BRISBANE, Australia, May 8, 1997 – A psychiatrist today cautioned against decriminalizing cannabis following a study showing its use may hamper recovery in young people suffering early psychosis. Dr Tim Rolfe, of Dandenong Hospital, said he had observed high levels of cannabis use among young people treated for a first episode of schizophrenia-like illness. A study of 60 young adults researched at the Centre for Young People’s Mental Health in Parkville, Victoria, found 30 per cent used cannabis at least daily and a further 35 per cent at least weekly. Dr Rolfe told the Royal Australian and New Zealand College of Psychiatrists’ 32nd annual congress in Sydney that the figures were higher than those for the average population and greater than previously reported for people with a mental illness.
He could not say whether they indicated cannabis may precipitate psychosis, or whether people with psychiatric conditions were more likely to turn to cannabis. “In this study I looked at whether cannabis use affects the nature of the presentation and symptoms and so far I have seen a greater level of depression in people who are cannabis users,” Dr Rolfe told AAP. The young people, aged 16 to 30 years, were assessed again after two months of pharmacological treatment. “The trend is for those people who were previously cannabis users and then gave up to recover to a greater extent,” Dr Rolfe said. Improvement was measured using standard psychiatric assessments of attention-span and ability to experience pleasure. Dr Rolfe said after minor intervention for their psychosis, half of the cannabis users gave up, many citing their own suspicions “it might be harmful”. Dr Rolfe said the study was important in view of the ongoing debate in Australia on decriminalising cannabis. “I would be guarded about it (decriminalisation) in view of these results,” he said. Dr Rolfe said wider availability may be associated with poorer outcomes in the long term. However benefits could include the fact that young people would not hide their use from doctors, and, if it was less expensive, may direct their funds to more useful ends, “such as housing”.
Anxiety disorders are a group of mental illnesses that cause people to feel excessively frightened, distressed, or uneasy during situations in which most other people would not experience these same feelings. When they are not treated, anxiety disorders can be severely impairing and can negatively affect a person’s personal relationships or ability to work or study. In the most severe cases, anxiety disorders can make even regular and daily activities such as shopping, cooking or going outside incredibly difficult. Anxiety disorders can further cause low self-esteem, lead to substance abuse, and isolation from one’s friends and family.
Anxiety disorders are the most common mental illnesses in America: they affect around 20 percent of the population at any given time. Fortunately there are many good treatments for anxiety disorders. Unfortunately, some people do not seek treatment for their illness because they do not realize how severe their symptoms are or are too ashamed to seek help. Furthermore, these disorders are often difficult to recognize for friends, family and even some doctors.
What are the most common anxiety disorders?
Panic Disorder—Characterized by “panic attacks,” panic disorder results in sudden feelings of terror that can strike repeatedly and sometimes without warning. Physical symptoms of a panic attack include chest pain, heart palpitations, shortness of breath, dizziness, upset stomach, feelings of being disconnected and fear of dying. Some people with this disorder may experience unrealistic worry of having more panic attacks and become very ashamed and self-consciousness. This can result in some people feeling too afraid to go to certain places (e.g., airplanes, elevator), which can be very intrusive in their daily lives.
Obsessive-compulsive Disorder (OCD)—OCD is characterized by repetitive, intrusive, irrational and unwanted thoughts (obsessions) and/or rituals that seem impossible to control (compulsions). Some people with OCD have specific compulsions (e.g.,counting, arranging, cleaning) that they “must perform” multiple times each day in order to momentarily release their anxiety that something bad might happen to themselves or to someone they love. People with OCD may be aware that their symptoms don’t make sense and are excessive, but on another level they may fear that the thoughts have are having might be true.
Posttraumatic Stress Disorder (PTSD)—When people experience or witness a traumatic event such as abuse, a natural disaster, or extreme violence, it is normal to be distressed and to feel “on edge” for some time after this experience. Some people who experience traumatic events have severe symptoms such as nightmares, flashbacks, being very easily startled or scared, or feeling numb/angry/irritable/distracted. Sometimes these symptoms last for weeks or even months after the event and are so severe that they make it difficult for a person to work, have loving relationships, or “return to normal.” This is when a person may be suffering from PTSD. Many people with PTSD have difficulty discussing their symptoms because they may be too embarrassed or scared to recall their trauma. This is common in victims of sexual abuse and in combat veterans.
