Bipolar Support Groups.com blog

Life is full of ups and downs and often times because our brains our wired to pay attention to the negative more, the losses are magnified, rehashed and fertile ground for self-criticism. Maybe you fall short on a test, don’t get the feedback you were expecting from a work project, end an intimate relationship, keep falling into bad habits or continue falling into bouts of stress, anxiety or depression. We see all of these as negatives in life.
But the key mindset that turns on this on it’s head and catalyzes growth and happiness is the learning mindset.

This is a single thread that weaves throughout Uncovering Happiness and also the newest releaseMBSR Every Day: Daily Practices from the Heart of Mindfulness-Based Stress Reduction. 
Every single experience in life contains information to help us get better and better with our intentions in life.
If you’ve followed my writings you know I’m a big fan of a short phrase to help us grow from the inevitable obstacles of life:

Forgive, Investigate and Invite

It doesn’t matter whether you fell short in a parenting moment, a business meeting, an intimate relationship or in trying to create better habits. These are all learning opportunities for the experiences in life that are going to come our way.

• Forgive – You can forgive yourself for what happened. That was the past, you did the best you could with what you knew and what was going on. Hindsight is 20/20, it couldn’t have been any other way.
• Investigate – This isn’t meant to be self-indulgent and we don’t want to let ourselves off the hook. This is an opportunity to learn and grow. Look at what happened, investigate it to see what you’ve learned and what new understanding you might bring to the next moment.
• Invite – Now that you’re in the present moment, with this new understanding, make the choice to begin again.

From a larger perspective, you can’t possibly lose in life if everything that comes our way is an experience to learn and grow from.
This learning mindset is something to intentionally practice and repeat in life, turning it from a state of mind to a trait of your character. This can be done in the same way you learned how to walk, talk and ride a bike. As you bring it into your life over and again, the brain memorizes it as a procedural approach to life and it can start becoming more automatic.

What would the days, weeks and months ahead be like for you if you came from a learning mindset? Could you learn to get better at communicating in relationships, parenting, work, exercise, or bringing more play into your life?
Whatever answer arises, use that as motivation to apply this mindset.
Warmly
Elisha Goldstein, PhD

Staying Well When You Have a Mental Illness

When you have a mental illness, you may not realize how important your overall health is to your recovery. Having poor overall health can get in the way and make recovery harder. Finding ways to take care of your health can aid your recovery and help you feel better overall.

Here are some things you can do.

Advocate for yourself. You deserve good health care. All too often, people with mental illnesses develop other health conditions, such as heart disease and diabetes, because their health is overlooked. If your doctor is not asking about your overall health, let him know that it’s important to you and essential to your recovery.

Get the care you need. Get routine check-ups and visit your doctor when you’re not feeling well. It may be due to your medicine or a symptom of your mental illness. But it could also be a different health problem.

Manage stress. Everyone has stress. It is a normal part of life. You can feel stress in your body when you have too much to do or when you haven’t slept well. You can also feel stress when you worry about your job, money, relationships, or a friend or family member who is ill or in crisis. Stress can make you feel run down. It can also cause your mind to race and make it hard to focus on the things you need to do. If you have a mental illness, lots of stress can make you feel worse and make it harder to function. If you are feeling stressed, there are steps you can take to feel better:

Slow down and take one thing at a time. If you feel like you have too much to do, make a list and work on it one task at a time.

Know your limits. Let others know, them too. If you’re overwhelmed at home or work, or with friends, learn how to say “no.” It may be hard at first, so practice saying “no” with the people you trust most.

Practice stress reduction techniques. There are a lot of things you can do to make your life more peaceful and calm. Do something you enjoy, exercise, connect with others or meditate.

Know your triggers. What causes stress in your life? If you know where stress is coming from, you will be able to manage it better.

Talk to someone. You don’t have to deal with stress on your own. Talking to a trusted friend, family member, support group or counselor can make you feel better. They also may help you figure out how to better manage stress in your life. Plan your sleep schedule. Sleep can affect your mood and your body and is important to your recovery. Not getting the right amount of sleep can make day-to-day functioning and recovery harder.

For tips on how to sleep better, contact the National Sleep Foundation at 202-347-3471 or visit www.sleepfoundation.org. Watch what you eat. Sometimes, medicine can cause you to gain weight. Other times, eating unhealthy foods can cause weight gain. Foods high in calories and saturated or “bad” fats can raise your blood pressure and cholesterol. This can increase you chances of gaining weight and having other health problems, like heart disease and diabetes. Here are some short cuts you can take to healthy eating.

If fresh vegetables are too costly, buy frozen vegetables. They can cost less and last a long time in your freezer.

If you eat at fast food restaurants, many now offer healthy foods such as salads or grilled chicken. Talk to your doctor to learn more about how to have a healthy diet.

Exercise. Along with a healthy diet, exercise can improve your health and well-being. Exercising regularly can increase your self-esteem and confidence; reduce your feelings of stress, anxiety and depression; improve your sleep; and help you maintain a healthy weight. Find a type of exercise that you enjoy and talk to your doctor. You might enjoy walking, jogging or even dancing. You don’t have to go to a gym or spend money to exercise. Here are some things you can start doing now to get active:

Check out your local community center for free, fun activities. n Take a short walk around the block with family, friends or coworkers.

Take the stairs instead of the elevator. Make sure the stairs are well lit.

