoms under control during the hours when they are engaged at school or work. But over time, resistance may weaken, and when this happens, OCD may become so severe that time-consuming rituals take over the sufferers' lives and make it impossible for them to have lives outside the home. OCD tends to last for years, even decades. The symptoms may become less severe from time to time, and there may be long intervals when the symptoms are mild, but for most individuals with OCD, the symptoms are chronic.   Causes The old belief that OCD was the result of life experiences has become less valid with the growing focus on biological factors. The fact that OCD patients respond well to specific medications that affect the neurotransmitter serotonin suggests the disorder has a neurobiological basis. For that reason, OCD is no longer attributed only to attitudes a patient learned in childhood -- inordinate emphasis on cleanliness, or a belief that certain thoughts are dangerous or unacceptable. The search for causes now focuses on the interaction of neurobiological factors and environmental influences, as well as cognitive processes. OCD is sometimes accompanied by depression, eating disorders, substance abuse, a personality disorder, attention deficit disorder or another of the anxiety disorders. Coexisting disorders can make OCD more difficult both to diagnose and to treat. Symptoms of OCD are seen in association with some other neurological disorders. There is an increased rate of OCD in people with Tourette's syndrome, an illness characterized by involuntary movements and vocalizations. Investigators are currently studying the hypothesis that a genetic relationship exists between OCD and the tic disorders. Other illnesses that may be linked to OCD are trichotillomania (the repeated urge to pull out scalp hair, eyelashes, eyebrows or other body hair), body dysmorphic disorder (excessive preoccupation with imaginary or exaggerated defects in appearance) and hypochondriasis (the fear of having -- despite medical evaluation and reassurance -- a serious disease). Researchers are investigating the place of OCD within a spectrum of disorders that may share certain biological or psychological bases. It is currently unknown how closely related OCD is to other disorders such as trichotillomainia, body dysmorphic disorder and hypochondriasis. There are also theories about OCD linking it to the interaction between behavior and the environment, which are not incompatible with biological explanations. A person with OCD has obsessive and compulsive behaviors that are extreme enough to interfere with everyday life. People with OCD should not be confused with a much larger group of people sometimes called "compulsive" for being perfectionists and highly organized. This type of "compulsiveness" often serves a valuable purpose, contributing to a person's self-esteem and success on the job. In that respect, it differs from the life-wrecking obsessions and rituals of the person with OCD.   Treatment Clinical and animal research sponsored by NIMH and other scientific organizations has provided information leading to both pharmacological and behavioral treatments that can benefit the person with OCD. One patient may benefit significantly from behavior therapy, yet another will benefit from pharmacotherapy. And others may benefit best from both. Others may begin with medication to gain control over their symptoms and then continue with behavior therapy. Which therapy to use should be decided by the individual patient in consultation with his or her therapist. Medication Clinical trials in recent years have shown that drugs that affect the neurotransmitter serotonin can significantly decrease the symptoms of OCD. The first of these serotonin re-uptake inhibitors (SRIs) specifically approved for the use in the treatment of OCD was the tricyclic anti-depressant clomipramine (Anafranil). It was followed by other SRIs that are called "selective serotonin re-uptake inhibitors" (SSRIs). Those that have been approved by the Food and Drug Administration for the treatment of OCD are flouxetine (Prozac), fluvoxamine (Luvox) and paroxetine (Paxil). Another that has been studied in controlled clinical trials is sertraline (Zoloft). Large studies have shown that more than three-quarters of patients are helped by these medications at least a little. And in more than half of patients, medications relieve symptoms of OCD by diminishing the frequency and intensity of the obsessions and compulsions. Improvement usually takes at least three weeks or longer. If a patient does not respond well to one of these medications, or has unacceptable side effects, another SRI may give a better response. For patients who are only partially responsive to these medications, research is being conducted on the use of an SRI as the primary medication and one of a variety of medications as an additional drug (an augmenter). Medications are of help in controlling the symptoms of OCD, but often, if the medication is discontinued, relapse will follow. Behavior Therapy Traditional psychotherapy, aimed at helping the patient develop insight into his or her problem, is generally not helpful for OCD. However, a specific behavior therapy approach called "exposure and response prevention" is effective for many people with OCD. In this approach, the patient deliberately and voluntarily confronts the feared object or idea, either directly or by imagination. At the same time the patient is strongly encouraged to refrain from ritualizing, with support and structure provided by the therapist, and possibly by others whom the patient recruits for assistance. For example, a compulsive hand washer may be encouraged to touch an object believed to be contaminated, and then urged to avoid washing for several hours until the anxiety provoked has greatly decreased. Treatment then proceeds on a step-by-step basis, guided by the patient's ability to tolerate the anxiety and control the rituals. As treatment progresses, most patients gradually experience less anxiety from the obsessive thoughts and are able to resist the compulsive urges. Studies of behavior therapy for OCD find it to be a successful treatment for the majority of patients who complete it, and the positive effects endure once treatment has ended, if there are follow-up sessions and other relapse-prevention components. According to studies, more than 300 OCD patients who were treated by exposure and response prevention, an average of 76 percent showed lasting results from 3 months to 6 years after treatment. One study provides new evidence that cognitive-behavioral therapy may prove an effective aid for those with OCD. This variant of behavior therapy emphasizes changing the OCD sufferer's beliefs and thinking patterns. Further studies are required before cognitive-behavioral therapy can be adequately evaluated. Self-Care and Family Support People with OCD will do best if they attend therapy, take all prescribed medications, seek support of family, friends, and a discussion group. When a family member suffers from obsessive-compulsive disorder it's helpful to be patient about their progress and acknowledge any successes, no matter how small. Sources:

• Diagnostic and Statistical Manual, Fourth Edition
• National Institutes of Mental Health
• National Library of Medicine