Phobias—A phobia is a disabling and irrational fear of something that really poses little or no actual danger for most people. This fear can be very disabling when it leads to avoidance of objects or situations that may cause extreme feelings of terror, dread and panic. “Specific” phobias center on particular objects (e.g., caterpillars, dogs) or situations (e.g., being on a bridge, flying in an airplane). Many people are very sensitive to being criticized and are ashamed of their phobias which can lead to problems with self-esteem.
Generalized Anxiety Disorder (GAD)—A severe, chronic, exaggerated worrying about everyday events is the most common symptom in people with GAD. This is a worrying that lasts for at least six months, makes it difficult to concentrate and to carry out routine activities, and happens for many hours each day in some people. Some people with this disorder anticipate the worst and often experience physical symptoms of fatigue, tension, headaches and nausea due to the severity of their anxiety.
Social Anxiety Disorder—An intense fear of social situations that leads to difficulties with personal relationships and at the workplace or in school is most common in people with social anxiety disorder. People with social anxiety disorder often have an irrational fear of being humiliated in public for “saying something stupid,” or “not knowing what to say.” People with this illness may have symptoms similar to “panic attacks” (e.g., heart palpitations, dizziness, shortness of breath) or may experience severe sweating (hyperhidrosis) when in social situations. This leads to avoidance of social situations, which can make it difficult to go to parties, school, or even family gatherings.
Other recognized anxiety disorders include: agoraphobia, acute stress disorder, anxiety disorder due to medical conditions, such as thyroid abnormalities, and substance-induced anxiety disorder, such as from too much caffeine.
Some people with other mental illnesses, such as depression or schizophrenia, may have symptoms of severe anxiety. These symptoms of worrying, panic attacks or compulsions may make treating their primary illness more complicated for mental health professionals. Therefore, complete treatment of depression or schizophrenia often requires treatment of anxiety symptoms.
People with anxiety disorders are more likely to use or abuse alcohol and other drugs including benzodiazepines (e.g., diazepam, alprazolam and clonazepam), opiates (e.g., pain-killers, heroin) or cigarettes. This is known as self-medication. Some people use drugs and alcohol to try and reduce their anxiety. This is very dangerous because even though some drugs make people feel less anxious when they are high, anxiety becomes even worse when the drugs wear off. Other people are anxious because they are intoxicated or withdrawing from drugs and alcohol.
Are there any known causes of anxiety disorders?
Although studies suggest that people are more likely to have an anxiety disorder if their parents have anxiety disorders, it has not been shown whether biology or environment plays the greater role in the development of these disorders. Some anxiety disorders have a very clear genetic link (e.g., OCD) that is being studied by scientists to help discover new treatments to target specific parts of the brain.
Some anxiety disorders can also be caused by medical illnesses. Scientists at the National Institute of Mental Health and elsewhere have discovered a link between some cases of OCD that occur following infection or exposure to a certain bacteria. This connection is described by the term Pediatric Autoimmune Neuropsychiatric Disorders (PANDAS). Other anxiety disorders can be caused by brain injury. Scientists have also found that certain areas of the brain, including a part of the brain called the amygdala, work differently in people with anxiety disorders.
The sudden appearance of severe anxiety symptoms in a person of any age requires immediate attention by both caregivers and doctors. Parents and friends should be aware that a traumatic event may be causing their loved one to become more nervous or to have other symptoms of anxiety disorders. Doctors should be aware that many medical problems including hormonal and neurological illnesses can cause symptoms of anxiety.
What treatments are available for anxiety disorders?
Effective treatments for anxiety disorders include psychotherapy, aerobic exercise and medications. Some psychotherapy techniques known as behavioral therapies or cognitive behavioral therapies are most useful in the treatment of anxiety disorders and are referred to as “first-line treatments.” Cognitive behavioral therapy involves examining the connection between thoughts, feelings, and behaviors. This is used to teach a person to address their fears by modifying the way he or she thinks and responds to stressful events. Relaxation techniques including mindfulness and meditation are also useful for people with anxiety disorders to decrease their stress and to help them cope with severe worrying.