Turn on some music and dance. Do something you enjoy. During the week, find time–30 minutes, a couple of hours or whatever you can fit in–to do something you enjoy. Read a book or magazine, go for a walk or spend time with friends. Taking time for yourself to have fun and laugh can help you relax, ease stress and improve the way you feel. Connect with others. Spending time with positive, loving people you care about and trust can ease stress, help your mood and improve the way you feel overall. They may be family members, close friends, members of a support group or a counselor at the local drop-in center.

Many communities even have warm lines you can call to talk to someone.

For more information, contact your local Mental Health America affiliate, call Mental Health America at 1-800-969-6642 or visit www.mentalhealthamerica.net. If you’re in crisis now, seek help immediately. Call 1-800-273-TALK (8255) or dial 911 for immediate assistance.

Substance Abuse:

If you find yourself drinking or using drugs to cope, it is time to seek help. Although using drugs and alcohol may seem to help you cope, substance abuse can make your symptoms worse, delay your treatment and complicate recovery. It can also cause abuse or addiction problems.

To find help now, call 800-662-HELP or visit www.findtreatment.samhsa.gov. 

Smoking If you smoke, talk to your doctor about quitting. Smoking puts you at risk for problems like heart disease and cancer. For more information about quitting, call 800-QUIT-NOW or visit www.becomeanex.org

FAST FACTS:
Fast Facts Mind/Body n Stress is linked to the six leading causes of death: heart disease, cancer, lung ailments, accidents, cirrhosis of the liver and suicide. (APA, 2004)  Chronic stress can double a person’s risk of having a heart attack. (BCBS MA, 2004)  Seventy-five percent of visits to doctors’ offices concern stress-related ailments. (APA, 2004)  Chronic stress can cause premature aging. (NAS, 2004)  People who have untreated mental health issues use more general health services than those who seek mental health care when they need it. (APA, 2004)  People who have heart disease and depression are up to twice as likely to die within two years of being diagnosed with heart disease than people who have heart disease only. (PM, 2004)  People who have depression are more likely than others to develop diabetes. (AJE, 2005)

Regular physical exercise can help people reduce stress, depression and anxiety, and enable them to better cope with adversity. (UNM, 2003) n People who have major depression and anxiety disorders are significantly (60 percent) less likely to relapse if they exercise regularly—and continue exercising over time—than if they take medication alone. (Mayo Clinic, 2003) Workplace n Mental health conditions are the second leading cause of workplace absenteeism (the leading cause is musculoskeletal conditions). (APF, 2005) n One in four people report they’ve missed work as a result of work-related stress. (APA, 2004)  Even just moderate levels of depressive or anxiety symptoms can affect work performance and productivity. (JOEM, 2005)

Depression is highly associated with work limitations that affect time management, interpersonal/mental functioning and overall output. (JOEM, 2005)  Workplace environments have a greater effect on employee stress levels than the number of hours employees work. (UA, 2003)  In a typical workplace with 20 employees, four will likely develop a mental illness this year. (NIMH, 2004)  Workers who have depression report losing 5.6 hours a week due to lost productivity compared with 1.6 hours a week among workers without depression. (JOEM, 2005) Depression is associated with a 50 percent increase in missed worked days. But early and proper treatment of depression is associated with a marked decreased in disability leave time. (JOEM, 2005)  More than three out of four employees who seek care for workplace issues or mental health problems see substantial improvement in work performance after treatment. (APF, 2003)  The total healthcare costs for workers who receive treatment for depression and have complete remission of symptoms are two-thirds less than the medical costs of untreated individuals. (JOEM, 2005)  Workers at one corporation who had depression in addition to one of four chronic physical conditions (heart disease, hypertension, diabetes or back problems) spent 1.7 times more healthcare dollars than workers who had one of the physical conditions alone. (JOEM, 2005) www.nmha.org

Use these thought-provoking statistics in educational material, websites, and communications with local media and policymakers to boost awareness of mental health issues and their impact on your community—and the nation. Organized by target audience, these statistics will add punch to your Mental Health Month message!

Untreated and mistreated mental illness costs the United States. $105 billion in lost productivity each year, and U.S. businesses foot up to $44 billion of the bill. (BMJ, 1998; NMHA, 2001)  The economic burden of anxiety disorders in 1998 was $63.1 billion. (JOEM, 2005)  In 2000, the total direct cost to treat depressive disorders was $26.1 billion, while the total cost of depressive disorders in the workplace was $51.5 billion. (JOEM, 2005)  Workers who abuse drugs cost their employers twice as much in medical and worker compensation claims than workers who do not abuse drugs. (NIDA, 2004)
Although 8 percent of the U.S. adult working population has a dependence on alcohol, less than 1 percent of health plan members are diagnosed with alcohol dependence. (APF, 2005)  Employers provide the healthcare benefits to 175 million works and their families. (EBRI, 2005) Consumers and Recovery  As many as 8 million Americans who have serious mental illnesses do not receive adequate treatment each year. (HU, 2002) n The treatment success rates for such disorders as depression (more than 80 percent), panic disorder (70-90 percent) and schizophrenia (60 percent), surpass those of other medical conditions, such as heart disease (45-50 percent). (NIMH, 2004)

Although an estimated 9 percent of American adults have depression, less than 4 percent of American adults have been diagnosed with the disorder. (APF, 2005)  An estimated 2.5 million Americans have bipolar disorder. The actual number may be two to three times higher because as many as 80 percent of people with this illness go undiagnosed or misdiagnosed. (NMHA, 2003)  Treatment of panic disorder decreases healthcare utilization and costs by 94 percent. (JOEM, 2005)  People who receive treatment for depression are two-thirds less likely to miss work days due to illness. (JOEM, 2005)

Older Adults n Only about half of older adults who acknowledge that they may have mental health problems receive treatment from any health care provider, and only a fraction of those receive specialty mental health services (3 percent), the lowest rate among any adult age group. (AAGP, 2004)  Older adults who are caregivers to spouses or other relatives may be at an increased risk for developing heart disease, arthritis, osteoporosis and some cancers due to long-term stress. (OSU, 2003) n Medical treatment outcomes are worse when complicated by mental health problems.