  Last Reviewed: 15 Apr 2005 Last Reviewed By: Fiery Cushman <!--

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Agoraphobia The term agoraphobia is translated from Greek as "fear of the marketplace." Agoraphobia involves intense fear and anxiety of any place or situation where escape might be difficult, leading to avoidance of situations such as being alone outside of the home; traveling in a car, bus, or airplane; being in a crowded area; or being on a bridge or in an elevator. Endurance of such situations can put a person with agoraphobia under great stress, and a panic attack may result. Such high discomfort and stress may require another person's company in such situations. Agoraphobia often accompanies another anxiety disorder, such as panic disorder or a specific phobia. If agoraphobia occurs with panic disorder, the onset is usually during the 20s; women are affected more often than men. Approximately 1.8 million American adults age 18 and over (about 0.8 percent of people in this age group in a given year) have agoraphobia without a history of panic disorder. In panic disorder, panic attacks recur and the person develops an intense apprehension of having another attack. This fear—called anticipatory anxiety or fear of fear—can be present most of the time and seriously interfere with the person's life even when a panic attack is not in progress. Agoraphobia affects about a third of all people with panic disorder. Typically, people with agoraphobia restrict themselves to a "zone of safety" that may include only the home or the immediate neighborhood. Any movement beyond the edges of this zone creates mounting anxiety. Even when they restrict themselves to "safe" situations, most people with agoraphobia continue to have panic attacks at least a few times a month. People with agoraphobia can be seriously disabled by their condition. Some are unable to work, and they may need to rely heavily on other family members, who must do the shopping and household errands, as well as accompany the affected person on rare excursions outside the "safety zone." People with this disorder may become housebound for years, with resulting impairment of social and interpersonal relationships. Thus the person with agoraphobia typically leads a life of extreme dependency as well as great discomfort.   Symptoms

• Fear of being alone
• Fear of losing control in a public place
• Fear of being in places where escape might be difficult
• Becoming housebound for prolonged periods
• Feelings of detachment or estrangement from others
• Feelings of helplessness
• Dependence upon others
• Feeling that the body is unreal
• Feeling that the environment is unreal
• Anxiety or panic attack (acute severe anxiety)
• Unusual temper or agitation with trembling or twitching

Additional symptoms that may occur:

• Lightheadedness, near fainting
• Dizziness
• Excessive sweating
• Skin flushing
• Breathing difficulty
• Chest pain
• Heartbeat sensations
• Nausea and vomiting
• Numbness and tingling
• Abdominal distress
• Confused or disordered thoughts
• Intense fear of going crazy
• Intense fear of dying

There may be a history of phobias, or the health care provider may receive a description of typical behaviors from family, friends, or the affected person. The pulse (heart rate) is often rapid, sweating is present, and the patient may have high blood pressure. A person may be described as having agoraphobia if other mental disorders or medical conditions do not provide better explanation for the person's symptoms.   Causes The etiology of most anxiety disorders, although not fully understood, has come into sharper focus in the last decade. In broad terms, the likelihood of developing anxiety involves a combination of life experiences, psychological traits, and/or genetic factors. The anxiety disorders are so heterogeneous that the relative roles of these factors are likely to differ. It is not clear why females have higher rates than males of most anxiety disorders, although some theories have suggested a role for the gonadal steroids. Other research on women's responses to stress also suggests that women experience a wider range of life events (such as those happening to friends) as stressful as compared with men who react to a more limited range of stressful events, specifically those affecting themselves or close family members.   Treatment The goal of treatment is to help the phobic person function effectively. The success of treatment usually depends upon the severity of the phobia. Systematic desensitization called "exposure therapy," is a behavioral technique used to treat phobias. It is based on having the person relax, then imagine the components of the phobia, working from the least fearful to the most fearful. Graded real-life exposure has also been used with success to help people overcome their fears. This technique involves exposure to actual situations progressing from small scale to more normal situations. For example, a person might be in contact with a few people then progressively spend time with more people in order to overcome fear of crowds. The individual will work with a therapist to develop coping strategies such as relaxation and breathing techniques. While "in vivo" or real-life exposure is ideal, imagined exposure is also an acceptable alternative in desensitization exercises. Treating agoraphobia with exposure therapy reduced anxiety, improved morale and quality of life within 75 percent of cases. Other types of therapy, such as cognitive therapy, assertiveness training, biofeedback, hypnosis, meditation, relaxation, or couples therapy were found to be helpful for some patients. Cognitive behavioral therapy is a combination of cognitive therapy, which can modify or eliminate thought patterns contributing to the patient's symptoms, and behavioral therapy, which aims to help the patient change his or her behavior. Treatment is complicated by the fact that patients have difficulty getting to appointments because of their fears. To address this issue, some therapists will go to an agoraphobic patient's home to conduct the initial sessions. Often therapists take their patients on excursions to shopping malls and other places the patients have been avoiding. Or they may accompany their patients who are trying to overcome fear of driving a car, for example. The patient approaches a feared situation gradually, attempting to stay in spite of rising levels of anxiety. In this way the patient sees that as frightening as the feelings are, they are not dangerous, and they do pass. On each attempt, the patient faces as much fear as he or she can stand. Patients find that with this step-by-step approach, aided by encouragement and skilled advice from the therapist, they can gradually master their fears and enter situations that had seemed unapproachable. Many therapists assign the patient "homework" to do between sessions. Sometimes patients spend only a few sessions in one-on-one contact with a therapist and continue to work on their own with the aid of a printed manual. Often the patient will join a therapy group with others striving to overcome panic disorder or phobias, meeting with them weekly to discuss progress, exchange encouragement, and receive guidance from the therapist. 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. 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. Cognitive behavioral therapy generally requires at least 8 to 12 weeks. Some people may need a longer time in treatment to learn and implement the skills. This kind of therapy, which is reported to have a low relapse rate, is effective in eliminating panic attacks or reducing their frequency. It also reduces anticipatory anxiety and the avoidance of feared situations. Treatment with Medications In this treatment approach, which is also called pharmacotherapy, a prescription medication is used both to prevent panic attacks or reduce their frequency and severity, and to decrease the associated anticipatory anxiety. When patients find that their panic attacks are less frequent and severe, they are increasingly able to venture into situations that had been off-limits to them. In this way, they benefit from exposure to previously feared situations as well as from the medication. The three groups of medications most commonly used are the tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs), the high-potency benzodiazepines, and the monoamine oxidase inhibitors (MAOIs). Determination of which drug to use is based on considerations of safety, efficacy, and the personal needs of the patient. Some information about each of the classes of drugs follows: Tricyclics are older than SSRIs and work as well as SSRIs for anxiety disorders other than OCD. Imipramine is the tricyclic most commonly used for this condition. When Imipramine is prescribed, the patient usually starts with small daily doses that are increased every few days until an effective dosage is reached. The slow introduction of Imipramine helps minimize side effects such as dry mouth, constipation, and blurred vision. 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. These medications are started at low doses and gradually increased until they have a beneficial effect. SSRIs have fewer side effects than older antidepressants (tricyclics), 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. The high-potency benzodiazepines are a class of medications that effectively reduce anxiety. Alprazolam, clonazepam, and lorazepam are medications that belong to this class. They take effect rapidly, have few bothersome side effects, and are well-tolerated by the majority of patients. However, some patients, especially those who have had problems with alcohol or drug dependency, may become dependent on benzodiazepines. Generally, the physician prescribing one of these drugs starts the patient on a low dose and gradually increases it until panic attacks cease. This procedure minimizes side effects. Treatment with high-potency benzodiazepines is usually continued for six months to a year. One drawback of these medications is that patients may experience withdrawal symptoms—malaise, weakness, and other unpleasant effects—when the treatment is discontinued. Reducing the dose gradually generally minimizes these problems. There may also be a recurrence of panic attacks after the medication is withdrawn. Of the MAOIs, a class of antidepressants that have been shown to be effective against panic disorder, phenelzine is the most commonly used. Treatment with phenelzine usually starts with a relatively low daily dosage that is increased gradually until panic attacks cease or the patient reaches a maximum dosage of about 100 milligrams a day. Use of phenelzine or any other MAOI requires the patient to observe exacting dietary restrictions, because there are foods and prescription drugs and certain substances of abuse that can interact with the MAOI to cause a sudden, dangerous rise in blood pressure. All patients who are taking MAOIs should obtain their physician's guidance concerning dietary restrictions and should consult with their physician before using any over-the-counter or prescription medications. Treatment with any of the previous medications such as high-potency benzodiazepines, imipramine, phenelzine or another MAOI generally lasts six months to a year. At the conclusion of the treatment period, the medication is gradually tapered. Combination Treatments Some patients with anxiety disorders may benefit from psychotherapy and pharmacotherapy treatment modalities, either combined or used in sequence. The combined approach is said to offer rapid relief, high effectiveness, and a low relapse rate. Drawing from the experiences of depression researchers, it seems likely that such combinations are not uniformly necessary and are probably more cost-effective when reserved for patients with more complex, complicated, severe, or comorbid disorders. The benefits of multimodal therapies for anxiety need further study. Comparing medications and psychological treatments and determining how well they work in combination is the goal of several studies. One study is designed to determine how treatment with imipramine compares with a cognitive-behavioral approach, and whether combining the two yields benefits over either method alone. 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. 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 and not help perpetuate their loved one's symptoms. Family members should not trivialize the disorder or demand improvement without treatment. If your family is doing either of these things, you may want to show them this information so they can become educated allies and help you succeed in therapy. Sources:

• National Institute of Mental Health
• American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Revised
• Archives of General Psychiatry
• Psychological Medicine
• National Institutes of Health - National Library of Medicine
• Public Health Service (1999). Mental Health: A Report of the Surgeon General

  Last Reviewed: 04 Dec 2007 Last Reviewed By: Laura Stephens <!--

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Bipolar Disorder Bipolar disorder, also known as manic-depressive illness, is a brain disorder that causes unusual shifts in mood, energy, and ability to function. These are not the normal ups and downs; the symptoms of bipolar disorder are severe. They can result in damaged relationships, poor job or school performance, and even suicide. About 5.7 million American adults or about 2.6 percent of the population age 18 and older in any given year have bipolar disorder. Bipolar disorder typically develops in late adolescence or early adulthood. However, some people have their first symptoms during childhood, and some develop them late in life. Bipolar disorder is often not recognized as an illness, and people may suffer for years before it is properly diagnosed and treated. It is a long-term illness that requires careful management throughout the person's life. Bipolar disorder causes dramatic mood swings from overly high and, or, irritable to sad and hopeless, and then back again, often with periods of normal mood in between. Severe changes in energy and behavior go along with these changes. The periods of highs and lows are called episodes of mania and depression.   Symptoms Signs and symptoms of manic episode:

• Increased energy, activity, and restlessness
• Excessively high, overly good, euphoric mood
• Extreme irritability
• Racing thoughts and talking fast, jumping from one idea to another
• Distractibility or lack of concentration
• Little sleep needed
• Unrealistic beliefs in one's abilities and powers
• Poor judgment
• Spending sprees
• A lasting period of behavior that is different from usual
• Increased sexual drive
• Abuse of drugs—cocaine, alcohol, and sleep medications
• Provocative, intrusive, or aggressive behavior
• Denial that anything is wrong

A manic episode is diagnosed if elevated mood occurs with three or more of the other symptoms most of the day, nearly every day, for one week or longer. If the mood is irritable, four additional symptoms must be present. Signs and symptoms of depressive episode:

• Lasting sad, anxious, or empty mood
• Feelings of hopelessness or pessimism
• Feelings of guilt, worthlessness, or helplessness
• Loss of interest or pleasure in activities once enjoyed, including sex
• Decreased energy, a feeling of fatigue or of being "slowed down"
• Difficulty concentrating, remembering, making decisions
• Restlessness or irritability
• Sleeping too much, or inability to sleep
• Change in appetite and, or, unintended weight loss or gain
• Chronic pain or other persistent physical symptoms not caused by physical illness or injury
• Thoughts of death or suicide, or suicide attempts