In most cases, a combination of psychotherapy and medications is most beneficial for people with severe anxiety disorders. Some commonly used medications for anxiety disorders are anti-depressant medications called selective serotonin reuptake inhibitors (SSRIs). These include fluvoxamine (Luvox), paroxetine (Paxil), fluoxetine (Prozac), sertraline (Zoloft), citalopram (Celexa), and escitalopram (Lexapro). Another commonly used type of medications are benzodiazepines: including diazepam (Valium), clonazepam (Klonopin) and alprazolam (Xanax).
Ask your doctor if the medication he or she is recommending is FDA approved for your specific condition. If they are recommending a compound that is not FDA approved (an off label use), ask them to help you better understand their reasoning so you can make an informed choice.
The importance of having a good diet and getting enough sleep are known to decrease symptoms in people with anxiety disorders. Regular exercise has also been scientifically proven to be effective.
Family and friends who have loved ones with anxiety disorders should attempt to be understanding of the symptoms that their loved one is trying to overcome. Family and friends should be careful not to blame themselves but rather to encourage their loved one to seek treatment for these complicated illnesses.
Attention deficit hyperactivity disorder (ADHD) is one of the most common childhood disorders and can continue through adolescence and adulthood. Symptoms include difficulty staying focused and paying attention, difficulty controlling behavior, and hyperactivity (over-activity).
ADHD has three subtypes:
- Predominantly hyperactive-impulsive
- Most symptoms (six or more) are in the hyperactivity-impulsivity categories.
- Fewer than six symptoms of inattention are present, although inattention may still be present to some degree.
- Predominantly inattentive
- The majority of symptoms (six or more) are in the inattention category and fewer than six symptoms of hyperactivity-impulsivity are present, although hyperactivity-impulsivity may still be present to some degree.
- Children with this subtype are less likely to act out or have difficulties getting along with other children. They may sit quietly, but they are not paying attention to what they are doing. Therefore, the child may be overlooked, and parents and teachers may not notice that he or she has ADHD.
- Combined hyperactive-impulsive and inattentive
- Six or more symptoms of inattention and six or more symptoms of hyperactivity-impulsivity are present.
- Most children have the combined type of ADHD.
Scientists are not sure what causes ADHD, although many studies suggest that genes play a large role. Like many other illnesses, ADHD probably results from a combination of factors. In addition to genetics, researchers are looking at possible environmental factors, and are studying how brain injuries, nutrition, and the social environment might contribute to ADHD.
Genes. Results from several international studies of twins show that ADHD often runs in families. Researchers are looking at several genes that may make people more likely to develop the disorder. Knowing the genes involved may one day help researchers prevent the disorder before symptoms develop. Learning about specific genes could also lead to better treatments.
Children with ADHD who carry a particular version of a certain gene have thinner brain tissue in the areas of the brain associated with attention. This NIMH research showed that the difference was not permanent, however, and as children with this gene grew up, the brain developed to a normal level of thickness. Their ADHD symptoms also improved.
Environmental factors. Studies suggest a potential link between cigarette smoking and alcohol use during pregnancy and ADHD in children. In addition, preschoolers who are exposed to high levels of lead, which can sometimes be found in plumbing fixtures or paint in old buildings, may have a higher risk of developing ADHD.
Brain injuries. Children who have suffered a brain injury may show some behaviors similar to those of ADHD. However, only a small percentage of children with ADHD have suffered a traumatic brain injury.
Sugar. The idea that refined sugar causes ADHD or makes symptoms worse is popular, but more research discounts this theory than supports it. In one study, researchers gave children foods containing either sugar or a sugar substitute every other day. The children who received sugar showed no different behavior or learning capabilities than those who received the sugar substitute. Another study in which children were given higher than average amounts of sugar or sugar substitutes showed similar results.
In another study, children who were considered sugar-sensitive by their mothers were given the sugar substitute aspartame, also known as Nutrasweet. Although all the children got aspartame, half their mothers were told their children were given sugar, and the other half were told their children were given aspartame. The mothers who thought their children had gotten sugar rated them as more hyperactive than the other children and were more critical of their behavior, compared to mothers who thought their children received aspartame.