For example, rehabilitation from a hip fracture or a heart attack is less successful and more expensive when complicated by depression. (NIMH, 2003)  About 11 percent of adults over age 55 have an anxiety disorder. (USSG, 1999)  Although 4.4 percent of older adults have a mood disorder such as depression, up to 20 percent have significant symptoms of depression. (USSG, 1999)  The highest rate of suicide for any age group (19.4 per 100,000) is among people age 85 and older. The second highest rate of suicide (17.7 per 100,000) is among those between age 75 and 84. (AAS, 2002) n Over half of older people who receive mental health care receive it from their primary care physicians. (AAGP, 2004)

Older men are far less likely to seek and receive treatment for depression than older women. (UCLA, 2003) Children and Families  Only about 21 percent of children in the United States who need mental health services actually receive them. (AJP, Sept. 2002) n About every two hours, a young person kills himself or herself. (AAS, 2002)

Three million teenagers have considered suicide or attempted suicide in the past year. (SAMHSA, 2002) n Suicide is the third leading cause of death among people under 24 years old after accidents and homicide. (CDC, 2002) www.nmha.org  The suicide rate among males between the ages of 15 and 24 has nearly quadrupled over the last 60 years, and the rate among females in the same age group has doubled. (CDC, 2002)

Five to 9 percent of children in the United States have a serious emotional disturbance. (USSG, 1999)  About 13 percent of children between 9 and 17 years old have an anxiety disorder. (USSG, 1999) About 4.1 percent of school-age children have attention-deficit hyperactivity disorder. (NIMH, 1999) n Early-childhood trauma can lead to memory problems and mental and cognitive declines later in life because early emotional stress can lead to a slow decline in neuron communication within the brain, particularly in the region associated with learning and memory recall. (JN, 2005)
Nearly 4 percent of boys and more than 6 percent of girls have symptoms of post-traumatic stress disorder caused by violence they have endured or witnessed. (JCCP, 2003)  Kids who say other students bully them at school are 50 percent more likely to admit they brought weapons to school during the past month than students who’ve never bullied or been bullied. (NICHHD, 2003) Nearly two-thirds of boys and three-quarters of girls in juvenile detention centers have a psychiatric disorder. (AGP, Dec. 2002) College Students n Seventy-seven percent of the college juniors reported feeling depressed either “frequently” or “occasionally” during the past year, compared to 61 percent who reported those feelings when they first entered college. (UCLA, 2004)

The number of students who rate their emotional health as either “below average” or in the “bottom 10 percent” more than doubled (from 6 to 14 percent) between their freshman and junior years. (UCLA, 2004)  About one-third of college students (32 percent) report that stress impedes their academic performance. Fifteen percent report that depression and anxiety are impediments to their academic performance. (ACHA, 2004)  About one student in five report that they have sought personal counseling since entering college. (UCLA, 2004)

Nearly 15 percent of college students have been diagnosed with depression. (ACHA, 2004)  Seven percent of college students have an anxiety disorder. (NIMH, 2000)  Up to 2 percent of all college-aged women have bulimia nervosa. (NEDA, 2004)  Nearly 4 percent of females will have anorexia at some point during their lifetime. (NIMH, 2004) Policymakers n Between 28 and 30 percent of the U.S. population has a mental health disorder, substance abuse disorder or both. (USSG, 1999) Untreated and mistreated mental illness costs the United States $150 billion in lost productivity and $8 billion in crime and welfare expenditures each year. A 5.5 percent increase in spending by businesses and government on mental health treatment could cut these costs by half. (CHP, 2004; NMHA, 2001)  Costs associated with the treatment of depression and anxiety disorders alone account for only 5 to 10 percent of the overall increase in health costs, with the remainder associated with costs to treatment somatic symptoms of the two disorders. (JOEM, 2005)
Although the rate of people who have received treatment for depression increased by 50 percent between 1990 and 2000, the economic burden of the disorder to society increased by only 7 percent, from about $77 billion in 1990 (adjusted for inflation) to about $83 billion in 2000. (JCP, 2003)  More than 85 million people have lacked health insurance coverage at some point in 2003 and 2004. (Families USA, 2004) One in five American families has at least one member who lacks health insurance coverage, a situation that can place the entire family at risk for financial ruin and poor health. (USCB, 2004)

Parents in 19 states surrendered custody of a total of nearly 13,000 children in 2001 to get their kids the mental heath treatment the parents could not afford. (GAO, 2003) www.nmha.org www.nmha.org  In 2002, 132,353 individuals were hospitalized following suicide attempts; 116,639 people were treated in hospital emergency departments after suicide attempts and released. (CDC, 2004)

The poor health and premature deaths of people who lack health insurance coverage cost the nation between $65 billion and $130 billion annually. (IOM, 2003)

Full mental health insurance parity will increase insurance premiums by only 0.9 percent to 1.0 percent. (APA, 2003)

Generalized Anxiety Disorder (GAD)[/size]
Generalized Anxiety Disorder (GAD) is characterized by six months or more of chronic, exaggerated worry and tension that is unfounded or much more severe than the normal anxiety most people experience. People with this disorder usually expect the worst. They worry excessively about money, health, family or work, even when there are no signs of trouble. They are unable to relax and often suffer from insomnia. Many people with GAD also have physical symptoms, such as fatigue, trembling, muscle tension, headaches, irritability or hot flashes.
Fortunately, through research supported by the National Institute of Mental Health (NIMH), effective treatments have been developed to help people with GAD.