A depressive episode is diagnosed if five or more of these symptoms last most of the day, nearly every day, for a period of two weeks or longer. A mild to moderate level of mania is called hypomania. Hypomania may feel good to the person who experiences it and may even be associated with good functioning and enhanced productivity. Thus, even when family and friends learn to recognize the mood swings as possible bipolar disorder, the person may deny that anything is wrong. Without proper treatment, however, hypomania can become severe mania in some people or can switch to depression. Sometimes, severe episodes of mania or depression include symptoms of psychosis. Common psychotic symptoms are hallucinations (hearing, seeing, or otherwise sensing the presence of things not actually there) and delusions (false, strongly held beliefs not influenced by logical reasoning or explained by a person's usual cultural concepts). Psychotic symptoms in bipolar disorder tend to reflect the extreme mood state at the time. For example, delusions of grandiosity, such as believing one is the president or has special powers or wealth, may occur during mania; delusions of guilt or worthlessness, such as believing that one is ruined and penniless or has committed some terrible crime, may appear during depression. People with bipolar disorder who have these symptoms are sometimes incorrectly diagnosed as having schizophrenia, another severe mental illness. It may be helpful to think of the various mood states in bipolar disorder as a spectrum. At the bottom end is severe depression, above which is moderate depression and then mild low mood, which many people call the short-lived blues. It is termed dysthymia when it is chronic. Then there is normal or balanced mood, above which comes hypomania (mild to moderate mania), and then severe mania. In some people, however, symptoms of mania and depression may occur together in what is called a mixed bipolar state. Symptoms of a mixed state often include agitation, trouble sleeping, significant change in appetite, psychosis, and suicidal thinking. A person may have a very sad, hopeless mood while at the same time feeling extremely energized. Bipolar disorder may appear to be a problem other than mental illness—for instance, alcohol or drug abuse, poor school or work performance, or strained interpersonal relationships. Such problems in fact may be signs of an underlying mood disorder. Some people with bipolar disorder become suicidal. Anyone who is thinking about committing suicide needs immediate attention, preferably from a mental health professional or a physician. Anyone who talks about suicide should be taken seriously. Risk for suicide appears to be higher earlier in the course of the illness. Therefore, recognizing bipolar disorder early and learning how best to manage it may decrease the risk of death by suicide. Course of Bipolar Disorder Episodes of mania and depression typically recur across one's life span. Between episodes, most people with bipolar disorder are free of symptoms, but as many as one-third of people have some residual symptoms. A small percentage of people experience chronic unremitting symptoms despite treatment. The classic form of the illness, which involves recurrent episodes of mania and depression, is called bipolar I disorder. Some people, however, never develop severe mania but instead experience milder episodes of hypomania that alternate with depression; this form of the illness is called bipolar II disorder. When four or more episodes of illness occur within a 12-month period, a person is said to have rapid-cycling bipolar disorder. Some people experience multiple episodes within a single week, or even within a single day. Rapid cycling tends to develop later in the course of illness and is more common among women than men. People with bipolar disorder can lead healthy and productive lives when the illness is effectively treated. Without treatment, however, the natural course of bipolar disorder tends to worsen. Over time a person may suffer more frequent rapid cycling and more severe manic and depressive episodes than those experienced when the illness first appeared. But in most cases, proper treatment can help reduce the frequency and severity of episodes and can help people with bipolar disorder maintain a good quality of life. Children and Adolescents with Bipolar Disorder Both children and adolescents can develop bipolar disorder. It is more likely to affect the children of parents who have the illness. Unlike many adults with bipolar disorder, whose episodes tend to be more clearly defined, children and young adolescents with the illness often experience very fast mood swings between depression and mania many times within a day. Children with mania are more likely to be irritable and prone to destructive tantrums than to be overly happy and elated. Mixed symptoms also are common in youths with bipolar disorder. Older adolescents who develop the illness may have more classic, adult-type episodes and symptoms. Bipolar disorder in children and adolescents can be hard to tell apart from other problems that may occur in these age groups. For example, while irritability and aggressiveness can indicate bipolar disorder, they also can be symptoms of attention-deficit hyperactivity disorder, conduct disorder, oppositional defiant disorder, or of other types of mental disorders that are more common among adults, such as major depression or schizophrenia. Drug abuse also may lead to such symptoms. For any illness, however, effective treatment depends on appropriate diagnosis. Children or adolescents with emotional and behavioral symptoms should be carefully evaluated by a mental-health professional. Conditions that Can Co-occur with Bipolar Disorder Alcohol and drug abuse are very common among people with bipolar disorder. Research findings suggest that many factors may contribute to these substance abuse problems, including self-medication of symptoms, mood symptoms either brought on or perpetuated by substance abuse, and risk factors that may influence the occurrence of both bipolar disorder and substance-use disorders. Treatment for co-occurring substance abuse, when present, is an important part of the overall treatment plan. Anxiety disorders, such as post-traumatic stress disorder and obsessive-compulsive disorder, also may be common in people with bipolar disorder. Co-occurring anxiety disorders may respond to treatments used for bipolar disorder, or they may require separate treatment.   Causes Scientists are learning about the possible causes of bipolar disorder. Most scientists now agree that there is no single cause for bipolar disorder; rather, many factors act together to produce the illness. Because bipolar disorder tends to run in families, researchers have been seeking specific genes that may increase a person's chance of developing the illness. But genes are not the whole story. Studies of identical twins, who share all the same genes, indicate that both genes and other factors play a role in bipolar disorder. If bipolar disorder was caused entirely by genetics, then the identical twin of someone with the illness would always develop the illness, and research has shown that this is not the case. But if one twin has bipolar disorder, the other twin is more likely to develop the illness than is another sibling. In addition, findings suggest that bipolar disorder, like other mental illnesses, does not occur because of a single gene. It is likely that many genes act together, in combination with other factors such as the person's environment. Finding these genes, each of which contributes only a small amount toward the vulnerability to bipolar disorder, has been extremely difficult. But scientists expect that the advanced research tools now being used will lead to these discoveries and to new and better treatments for bipolar disorder. Brain-imaging studies are helping scientists learn what goes wrong in the brain to produce bipolar disorder and other mental illnesses. New brain-imaging techniques allow researchers to take pictures of the living brain at work, to examine its structure and activity, without the need for surgery or other invasive procedures. These techniques include magnetic resonance imaging (MRI), positron emission tomography (PET), and functional magnetic resonance imaging (fMRI). There is evidence from imaging studies that the brains of people with bipolar disorder may differ from the brains of healthy individuals. As the differences are more clearly identified and defined through research, scientists will gain a better understanding of the underlying causes of the illness and eventually may be able to predict which types of treatment will work most effectively.   