Food additives. Recent British research indicates a possible link between consumption of certain food additives like artificial colors or preservatives, and an increase in activity. Research is under way to confirm the findings and to learn more about how food additives may affect hyperactivity.
Signs & Symptoms
Inattention, hyperactivity, and impulsivity are the key behaviors of ADHD. It is normal for all children to be inattentive, hyperactive, or impulsive sometimes, but for children with ADHD, these behaviors are more severe and occur more often. To be diagnosed with the disorder, a child must have symptoms for 6 or more months and to a degree that is greater than other children of the same age.
Children who have symptoms of inattention may:
- Be easily distracted, miss details, forget things, and frequently switch from one activity to another
- Have difficulty focusing on one thing
- Become bored with a task after only a few minutes, unless they are doing something enjoyable
- Have difficulty focusing attention on organizing and completing a task or learning something new
- Have trouble completing or turning in homework assignments, often losing things (e.g., pencils, toys, assignments) needed to complete tasks or activities
- Not seem to listen when spoken to
- Daydream, become easily confused, and move slowly
- Have difficulty processing information as quickly and accurately as others
- Struggle to follow instructions.
Children who have symptoms of hyperactivity may:
- Fidget and squirm in their seats
- Talk nonstop
- Dash around, touching or playing with anything and everything in sight
- Have trouble sitting still during dinner, school, and story time
- Be constantly in motion
- Have difficulty doing quiet tasks or activities.
Children who have symptoms of impulsivity may:
- Be very impatient
- Blurt out inappropriate comments, show their emotions without restraint, and act without regard for consequences
- Have difficulty waiting for things they want or waiting their turns in games
- Often interrupt conversations or others’ activities.
ADHD Can Be Mistaken for Other Problems
Parents and teachers can miss the fact that children with symptoms of inattention have the disorder because they are often quiet and less likely to act out. They may sit quietly, seeming to work, but they are often not paying attention to what they are doing. They may get along well with other children, compared with those with the other subtypes, who tend to have social problems. But children with the inattentive kind of ADHD are not the only ones whose disorders can be missed. For example, adults may think that children with the hyperactive and impulsive subtypes just have emotional or disciplinary problems.
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.
What are the different forms of 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.
Depression is a common but serious illness. Most who experience depression need treatment to get better.
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.1
- 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). More information about bipolar disorder is available.
What are the signs and symptoms of depression?
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.
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.
What illnesses often co-exist with depression?
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.3,4 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.
In a National Institute of Mental Health (NIMH)-funded study, researchers found that more than 40 percent of people with PTSD also had depression 4 months after the traumatic event.5
Alcohol and other substance abuse or dependence may also co-exist with depression. Research shows that mood disorders and substance abuse commonly occur together.6
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.7 Treating the depression can also help improve the outcome of treating the co-occurring illness.8
What causes depression?
Most likely, depression is caused by a combination of genetic, biological, environmental, and psychological factors.
Depressive illnesses are disorders of the brain. Longstanding theories about depression suggest that important neurotransmitters—chemicals that brain cells use to communicate—are out of balance in depression. But it has been difficult to prove this.
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.
Research indicates that depressive illnesses are disorders of the brain.
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.
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.11 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.12
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.13,14
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.15
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.16
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.17
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.18
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.19
Most older adults with depression improve when they receive treatment with an antidepressant, psychotherapy, or a combination of both.20 Research has shown that medication alone and combination treatment are both effective in reducing depression in older adults.21 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.22,23
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.24
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.25
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.24,26
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.27 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 is depression diagnosed and treated?
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.
Once diagnosed, a person with depression can be treated in several ways. The most common treatments are medication and psychotherapy.
I called my doctor and talked about how I was feeling. She had me come in for a checkup and gave me the name of a specialist, who is an expert in treating depression.
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 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.
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.28,29
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.
More information about mental health medications is available on the NIMH website.
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 .
Children, adolescents, and young adults taking antidepressants should be closely monitored.
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.30 The study was funded in part by NIMH.