Causes

Some research suggests that GAD may run in families, and that it may grow worse during stress. GAD usually begins at an earlier age and symptoms may manifest themselves more slowly than in most other anxiety disorders.

Treatments

Treatments for GAD include medications and behavioral or cognitive-behavioral therapy.

• Medication: Successful treatment may include antianxiety medications, such as buspirone and the benzodiazepines or antidepressants.
• Behavioral therapy: Behavioral therapy focuses on using specific relaxation techniques to change anxiety-causing behaviors. For example, one technique trains patients in a special breathing exercise involving slow, deep breaths to reduce anxiety. This is necessary because people who are anxious often hyperventilate, taking rapid, shallow breaths that can trigger rapid heartbeat, lightheadedness, and other symptoms. Another technique—exposure therapy—gradually exposes patients to what frightens them and helps them cope with their fears.
• Cognitive-behavioral therapy: Like behavioral therapy, cognitive-behavioral therapy teaches patients to react differently to the situations and bodily sensations that trigger anxiety symptoms. However, patients also learn to understand how their thinking patterns contribute to their symptoms and how to change their thoughts so that symptoms are less likely to occur. This awareness of thinking patterns is combined with behavioral techniques to help people confront their feared situations.

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Co-occurring Illnesses

Research shows that GAD often coexists with depression, substance abuse, or other anxiety disorders. Other conditions associated with stress, such as irritable bowel syndrome, often accompany GAD. Patients with physical symptoms, such as insomnia or headaches, should also tell their doctors about their feelings of worry and tension. This will help the patient’s health care provider to recognize that the person is suffering from GAD.

Types of Bipolar Disorder
There are several kinds of bipolar disorder. Each kind is defined by the length, frequency and pattern of episodes of mania and depression.

Bipolar I Disorder

Bipolar I disorder is characterized by one or more manic episodes or mixed episodes (symptoms of both a mania and a depression occurring nearly every day for at least one week) and one or more major depressive episodes. Bipolar I disorder is the most severe form of the illness marked by extreme manic episodes.

Bipolar II Disorder

While bipolar I disorder is characterized by one or more manic episodes or mixed episodes and one or more major depressive episodes; bipolar II disorder is diagnosed after one or more major depressive episodes and at least one episode of hypomania, with possible periods of level mood between episodes.
The highs in bipolar II, called hypomanias, are not as high as those in bipolar I (manias). Bipolar II disorder is sometimes misdiagnosed as major depression if hypomanic episodes go unrecognized or unreported. If you have recurring depressions that go away periodically and then return, ask yourself if you have also:

• Had periods (lasting four or more days) when your mood was especially or abnormally energetic or irritable?
• Were you:
  • Feeling abnormally self-confident or social?
  • Needing less sleep or more energetic?
  • Unusually talkative or hyper?
  • Irritable or quick to anger?
  • Thinking faster than usual?
  • More easily distracted/having trouble concentrating?
  • More goal-directed or productive at work, school or home?
  • More involved in pleasurable activities, such as spending or sex?
• Did you feel or did others say that you were doing or saying things that were unusual, abnormal or not like your usual self?

If so, talk to your health care provider about these energetic episodes, and find out if they might be hypomania. Getting a correct diagnosis of bipolar II disorder can help you find treatment that may also help lift your depression.

Not Otherwise Specified (NOS)

Bipolar disorder that does not follow a particular pattern (for example, re-occuring hypomanic episodes without depressive symptoms, or very rapid swings between some symptoms of mania and some symptoms of depression) is called bipolar disorder Not Otherwise Specified (NOS).

Cyclothymia

Cyclothymia is a milder form of bipolar disorder characterized by several hypomanic episodes and less severe episodes of depression that alternate for at least two years. The severity of this illness may change over time.

Rapid Cycling

Bipolar disorder with rapid cycling is diagnosed when a person experiences four or more manic, hypomanic, or depressive episodes in any 12-month period. Rapid cycling can occur with any type of bipolar disorder, and may be a temporary condition for some people.

Diagnosis

DBSA has found that nearly 7 of every 10 people with bipolar disorder are misdiagnosed at least once, and that the average length of time from a person’s first bipolar symptoms to correct diagnosis and treatment is 10 years. One of the reasons for this is that many people don’t report all of their symptoms. It is important for people to share all symptoms, even those not present during a health care appointment, as well as their family history to help health care providers make a correct diagnosis.
Sometimes symptoms of hypomania (a milder form of mania) are mistaken for “a really good day.” Many people don’t report symptoms of mania or hypomania because they feel good and it often doesn’t feel like an illness.

What is the difference between bipolar disorder and ordinary mood swings?