Treatment Most people with bipolar disorder, even those with the most severe forms, can achieve substantial stabilization of their mood swings and related symptoms with proper treatment. Because bipolar disorder is a recurrent illness, long-term preventive treatment is strongly recommended and almost always indicated. A strategy that combines medication and psychosocial treatment is optimal for managing the disorder over time. In most cases, bipolar disorder is much better controlled if treatment is continuous rather than on and off. But even when there are no breaks in treatment, mood changes can occur and should be reported immediately to your doctor. The doctor may be able to prevent a full-blown episode by making adjustments to the treatment plan. Working closely with the doctor and communicating openly about treatment concerns and options can make a difference in treatment effectiveness. In addition, keeping a chart of daily mood symptoms, treatments, sleep patterns, and life events may help people with bipolar disorder and their families to better understand the illness. This chart also can help the doctor track and treat the illness most effectively. Medications While primary-care physicians who do not specialize in psychiatry also may prescribe these medications, it is recommended that people with bipolar disorder see a psychiatrist for treatment. Medications known as mood stabilizers are usually prescribed to help control bipolar disorder. Several types of mood stabilizers are available. In general, people with bipolar disorder continue treatment with mood stabilizers for years. Other medications are added when necessary, typically for shorter periods, to treat episodes of mania or depression. Lithium, the first mood-stabilizing medication approved by the U.S. Food and Drug Administration (FDA) for treatment of mania, is often very effective in controlling mania and preventing the recurrence of both manic and depressive episodes. Anticonvulsant medications such as valproate or carbamazepine also can have mood-stabilizing effects and may be especially useful for difficult-to-treat bipolar episodes. Valproate was FDA-approved in 1995 for treatment of mania. Newer anticonvulsant medications, including lamotrigine, gabapentin, and topiramate, are being studied to determine how well they work in stabilizing mood cycles. Anticonvulsant medications may be combined with lithium, or with each other, for maximum effect. Children and adolescents with bipolar disorder generally are treated with lithium, but valproate and carbamazepine also are used. Researchers are evaluating the safety and efficacy of these and other psychotropic medications in children and adolescents. There is some evidence that valproate may lead to adverse hormone changes in teenage girls and polycystic ovary syndrome in women who begin taking the medication before age 20. Therefore, young female patients taking valproate should be monitored carefully by a physician. Women with bipolar disorder who wish to conceive or who become pregnant face special challenges due to the possible harmful effects of existing mood stabilizing medications on the developing fetus and the nursing infant. Therefore, the benefits and risks of all available treatment options should be discussed with a clinician skilled in this area. New treatments with reduced risks during pregnancy and lactation are under study. Research has shown that people with bipolar disorder are at risk of switching into mania or hypomania, or of developing rapid cycling, during treatment with antidepressant medication. Therefore, mood-stabilizing medications generally are required, alone or in combination with antidepressants, to protect people with bipolar disorder from this switch. Lithium and valproate are the most commonly used mood-stabilizing drugs today. However, research studies continue to evaluate the potential mood-stabilizing effects of newer medications. Atypical antipsychotic medications, including clozapine and ziprasidone, are being studied as possible treatments for bipolar disorder. Evidence suggests clozapine may be helpful as a mood stabilizer for people who do not respond to lithium or anticonvulsants. Other research has supported the efficacy of olanzapine for acute mania, an indication that has recently received FDA approval. Olanzapine may also help relieve psychotic depression. If insomnia is a problem, a high-potency benzodiazepine medication such as clonazepam or lorazepam may be helpful. However, because these medications may be habit-forming, they are best prescribed short-term. Other types of sedative medications, such as zolpidem, are sometimes used instead. Changes to the treatment plan may be needed at various times during the course of bipolar disorder to manage the illness most effectively. A psychiatrist should guide any changes in type or dose of medication. It is important to tell the psychiatrist about all other prescription drugs, over-the-counter medications, or natural supplements you may be taking. This is important because certain medications and supplements taken together may cause adverse reactions. To reduce the chance of relapse or developing a new episode, it is important to stick to the treatment plan. Talk to your doctor if you have any concerns about the medications. Thyroid Function People with bipolar disorder often have abnormal thyroid gland function. Because too much or too little thyroid hormone alone can lead to mood and energy changes, it is important that thyroid levels are carefully monitored by a physician. People with rapid cycling tend to have co-occurring thyroid problems and may need to take thyroid pills in addition to their medications for bipolar disorder. Lithium treatment may cause low thyroid levels in some people, resulting in the need for thyroid supplementation. Medication Side Effects Before starting a new medication for bipolar disorder, always talk with your psychiatrist or pharmacist about possible side effects. Depending on the medication, side effects may include weight gain, nausea, tremors, reduced sexual drive, anxiety, hair loss, movement problems, or dry mouth. Be sure to tell the doctor about all side effects during treatment. She may be able to change the dose or offer a different medication to relieve them. Your medication should not be changed or stopped without the psychiatrist's guidance. Psychosocial Treatment As an addition to medication, psychosocial treatments—including certain forms of psychotherapy (or talk therapy)—are helpful in providing support, education, and guidance to patients and their families. Studies have shown that psychosocial interventions can lead to increased mood stability, fewer hospitalizations, and improved functioning in several areas. A licensed psychologist, social worker, or counselor typically provides these therapies and often works together with the psychiatrist to monitor progress. The number, frequency, and type of sessions should be based on the treatment needs of each person. Psychosocial interventions commonly used for bipolar disorder are cognitive behavioral therapy, psychoeducation, family therapy, and a newer technique—interpersonal and social rhythm therapy. Researchers at the National Institute of Mental Health are studying how these interventions compare to one another when added to medication treatment for bipolar disorder. Cognitive behavioral therapy helps people with bipolar disorder learn to change inappropriate or negative thought patterns and behaviors associated with the illness. Psychoeducation involves teaching people with bipolar disorder about the illness and its treatment, and how to recognize signs of relapse so that early intervention can be sought before a full-blown episode occurs. Psychoeducation may also be helpful for family members. Family therapy uses strategies to reduce the level of family distress that may either contribute to or result from the ill person's symptoms. Interpersonal and social rhythm therapy helps people with bipolar disorder both to improve interpersonal relationships and to regulate daily routines. Daily routines and sleep schedules may help protect against manic episodes. As with medication, it is important to follow the treatment plan for any psychosocial intervention to achieve the greatest benefit. Other Treatments Electroconvulsive Therapy In situations where medication, psychosocial treatment, and the combination of these interventions prove ineffective or work too slowly to relieve severe symptoms such as psychosis or suicidal thoughts, electroconvulsive therapy (ECT) may be considered. ECT may also be considered to treat acute episodes when medical conditions, including pregnancy, make the use of medications too risky. ECT is a highly effective treatment for severe depressive, manic, or mixed episodes. The possibility of long-lasting memory problems has been significantly reduced with modern ECT techniques. However, the potential benefits and risks of ECT and of available alternative interventions, should be carefully reviewed and discussed with individuals considering this treatment and, when appropriate, with family or friends. Herbal and Natural Supplements Herbal or natural supplements, such as St. John's Wort, have not been well studied, and little is known about their effects on bipolar disorder. Because the FDA does not regulate their production, different brands of these supplements can contain different amounts of active ingredient. Before trying herbal or natural supplements, it is important to discuss them with your doctor. There is evidence that St. John's Wort can reduce the effectiveness of certain medications. In addition, like prescription antidepressants, St. John's Wort may cause a switch into mania in some individuals with bipolar disorder, especially if no mood stabilizer is being taken. Omega-3 fatty acids found in fish oil are being studied to determine their usefulness, alone and when added to conventional medications, for long-term treatment of bipolar disorder. Even though episodes of mania and depression come and go, it is important to understand that bipolar disorder is a long-term illness that has no cure. Staying on treatment, even during periods without episodes, can help keep the disease under control and reduce the chance of having recurrent, worsening episodes. People with bipolar disorder may need help to get help:

• Often people with bipolar disorder do not realize how impaired they are, or they blame their problems on some cause other than mental illness.
• A person with bipolar disorder may need strong encouragement from family and friends to seek treatment. Family physicians can play an important role in providing a referral to a mental-health professional.
• Sometimes a family member or friend may need to take the person with bipolar disorder for proper mental health evaluation and treatment.
• A person who is in the midst of a severe episode may need to be hospitalized for his or her own protection and for much-needed treatment. There may be times when the person must be hospitalized against his or her wishes.
• Ongoing encouragement and support are needed after a person obtains treatment, because it may take a while to find the best treatment plan for the individual.
• In some cases, individuals with bipolar disorder may agree, when the disorder is under good control, to a preferred course of action in the event of a future manic or depressive relapse.
• Like other serious illnesses, bipolar disorder is also hard on spouses, family members, friends, and employers.
• Family members of people with bipolar disorder often have to cope with the person's serious behavioral problems, such as wild spending sprees during mania or extreme withdrawal from others during depression, and the lasting consequences of these behaviors.

Sources:

• National Institute of Mental Health
• Archives of General Psychiatry
• Scientific American
• Medicine
• Goodwin FK & Jamison KR. Manic-depressive illness. New York: Oxford University Press, 1990.
• Journal of the American Academy of Child and Adolescent Psychiatry
• National Institute of Mental Health
• Biological Psychiatry
• Journal of Psychiatric Research
• Postgraduate Medicine, 2000
• Harvard Review of Psychiatry
• Annals of Neurology
• Journal of Clinical Psychiatry
• American Journal of Psychiatry
• U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health
• Journal of the American Medical Association
• Clinical Psychology Review
• Journal of Consulting and Clinical Psychology

  Last Reviewed: 10 Jan 2008 Last Reviewed By: Laura Stephens <!--

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Depressive Disorders A depressive disorder is an illness that involves the body, mood, and thoughts. When a person has a depressive disorder, it interferes with daily life, normal functioning, and causes pain for both the person with the disorder and those who care about him or her. A depressive disorder is not the same as a passing blue mood. It is not a sign of personal weakness or a condition that can be willed or wished away. People with a depressive illness cannot merely "pull themselves together" and get better. Without treatment, symptoms can last for weeks, months, or years. Depression is a common but serious illness, and most people who experience it need treatment to get better. Appropriate treatment, however, can help most people who suffer from depression. Depressive disorders come in different forms, just as is the case with other illnesses such as heart disease. Three of the most common types of depressive disorders are described here. However, within these types there are variations in the number of symptoms as well as their severity and persistence. Major depression is manifested by a combination of symptoms (see symptom list) that interfere with the ability to work, study, sleep, eat, and enjoy once pleasurable activities. Such a disabling episode of depression may occur only once but more commonly occurs several times in a lifetime. Dysthymic disorder, also called dysthymia, involves long-term (two years or longer) less severe symptoms that do not disable, but keep one from functioning normally or from feeling good. Many people with dysthymia also experience major depressive episodes at some time in their lives. Some forms of depressive disorder exhibit slightly different characteristics than those described above, or they may develop under unique circumstances. However, not all scientists agree on how to characterize and define these forms of depression. They include: Psychotic depression, which occurs when a severe depressive illness is accompanied by some form of psychosis, such as a break with reality, hallucinations, and delusions. Postpartum depression, which is diagnosed if a new mother develops a major depressive episode within one month after delivery. 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 a depressive illness 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 respond to 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 prevalent as major depression or dysthymia, and characterized by cycling mood changes: severe highs (mania) and lows (depression).   Symptoms Not everyone who is depressed or manic experiences every symptom. Some people experience a few symptoms, some many. Severity of symptoms varies with individuals and also varies over time.

• Persistent sad, anxious, or empty mood
• Feelings of hopelessness or pessimism
• Feelings of guilt, worthlessness, or helplessness
• Loss of interest or pleasure in hobbies and activities that were once enjoyed, including sex
• Decreased energy, fatigue, being "slowed down"
• Difficulty concentrating, remembering, or making decisions
• Insomnia, early morning awakening or oversleeping
• Appetite and/or weight loss, or overeating and weight gain
• Thoughts of death or suicide, suicide attempts
• Restlessness, irritability
• Persistent physical symptoms that do not respond to treatment, such as headaches, digestive disorders and chronic pain