Also, the FDA issued a warning that combining an SSRI or SNRI antidepressant with one of the commonly-used “triptan” medications for migraine headache could cause a life-threatening “serotonin syndrome,” marked by agitation, hallucinations, elevated body temperature, and rapid changes in blood pressure. Although most dramatic in the case of the MAOIs, newer antidepressants may also be associated with potentially dangerous interactions with other medications.
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. In the United States, it is one of the top-selling botanical products.
In an 8-week trial involving 340 patients diagnosed with major depression, St. John’s wort was compared to a common SSRI and a placebo (sugar pill). The trial found that St. John’s wort was no more effective than the placebo in treating major depression.31 However, use of St. John’s wort for minor or moderate depression may be more effective. Its use in the treatment of depression remains under study.
St. John’s wort can interact with other medications, including those used to control HIV infection. 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.
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 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.27 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.23
More information on psychotherapy is available on the NIMH website.
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.
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.32
Nevertheless, patients always provide informed consent before receiving ECT, ensuring that they understand the potential benefits and risks of the treatment.
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.
The National Institute of Mental Health funds cutting-edge research into this debilitating disorder.
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.
Everything didn’t get better overnight, but I find myself more able to enjoy life and my children.
Schizophrenia is a complex form of psychopathology usually characterized by the presence of hallucinations and delusions. Schizophrenia is not like dissociative identity disorder or multiple personality, although there exists a “schizophrenic split” in the personality. That split is the source of confusion between it and multiple personality. In schizophrenia, patients are torn between their own, distorted perceptions of reality and the world’s, shared perceptions. The split comes as the schizophrenic’s distorted perception comes to dominate activity and behavior. Schizophrenics may cope with maintaining two competing views of reality for a long time, but at last they cannot, and they give in and accept their distorted view. That point is when they begin to have trouble coping with the world.
So, eventually, and without treatment, schizophrenics end up in their own world, literally. That world contains their unique perceptions as well as their unique hallucinations and delusions, which serve to maintain their perceptions. For example, auditory hallucinations are common. Nearly any mental health facility will probably admit you quickly if you admit to “hearing voices.” David Berkowitz, the “Son of Sam” killer, admitted to hearing voices from his neighbor’s dog that told him to go kill. Delusions are also common, especially delusions about drugs. One patient, for example, insisted that some crumpled flowers were opium poppies (they were not). In therapy, such patients are usually challenged when they make such statements. Left unchecked, such delusions spin the patient deeper into the schizophrenic vortex.
Schizophrenia is not just one condition. Undifferentiated schizophrenia, for instance, is probably the most common, but sufferers are less likely to get in trouble than are other schizophrenics. The onset of the condition is usually gradual. Sufferers with social networks are more likely to be treated, as their friends and family notice changes. But those who live alone may become more asocial, and simply change their lifestyle as the schizophrenia progresses. Many of the street characters seen in large US cities are undifferentiated schizophrenics. I had an extended encounter with one once. It happened at the Milwaukee public library. I was waiting for a book to be retrieved from the basement, so I was passing the time at a second floor poster exhibit. I happened to make eye contact with a young woman who was coming up the escalator. What drew my attention toward her in the first place was that she was riding up the escalator with one arm and index finger pointed skyward at a 45 degree angle. She was also dressed in an unusual manner; she had a shawl, and a long, flowing, skirt on. As she passed near me, she said, “Follow me.” I did not. I thought no more about her, until, on the way down the escalator, I noticed her arm and finger pointing over my shoulder. I left the escalator, and proceeded to the librarian’s desk with her behind me, in step, and with her arm still over my shoulder. The librarian gave me a startled look as I approached, so I just shrugged and took the book. I made my way to a library table with her still behind me. As I pulled out a chair, she stopped me, pulled out another chair, and bade me sit in it; I did.
We sat there, together and alone; then she put her purse, a large carpetbag , on the table. As I watched intently, she removed a small wadded up red ticket and a brown and white woman’s patent leather pump (a shoe). Inside the shoe was a small bar of hotel soap, still in the wrapper, that she also carefully removed, and placed in front of me.