The three main things that make bipolar disorder different from ordinary mood swings are:
Intensity: Mood swings that come with bipolar disorder are usually more severe than ordinary mood swings.
Length: A bad mood is usually gone in a few days but mania or depression can last weeks or months. With rapid cycling, moods last a short time but change quickly from one extreme to another. With rapid cycling, “level” (euthymic) moods do not last long.
Interference with life: The extremes in mood that come with bipolar disorder can severely disrupt your life. For example, depression can make a person unable to get out of bed or go to work or mania can cause a person to go for days without sleep.
For more detailed information on the types of bipolar disorder and their symptoms, read the Mood Disorders section of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), which may be available at your local library.

obert M. A. Hirschfeld, M.D. APA’s Practice Guideline for the Treatment of Patients With Bipolar Disorder, 2nd Edition, was published in April 2002

(1). Since that time, a number of controlled treatment studies on aspects of bipolar disorder have been completed and published or are in press, including studies of second-generation (atypical) antipsychotics as monotherapy and as adjunctive treatment (with more traditional mood stabilizers) for the acute treatment of mania, studies of antiepileptic agents for the acute treatment of mania, trials for three medications for the acute treatment of bipolar depression, four monotherapy and one combination therapy relapse prevention studies, and studies of psychosocial interventions for maintenance. The evidence from these studies supports a substantially expanded set of options for clinicians who treat patients with bipolar disorder. This guideline watch briefly reviews the most important of the studies. The majority of the studies were industry supported.

PSYCHIATRIC MANAGEMENT Recently completed epidemiological studies have estimated the lifetime prevalence of bipolar I and II disorders in the general population to be 3.7%–3.9% (2, 3). The prevalence in samples of patients presenting with depression is much higher, ranging from 21% (4) to 26% (5) in primary care settings and from 28% (6) to 49% (7) in psychiatric clinics. Use of a screening instrument, such as the Mood Disorder Questionnaire, can substantially improve recognition of patients with bipolar disorder, particularly among depressed patients (. The American Psychiatric Association (APA) practice guidelines are developed by expert work groups using an explicit methodology that includes rigorous review of available evidence, broad peer review of iterative drafts, and formal approval by the APA Assembly and Board of Trustees. APA practice guidelines are intended to assist psychiatrists in clinical decision making. They are not intended to be a standard of care. The ultimate judgment regarding a particular clinical procedure or treatment plan must be made by the psychiatrist in light of the clinical data presented by the patient and the diagnostic and treatment options available. Guideline watches summarize significant developments in practice since publication of an APA practice guideline. Watches may be authored and reviewed by experts associated with the original guideline development effort and are approved for publication by APA’s Executive Committee on Practice Guidelines. Thus, watches represent opinion of the authors and approval of the Executive Committee but not policy of the APA. This guideline watch was published in November 2005. Copyright © 2005. American Psychiatric Association. All rights reserved. Suggested citation: Hirschfeld RMA: Guideline Watch: Practice Guideline for the Treatment of Patients With Bipolar Disorder. Arlington, VA: American Psychiatric Association. Available online athttp://www.psych.org/psych_pract/treatg/pg/prac_guide.cfm. 2 APA

Practice Guidelines Acute treatment Manic or mixed episodes Two randomized, double-blind, controlled studies have shown olanzapine monotherapy to be significantly better than placebo for the acute treatment of patients with mania or mixed episodes, with initial dosing of either 10 mg/day or 15 mg/day (9, 10). Somnolence, dry mouth, dizziness, and weight gain occurred significantly more frequently in the olanzapine group than in the placebo group. In another randomized, double-blind study, olanzapine was equivalent to haloperidol for patients with acute mania and was superior to haloperidol for patients whose index episode did not include psychotic features (11). Olanzapine monotherapy has also been compared with divalproex monotherapy in two randomized, double-blind, controlled studies. In one there was equivalent efficacy (12), and in the other olanzapine had superior efficacy (13). However, the side-effect profile for divalproex was more benign. Olanzapine has also been studied as an adjunctive agent to traditional mood stabilizers. In a double-blind, randomized, controlled trial, olanzapine added to divalproex or lithium was superior to divalproex or lithium alone in patients who had had an inadequate response to at least 2 weeks of lithium or valproate monotherapy (14). Side effects included somnolence, hyperkinesia, and nausea. The efficacy of risperidone monotherapy for the acute treatment of mania has been demonstrated in three randomized, double-blind, placebo-controlled trials. Risperidone monotherapy was superior to placebo in all three studies. In the three studies patients were started on 3 mg/day of risperidone, with titration to a maximum of 6 mg/day. Onset of action in one study was seen at day 3 (15), and in another at 1 week (16). In the third study, risperidone was equivalent to haloperidol and superior to placebo (17). Side effects included somnolence, hyperkinesia, and nausea. Two randomized, double-blind, placebo-controlled studies examined the adjunctive use of risperidone with traditional mood stabilizers (i.e., lithium or divalproex) (18, 19). In both studies the combination of risperidone with mood stabilizer outperformed mood stabilizer alone. The addition of risperidone substantially increased the prevalence of extrapyramidal symptoms. The efficacy of ziprasidone as monotherapy in the acute treatment of patients with manic or mixed episodes was tested in two randomized, double-blind, placebo-controlled studies, with initial dosing of 40 mg twice a day (20, 21). Ziprasidone had an onset of action at day 2 in both trials and was superior to placebo at endpoint. The mean dosage in the two studies was 130 mg/day and 112 mg/day, respectively. Side effects included somnolence, dizziness, extrapyramidal syndrome, nausea, akathisia, and tremor. Two studies of aripiprazole monotherapy in the acute treatment of mania have been published (22, 23). In a randomized, double-blind, controlled study, aripiprazole at a starting dosage of 30 mg/day was compared with placebo in patients with manic or mixed episodes (22). Aripiprazole was superior to placebo in efficacy, beginning at day 4. Side effects included nausea, dyspepsia, somnolence, vomiting, insomnia, and akathisia. A second study compared aripiprazole and haloperidol over 12 weeks (23). The drugs performed similarly regarding improvement in manic symptoms, but substantially more aripiprazole patients completed the study. Extrapyramidal symptoms were much higher for haloperidol. The efficacy of quetiapine in patients with manic episodes has been studied in two different 12-week randomized, double-blind, placebo-controlled trials—one against lithium and the other against haloperidol (24, 25). Quetiapine was initiated at 100 mg on day 1, with an upward titration to 800 mg/day or higher. Quetiapine was equivalent in efficacy to the two active comparators, and both were superior to placebo at day 21. Side effects included dry mouth, somnolence, weight gain, and dizziness. In another study, adjunctive quetiapine or placebo was given to acutely manic patients who were still manic after at least 7 days of treatment with lithium or divalproex. Quetiapine was initiated at 100 mg and titrated to 400 mg/day by day 4, with a target dose of 200–800 mg/day (26). Guideline Watch for the Practice Guideline for the Treatment of Patients With Bipolar Disorder 3 The quetiapine treatment group had a significantly higher response rate and reduction in manic symptoms. The mean last-week dosage in all patients receiving quetiapine was 504 mg/day. There have been two recently published randomized, double-blind, placebo-controlled studies of the extended-release formulation of the anticonvulsant carbamazepine for the acute treatment of manic or mixed episodes (27, 28). In both studies, carbamazepine extendedrelease was initiated at 400 mg in divided doses on day 1 and increased as tolerated up to 1,600 mg/day. The mean final dosages were 756 mg/day (27) and 643 mg/day (28), respectively. An onset of action was seen at day 14 in the first trial and at day 7 in the second trial, and both trials found carbamazepine extended-release to be superior to placebo at endpoint. Side effects included dizziness, somnolence, nausea, vomiting, ataxia, blurred vision, dyspepsia, dry mouth, pruritus, and speech disorder. The many monotherapy and adjunctive therapy studies of mania since 2002 provide a number of new options for clinicians in the acute treatment of patients with mania. A significant clinical concern is metabolic effects associated with second-generation antipsychotics (29). Clozapine and olanzapine are associated with increased risks of developing diabetes mellitus and dyslipidemia. A recent comparative antipsychotic trial in schizophrenia suggested significantly greater weight gain for olanzapine than for the other antipsychotics studied (i.e., perphenazine, quetiapine, risperidone, and ziprasidone) (30). Clozapine and olanzapine are associated with the most weight gain, risperidone and quetiapine with moderate weight gain, and ziprasidone and aripiprazole with minimal weight change. Because of these risks, clinicians have been advised to monitor weight, waist circumference, blood pressure, glucose, and lipids at baseline and at monthly intervals in patients on these medications (31).