  Causes There is no single known cause of depression. Rather, it likely results from a combination of genetic, biochemical, environmental, and psychological factors. Research indicates that 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 responsible for regulating mood, thinking, sleep, appetite, and behavior appear to function abnormally. In addition, important neurotransmitters—chemicals that brain cells use to communicate—appear to be out of balance. But these images do not reveal why the depression has occurred. Some types of depression tend to run in families, suggesting a genetic link. However, depression can occur in people without family histories of it as well. Genetics research indicates that risk for depression results from the influence of multiple 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. Subsequent depressive episodes may occur with or without an obvious trigger. Depression in Women Women experience depression about twice as often as men. Biological, life cycle, hormonal, and other factors unique to women may be linked to their higher depression rate. Researchers have shown that hormones directly affect brain chemistry that controls emotions and mood. Some women may be susceptible to a severe form of premenstrual syndrome called premenstrual dysphoric disorder (PMDD). Women affected by PMDD typically experience depression, anxiety, irritability, and mood swings the week before menstruation, in such a way that interferes with their normal functioning. Women with debilitating PMDD do not necessarily have unusual hormone changes, but they do have different responses to these changes. They may also have a history of other mood disorders and differences in brain chemistry that cause them to be more sensitive to menstruation-related hormone changes. Scientists are exploring how the cyclical rise and fall of estrogen and other hormones may affect the brain chemistry that is associated with depressive illness. For example, women are particularly vulnerable to depression after giving birth, when hormonal and physical changes, along with the new responsibility of caring for a newborn, can be overwhelming. Many new mothers experience a brief episode of the "baby blues," but some will develop postpartum depression, a much more serious condition that requires active treatment and emotional support for the new mother. Some studies suggest that women who experience postpartum depression have had prior depressive episodes. Treatment by a sympathetic physician and the family's emotional support for the new mother are prime considerations in aiding her to recover her physical and mental well-being as well as her ability to care for and enjoy the infant. Many women also face additional stresses of work and home responsibilities, single parenthood and caring for children and aging parents, abuse, poverty, and relationship strains. It remains unclear why some women faced with enormous challenges develop depression, while others with similar challenges do not. Depression in Men Researchers estimate that at least 6 million men in the United States suffer from a depressive disorder every year. Research and clinical evidence reveal that while both women and men can develop the standard symptoms of depression, they often experience depression differently and may have different ways of coping with the symptoms. Men may be more willing to acknowledge fatigue, irritability, loss of interest in work or hobbies, and sleep disturbances rather than feelings of sadness, worthlessness, and excessive guilt. Some researchers question whether the standard definition of depression and the diagnostic tests based upon it adequately capture the condition as it occurs in men. Depression can also affect the physical health in men differently from women. One study shows that, although depression is associated with an increased risk of coronary heart disease in both men and women, only men suffer a high death rate. Instead of acknowledging their feelings, asking for help, or seeking appropriate treatment, men may turn to alcohol or drugs when they are depressed, or become frustrated, discouraged, angry, irritable, and, sometimes, violently abusive. Some men deal with depression by throwing themselves compulsively into their work, attempting to hide their depression from themselves, family, and friends. Other men may respond to depression by engaging in reckless behavior, taking risks, and putting themselves in harm's way. More than four times as many men as women die by suicide in the United States, even though women make more suicide attempts during their lives. In light of the research indicating that suicide is often associated with depression, the alarming suicide rate among men may reflect the fact that many men with depression do not obtain adequate diagnosis and treatment that may be life saving. Even if a man realizes that he is depressed, he may be less willing than a woman to seek help. Encouragement and support from concerned family members can make a difference. In the workplace, employee assistance professionals or work-site mental health programs can be of assistance in helping men understand and accept depression as a real illness that needs treatment. Depression in the Elderly Some people have the mistaken idea that it is normal for the elderly to feel depressed. On the contrary, older people feel satisfied with their lives. Sometimes, though, when depression develops, it may be dismissed as a normal part of aging. However, when older adults do have depression, it may be overlooked because seniors may show different, less obvious symptoms, and may be less inclined to experience or acknowledge feelings of sadness or grief. In addition, older adults 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, a co-existing cardiovascular illness or stroke. The majority of 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 the rate of depressive recurrences in older adults. Psychotherapy alone also can be effective in prolonging periods free of depression, especially for older adults with minor depression, and it is particularly useful for those who are unable or unwilling to take antidepressant medication. Improved recognition and treatment of depression in late life will make those years more enjoyable and fulfilling for the depressed elderly person, the family, and caretakers.   Treatment Depression, even the most severe cases, is a highly treatable disorder. As with many illnesses, the earlier that treatment can begin, the more effective it is and the greater the likelihood that recurrence can be prevented. Appropriate treatment for depression starts with a physical examination by a physician. Certain medications, as well as some medical conditions such as viral infections or a thyroid disorder, can cause the same symptoms as depression, and the physician should rule out these possibilities through examination, interview and lab tests. If a physical cause for the depression is ruled out, a psychological evaluation that includes a mental status exam should be done either by the physician or by referral to a mental health professional. He or she should discuss any family history of depression including their treatment, and get a complete history of symptoms, such as when they started, how long they have lasted, how severe they are, whether the patient had them before. And if so, whether the symptoms were treated and what treatment was given. The doctor should ask about alcohol and drug use, and if the patient has thoughts about death or suicide. Once diagnosed, a person with depression can be treated with a number of methods. The most common treatments are medication and psychotherapy. Medications Antidepressants work to normalize naturally occurring brain chemicals called neurotransmitters, notably serotonin and norepinephrine. Other antidepressants work on the neurotransmitter dopamine. The newest and most popular medications are called selective serotonin reuptake inhibitors (SSRIs). SSRIs include fluoxetine (Prozac), citalopram (Celexa), sertraline (Zoloft) and several others. Serotonin and norepinephrine reuptake inhibitors (SNRIs) are similar to SSRIs and include venlafaxine (Effexor) and duloxetine (Cymbalta). SSRIs and SNRIs are more popular than the older classes of antidepressants, such as tricyclics—named for their chemical structure—and monoamine oxidase inhibitors (MAOIs) because they tend to have fewer side effects. However, medications affect everyone differently so "no one-size-fits-all" approach to medication exists. Therefore, for some people, tricyclics or MAOIs may be the best choice. People taking MAOIs must adhere to significant food and medicinal restrictions to avoid potentially serious interactions. They must avoid certain foods that contain high levels of the chemical tyramine, which is found in many cheeses, wines and pickles, and some medications including decongestants. MAOIs interact with tyramine in such a way that may cause a sharp increase in blood pressure, which could lead to a stroke. A doctor should give a patient taking an MAOI a complete list of prohibited foods, medicines and substances. For all classes of antidepressants, patients must take regular doses for at least three to four weeks before they are likely to experience a full therapeutic effect. They should continue taking the medication for the time specified by their doctor, even if they are feeling better, in order to prevent a relapse of the depression. 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, abruptly ending an antidepressant can cause withdrawal symptoms or lead to a relapse. 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, the doctor may switch to another medication and patients should be open to trying another. NIMH-funded research has shown that patients who did not improve after taking a first medication increased their chances of becoming symptom-free 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 in conjunction with an antidepressant, especially if the patient has a co-existing mental or physical disorder. 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. Medications of any kind—prescribed, over-the-counter or borrowed—should never be mixed without consulting the doctor. All health professionals who are working with the patient should be told of all the medications that are being taken. Some drugs, though safe when taken alone, can cause severe and dangerous side effects if taken with others. Some drugs, like alcohol or street drugs, may reduce the effectiveness of antidepressants and should be avoided. 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. Based on the FDA's thorough review of published and unpublished controlled clinical trials of antidepressants of nearly 4,400 children and adolescents, the FDA was prompted, 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. Questions about any antidepressant prescribed, or problems that may be related to the medication, should be discussed with the doctor. Side Effects Antidepressants may cause mild and, usually, temporary side effects (sometimes referred to as adverse effects) in some people. Typically these are annoying, but not serious. However, any unusual reactions or side effects or those that interfere with functioning should be reported to the doctor immediately. The most common side effects of tricyclic antidepressants, and ways to deal with them, are:

• Dry mouth—it is helpful to drink sips of water, chew sugarless gum and clean teeth daily.
• Constipation—eat bran cereals, prunes, fruit and vegetables.
• Bladder problems—emptying the bladder may be troublesome, and the urine stream may not be as strong as usual; the doctor should be notified if there is marked difficulty or pain.
• Sexual problems—sexual functioning may change; if worrisome, discuss with the doctor.
• Blurred vision—this will pass soon and will not usually necessitate new glasses.
• Dizziness—rising from the bed or chair slowly is helpful.
• Drowsiness as a daytime problem—this usually passes soon. A person feeling drowsy or sedated should not drive or operate heavy equipment. The more sedating antidepressants are generally taken at bedtime to help sleep and minimize daytime drowsiness.