I now was sure that I was dealing with a undifferentiated schizophrenic. Those items above very likely were laden with delusional content. To her, they were not the items I, and the rest of the world, perceived. At this point, I also inferred that she had probably been in treatment previously, and had be judged not to be a danger to herself or to others. Today, patients who wish to be discharged from treatment, and who meet that standard, may no longer be kept in inpatient care. So, with that knowledge, I planned my escape. I was worried that she would follow me home.
I simply gave her one of my library books, and told her to watch it for me. I returned the reference book the librarian had given me earlier, and left the library in a hurry. I never saw her again. There are many like her in America. They live in their own worlds, but do not cause others a great deal of discomfort, so they are usually left to their own devices. Other forms of schizophrenia cause their sufferers to become more seriously in trouble, so those patients are usually hospitalized and treated.
In catatonic schizophrenia, the schizophrenic split causes immobility. It is as though the conflict of realities is resolved by immobility, passivity, and lack of verbal behavior. In inpatient settings, catatonics may spend many hours in one place, not moving. If someone talks to them they do not respond. If their limbs are moved for them, they often leave them where they were last placed. This phenomenon is called waxiness, because it is like they are wax dolls. They do not respond well to insight therapy, or to any other therapy that depends largely on conversation. The benzodiazepine drugs, will usually bring them out of the catatonia, to a point where insight therapies can have some effect.
Disorganized schizophrenia is active, in contrast to catatonia. Disorganized schizophrenics are likely to make up their own words, neologisms, or string long chains of words or sounds together in a bizarre way (word salad). In the movie, The Ruling Class, Peter O’Toole does a masterful job of displaying the symptoms of disorganized schizophrenia in an extended scene. It is nearly impossible for an unaffected individual to maintain such behavior for a long time. It is that bizarre behavior that gets disorganized schizophrenia noticed and then treated.
Paranoid schizophrenia, another Hollywood favorite, occurs when hallucinations and delusions have a distinct paranoid quality. Paranoia, in general, occurs when individuals believe that others are out to get them. In paranoid schizophrenia, people who are schizophrenic are also paranoid. In one case, for example, a young man believed that he was the target of drug dealers’ revenge. He further believed that they drove a red Volkswagen automobile. Every time he saw a red volkswagen he would quickly hide, even when a long way from home (e.g., 2000 miles away). That behavior illustrates a delusion of reference. Normals have these often, as when seeing a person in Europe, and you believe them to be an acquaintance, but you do not know them. Schizophrenics, however, are much more likely than normals to have such delusions. Eventually, the young man grew so paranoid that he could not sleep. He had to be hospitalized when found outside fighting with imagined adversaries the morning after a sleepless night. Paranoid schizophrenics obviously pose a danger to themselves or to others. Catatonics also obviously need care, and disorganized schizophrenics do such outlandish things, that they, too, are likely to receive care.
Another way to look at schizophrenia is in terms of its development. When schizophrenia was first described by Bleuler, he called it dementia praecox, or dementia of the young. He did so because many of its victims were teenagers and young adults. Those patients likely had what today we would call reactive schizophrenia, or a schizophrenia that develops fairly rapidly, and usually in response to some particular set of events. The prognosis for reactive schizophrenia is actually quite favorable. On the other hand, some schizophrenias develop quite slowly, over the course of many years. These cases are called process schizophrenia, and the prognoses here are usually unfavorable.
Finally, some schizophrenias can be traced to specific conditions, such as drug overdose. In such cases, the schizophrenic symptoms usually disappear when the substance is removed. In one particularly bizarre case, a navy pilot became schizophrenic, and tests revealed he had been taking PCP, a potent drug (angel dust is one street name). The pilot swore he had never taken the drug, but the tests were positive and he was discharged. The pilot persisted, and he later found that he had taken the drug unknowingly via his clothes. It seems that, on a commercial flight, his luggage had been soaked by a leak of liquid PCP from someone else’s luggage. Over a period, he had built up enough of a PCP dose by wearing the clothes that had been soaked in PCP. He presented his findings, and was reinstated.
So, schizophrenia is a complex condition that manifests itself in several forms. All forms are characterized by hallucinations and delusions, and the formation of a schizophrenic split in personality. But that split is completely unlike that found in dissociative identity disorder or multiple personality.