Depressive episodes

The impact (in terms of duration of episodes and quality of life) of depressive episodes in bipolar patients is substantially worse than the impact of manic episodes (32, 33). Unfortunately, far less research attention has been paid to the treatment of bipolar depression (34, 35). This section reviews three studies published since the 2002 publication of the second edition practice guideline. In an 8-week placebo-controlled, double-blind study, olanzapine monotherapy and the combination of olanzapine and fluoxetine were examined in the acute treatment of bipolar I depression (36). Although both olanzapine and the combination of olanzapine and fluoxetine were superior to placebo in efficacy, the response in the combination group was much greater, and only the combination of olanzapine and fluoxetine received an indication from the Food and Drug Administration for the acute treatment of bipolar depression.

The first separation from placebo occurred at week 1 and continued throughout the trial. The mean dosage in the combination group was 7.4 mg/day of olanzapine and 39.3 mg/day of fluoxetine. By the end of the study, 8 of 10 core symptoms of depression had improved relative to placebo. Side effects included somnolence, weight gain, increased appetite, dry mouth, asthenia, and diarrhea. Neither olanzapine monotherapy nor the combination of olanzapine and fluoxetine caused switching into mania or hypomania. A large randomized, double-blind, placebo-controlled trial supported the efficacy of quetiapine monotherapy for the treatment of bipolar I or II depression (37). Quetiapine initiated at 50 mg/day and titrated to either 300 mg/day or 600 mg/day within 1 week was found to be effective compared with placebo at both doses, with no significant difference in efficacy between the two dosage groups. Onset of action occurred by 1 week and continued throughout the trial. Statistical significance was achieved at endpoint in 9 of 10 core features of depression. Side effects included dry mouth, sedation, somnolence, dizziness, and constipation and were substantially greater in the 600 mg/day group compared with the 300 mg/day group. Incidence of treatment-emergent mania did not differ from that of placebo. 4 APA

Practice Guidelines A single-blind, randomized, nonplacebo-controlled comparison of venlafaxine and paroxetine was conducted with patients with bipolar disorder who were currently presenting with a major depressive episode and who were currently taking a mood stabilizer (38). Both medications yielded significant improvements in depressive symptomatology with no significant differences in safety measures. Among the patients treated with paroxetine, 3% switched to hypomania or mania, compared with 13% in the venlafaxine group. Two small, controlled studies of the adjunctive use of the dopamine agonist pramipexole in the treatment of bipolar depression suggest efficacy (39, 40).

Both studies were 6-week placebo-controlled studies of pramipexole (mean peak dosage = 1.7 mg/day) added to the therapeutic levels of traditional mood stabilizers. Results were strongly positive in both studies, with few adverse events. In conclusion, medications having the strongest evidence for efficacy for acute treatment of depression in patients with bipolar I disorder are the olanzapine-fluoxetine combination, quetiapine, and lamotrigine. There is suggestive evidence that the adjunctive use of pramipexole may be helpful. Evidence for the efficacy of an antidepressant with adjunctive mood stabilizer is modest. Prescription of antidepressants in the absence of a mood stabilizer is not recommended for bipolar I patients. Maintenance treatment Since publication of the second edition practice guideline, new studies have been published on the long-term treatment of patients with bipolar disorder. Pharmacological interventions Two large randomized, double-blind studies examined the utility of lamotrigine in the maintenance treatment of patients with bipolar I disorder (41, 42).