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

• Headache—this usually goes away.
• Nausea—this is also temporary, but even when it occurs, it is transient after each dose.
• Nervousness and insomnia (trouble falling asleep or waking often during the night)—these may occur during the first few weeks; dosage reductions or time will usually resolve them.
• Agitation (feeling jittery)—if this happens for the first time after the drug is taken and is more than transient, the doctor should be notified.
• Sexual problems—the doctor should be consulted if the problem is persistent or worrisome.

Herbal Therapy In the past few years, there has been much interest in the use of herbs in the treatment of both depression and anxiety. St. John's Wort (Hypericum perforatum), an herb used extensively in the treatment of mild to moderate depression in Europe, has aroused interest in the United States. St. John's Wort, an attractive bushy, low-growing plant covered with yellow flowers in summer, has been used for centuries in many folk and herbal remedies. Because of the widespread interest in St. John's Wort, the National Institutes of Health (NIH) conducted a three-year study, sponsored by three NIH components—the National Institute of Mental Health, the National Center for Complementary and Alternative Medicine, and the Office of Dietary Supplements. The study was designed to include 336 patients with major depression of moderate severity, randomly assigned to an eight-week trial. One third of patients received a uniform dose of St. John's Wort; another third, sertraline, a selective serotonin reuptake inhibitor (SSRI) commonly prescribed for depression; and the final third, a placebo (a pill that looks exactly like the SSRI and St. John's Wort, but has no active ingredients). The trial found that St. John's wort was no more effective than the placebo in treating major depression. A late 2008 German study reviewed and analyzed previous studies on St. John's Wort in the treatment of mild or minor depression. Their results indicated that the herbal remedy was effective and study participants experienced fewer side effects. Yet the researchers issued some caveats regarding their findings. First, the St. John's Wort that is available on the market varies widely so their results are only applicable to the preparations tested. Secondly, they cautioned against using the remedy without medical advice because St. John's Wort can affect the effectiveness of other drugs. In February 2000, the Food and Drug Administration had issued a Public Health Advisory, stating that St. John's Wort appears to interfere with certain drugs prescribed to treat conditions such as AIDS, heart disease, depression, seizures, certain cancers and organ transplant rejection. The herb also may interfere with the effectiveness of oral contraceptives. Because of these potential interactions, patients should always consult with their doctors before taking any herbal supplement. Psychotherapies Many forms of psychotherapy, including some short-term (10- to 20-week) and other regimens are longer-term, depending on the needs of the individual. Two main types of psychotherapies—cognitive-behavioral therapy (CBT) and interpersonal therapy (IPT)—have been shown to be effective in treating depression. By teaching new ways of thinking and behaving, CBT helps people change negative styles of thinking and behaving that may contribute to their depression. IPT helps people understand and work through troubled personal relationships that may cause their depression or make it worse. For mild to moderate depression, psychotherapy may be the best treatment option. However, for major depression or for certain people, psychotherapy may not be enough. Studies have indicated that for adolescents, a combination of medication and psychotherapy may be the most effective approach to treating major depression and reducing the likelihood for recurrence. Similarly, a study examining depression treatment among older adults found that patients 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 two years. Electroconvulsive therapy (ECT) is useful, particularly for individuals whose depression is severe or life threatening, or for those who cannot take antidepressant medication. ECT often is effective in cases where antidepressant medications do not provide sufficient relief of symptoms. In recent years, ECT has been much improved. A muscle relaxant is given before treatment, which is done under brief anesthesia. Electrodes are placed at precise locations on the head to deliver electrical impulses. The stimulation causes a brief (about 30 seconds) seizure within the brain. The person receiving ECT does not consciously experience the electrical stimulus. For full therapeutic benefit, at least several sessions of ECT, typically given at the rate of three per week, are required. How to Help Yourself If You Are Depressed Depressive disorders can make a person feel exhausted, worthless, helpless and hopeless. Such negative thoughts and feelings make some people feel like giving up. It is important to realize that these negative views are part of the depression and typically do not reflect actual circumstances. Negative thinking fades as treatment begins to take effect. In the meantime:

• Set realistic goals in light of the depression and assume a reasonable amount of responsibility.
• Break large tasks into small ones, set some priorities and do what you can, as you can.
• Try to be with other people and to confide in someone; it is usually better than being alone and secretive.
• Participate in activities that may make you feel better.
• Mild exercise, going to a movie or a ball game, or participating in religious, social or other activities may also help.
• Expect your mood to improve gradually, not immediately; feeling better takes time.
• It is advisable to postpone important decisions until the depression has lifted. Before deciding to make a significant transition—change jobs, get married or divorce—discuss it with others who know you well and have a more objective view of your situation.
• People rarely "snap out of" a depression. But they can feel a little better day by day.
• Remember, positive thinking will replace the negative thinking that is part of the depression, and this negative thinking will disappear as your depression responds to treatment.
• Let your family and friends help you.

How Family and Friends Can Help the Depressed Person If you know someone who is depressed, it affects you too. The most important thing anyone can do for the depressed person is to help him or her get an appropriate diagnosis and treatment. You may need to make an appointment on behalf of your friend or relative and go with her to see the doctor. Encourage him to stay in treatment, or to seek different treatment if no improvement occurs after six to eight weeks. The second most important thing is to offer emotional support. This involves understanding, patience, affection and encouragement. Engage the depressed person in conversation and listen carefully. Do not disparage feelings expressed, but point out realities and offer hope. Do not ignore remarks about suicide. Report them to the depressed person's therapist. Invite the depressed person for walks, outings, to the movies and other activities. Keep trying if he declines, but don't push her to take on too much too soon. Although diversions and company are needed, too many demands may increase feelings of failure. Remind your friend or relative that with time and treatment, the depression will lift. Sources:

• Medscape Women's Health Depression
• National Health and Nutrition Examination Survey
• Archives of Internal Medicine
• Psychopharmacology Bulletin
• Journal of the American Medical Association
• National Institute of Mental Health
• U.S. Department of Health and Human Services
• Biological Psychiatry
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• Pollack W. Mourning, melancholia, and masculinity: recognizing and treating depression in men. In: Pollack W, Levant R, eds. New Psychotherapy for Men. New York: Wiley, 1998; 147 66.
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• Rush JA, Trivedi MH, Wisniewski SR, Stewart JW, Nierenberg AA, Thase ME, Ritz L, Biggs MM, Warden D, Luther JF, Shores-Wilson K, Niederehe G, Fava M. Bupropion-SR, Sertraline, or Venlafaxine-XR after failure of SSRIs for depression. New England Journal of Medicine, 2006 Mar 23; 354(12): 1231-1242.
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  Last Reviewed: 27 Oct 2008 Last Reviewed By: Laura Stephens <!--

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