Both studies were placebo controlled and included lithium monotherapy as an active comparator. In one study, patients had most recently suffered a depressive episode (41) and, in the other, a manic or hypomanic episode (42). Both studies involved an open-label stabilization period of 8–16 weeks followed by an 18-month trial of lamotrigine monotherapy, lithium monotherapy, or placebo in patients who had recovered and were stable. In the study of recently depressed patients (41), both lamotrigine (200 mg/day or 400 mg/ day) and lithium (0.8–1.1 meq/liter) were superior to placebo in preventing any mood episode. Lamotrigine, but not lithium, was superior to placebo in preventing a depressive episode. Lithium, but not lamotrigine, was superior to placebo in preventing a manic, hypomanic, or mixed episode. With the exception of rash, there were no side effects of lamotrigine that exceeded placebo. There were no serious rashes. For the lithium group, the incidence of somnolence and tremor exceeded that of placebo. In the study of recently manic or hypomanic patients (42), both lamotrigine (target dosage of 200 mg/day) and lithium (0.8–1.1 meq/liter) were superior to placebo in delaying onset of any mood episode.

Lithium, but not lamotrigine, was superior to placebo in prevention of a manic episode, but neither agent was superior to placebo in preventing depressive episodes. There were no adverse events for which lamotrigine statistically exceeded placebo. Lithium exceeded placebo for diarrhea only. When the data from both studies were pooled, lamotrigine was superior to placebo in time to intervention for any mood episode, as well as for prevention of depressive episodes and manic, hypomanic, or mixed episodes (43). Similarly, lithium was superior to placebo in time to intervention for a mood episode and for prevention of a manic, hypomanic, or mixed episode. Lithium was not superior to placebo in prevention of a depressed episode. Given the results from these studies, both lamotrigine and lithium appear to have substantial utility in the maintenance treatment of patients with bipolar disorder.

The utility of lamotrigine was somewhat greater for the prevention of depressive compared with manic episodes, and the opposite is true for lithium. Guideline Watch for the Practice Guideline for the Treatment of Patients With Bipolar Disorder 5 A 47-week, randomized, double-blind study of olanzapine versus divalproex for manic or mixed episodes was completed (44). The median time to remission was shorter for olanzapine than for divalproex, although the remission rates at the end of the study did not differ between agents. Adverse events for olanzapine included somnolence, dry mouth, increased appetite, weight gain, akathisia, and high alanine aminotransferase levels, while adverse events for divalproex were nausea and nervousness. A randomized, double-blind, controlled trial compared the efficacy of olanzapine and lithium for the prevention of relapse or recurrence of a manic or mixed episode (45). In this study patients currently experiencing a manic or mixed episode were treated acutely with olanzapine and lithium for 6–12 weeks. Patients who achieved remission were randomly assigned to 52 weeks of olanzapine or lithium monotherapy.

A relapse into mania or depression occurred in 30% of the olanzapine-treated patients and in 39% of the lithium-treated patients—an insignificant difference. Olanzapine was superior to lithium in rates of symptomatic recurrence of mania or mixed episodes (14% vs. 28%), but rates of depression recurrence did not differ. Treatment-emergent insomnia was higher in the lithium group than in the olanzapine group. Among the lithium group, 26% discontinued treatment because of side effects, compared with 19% of the olanzapine group. A randomized, double-blind, controlled study examined the utility of continued combination treatment with a mood stabilizer (lithium, carbamazepine, or valproate) and a first-generation (typical) antipsychotic (perphenazine) (46).

Immediately following remission from a manic episode, patients were randomly assigned to remain on the combination therapy or to receive the mood stabilizer plus placebo. Among those on continued combination therapy, there was shorter time to depressive relapse, a higher rate of discontinuation, and higher rates of dysphoria, depressive symptoms, and extrapyramidal symptoms. The study concluded that there were no short-term benefits with the continuation of the first-generation antipsychotic with a mood stabilizer; in fact, its continued use was associated with the aforementioned detrimental effects. However, a similar study of the second-generation antipsychotic olanzapine plus mood stabilizer versus mood stabilizer plus placebo had somewhat different results (47). In this randomized, double-blind, controlled study, patients who achieved remission after 6 weeks of treatment with olanzapine plus either lithium or valproate received continued lithium or valproate plus olanzapine or plus placebo for 18 months. There were no differences in time to relapse into mania or depression between the monotherapy and combination therapy groups, but combination therapy was significantly better for prevention of symptomatic relapse. Combination therapy was associated with increased somnolence, weight gain, and tremor.

Psychosocial interventions Knowledge of the utility of psychosocial interventions has expanded recently. Family-focused therapy is a manualized psychosocial program involving all available family members in which weekly psychoeducation, communication enhancement training, and problem-solving skills training occur adjunctively with pharmacotherapy. A 2-year randomized, controlled study of family-focused therapy plus pharmacotherapy versus a crisis management intervention and pharmacotherapy (supported by grants from the National Institute of Mental Health, the National Alliance for Research on Schizophrenia, and the MacArthur Foundation) found that postepisode symptomatic adjustment and drug adherence were enhanced with the familyfocused therapy and pharmacotherapy combination compared with the other (48). Patients in the group receiving family-focused therapy had fewer relapses and longer survival intervals. Another randomized, controlled study examined the utility of cognitive therapy in conjunction with pharmacotherapy over a 12-month period (49).

Those treated with cognitive therapy and pharmacotherapy had significantly fewer bipolar episodes, days in an episode, and number of admissions. 6 APA Practice Guidelines Two controlled studies (supported by grants from the Stanley Medical Research Institute, the Instituto de Salud Carlos III, the Fundació Marató de TV3, and the Fundació María Francisca Roviralta) of a longitudinal (21-session) psychoeducational program were conducted in Spain (50, 51). In both studies psychoeducation reduced recurrences over 2 years. Psychoeducation enhanced lifestyle regularity and early syndrome detection. A recent study (supported by grants from the National Institute of Mental Health) found that a psychosocial intervention focused on addressing interpersonal problems and regulating social rhythms during acute treatment in bipolar I patients extended the time to new episode and reduced the likelihood of recurrence (52).

CONCLUSION Since the publication in 2002 of the Practice Guideline for the Treatment of Patients With Bipolar Disorder, 2nd Edition, new options for the acute treatment of manic, mixed, or depressive episodes have emerged. Knowledge of pharmacological and psychosocial interventions for maintenance has also increased.

• Introduction
• The Growing Brain
• The Working Brain
• Brain Basics in Real Life
• Brain Research
• Glossary
• Brain Basics

Welcome. Brain Basics provides information on how the brain works, how mental illnesses are disorders of the brain, and ongoing research that helps us better understand and treat disorders.
Mental disorders are common. You may have a friend, colleague, or relative with a mental disorder, or perhaps you have experienced one yourself at some point. Such disorders include Depression, Anxiety, Bipolar Disorder, ADHD, and many others.
Some people who develop a mental illness may recover completely; others may have repeated episodes of illness with relatively stable periods in between. Still others live with symptoms of mental illness every day. They can be moderate, or serious and cause severe disability.
Through research, we know that mental disorders are brain disorders. Evidence shows that they can be related to changes in the anatomy, physiology, and chemistry of the nervous system. When the brain cannot effectively coordinate the billions of cells in the body, the results can affect many aspects of life.
Scientists are continually learning more about how the brain grows and works in healthy people, and how normal brain development and function can go awry, leading to mental illnesses.
Brain Basics will introduce you to some of this science, such as:

• How the brain develops
• How genes and the environment affect the brain
• The basic structure of the brain
• How different parts of the brain communicate and work with each other
• How changes in the brain can lead to mental disorders, such as depression.

The Growing Brain

Inside the Brain: Neurons & Neural Circuits 
Neurons are the basic working unit of the brain and nervous system. These cells are highly specialized for the function of conducting messages.
A neuron has three basic parts:

• Cell body which includes the nucleus, cytoplasm, and cell organelles. The nucleus contains DNA and information that the cell needs for growth, metabolism, and repair. Cytoplasm is the substance that fills a cell, including all the chemicals and parts needed for the cell to work properly including small structures called cell organelles.
• Dendrites branch off from the cell body and act as a neuron’s point of contact for receiving chemical and electrical signals called impulses from neighboring neurons.
• Axon which sends impulses and extends from cell bodies to meet and deliver impulses to another nerve cell. Axons can range in length from a fraction of an inch to several feet.

Each neuron is enclosed by a cell membrane, which separates the inside contents of the cell from its surrounding environment and controls what enters and leaves the cell, and responds to signals from the environment; this all helps the cell maintain its balance with the environment.
Synapses are tiny gaps between neurons, where messages move from one neuron to another as chemical or electrical signals.
The brain begins as a small group of cells in the outer layer of a developing embryo. As the cells grow and differentiate, neurons travel from a central “birthplace” to their final destination. Chemical signals from other cells guide neurons in forming various brain structures. Neighboring neurons make connections with each other and with distant nerve cells (via axons) to form brain circuits. These circuits control specific body functions such as sleep and speech.
The brain continues maturing well into a person’s early 20s. Knowing how the brain is wired and how the normal brain’s structure develops and matures helps scientists understand what goes wrong in mental illnesses.
Scientists have already begun to chart how the brain develops over time in healthy people and are working to compare that with brain development in people mental disorders. Genes and environmental cues both help to direct this growth.
The Changing Brain—Effects of Genes and the Environment

There are many different types of cells in the body. We say that cells differentiate as the embryo develops, becoming more specialized for specific functions. Skin cells protect, muscle cells contract, and neurons, the most highly specialized cells of all, conduct messages.
Every cell in our bodies contains a complete set of DNA. DNA, the “recipe of life,” contains all the information inherited from our parents that helps to define who we are, such as our looks and certain abilities, such as a good singing voice. A gene is a segment of DNA that contains codes to make proteins and other important body chemicals. DNA also includes information to control which genes are expressed and when, in all the cells of the body.
As we grow, we create new cells, each with a copy of our original set of DNA. Sometimes this copying process is imperfect, leading to a gene mutation that causes the gene to code for a slightly different protein. Some mutations are harmless, some can be helpful, and others give rise to disabilities or diseases.
Genes aren’t the only determinants of how our bodies function. Throughout our lives, our genes can be affected by the environment. In medicine, the term environment includes not only our physical surroundings but also factors that can affect our bodies, such as sleep, diet, or stress. These factors may act alone or together in complex ways, to change the way a gene is expressed or the way messages are conducted in the body.
Epigenetics is the study of how environmental factors can affect how a given gene operates. But unlike gene mutations, epigenetic changes do not change the code for a gene. Rather, they effect when a gene turns on or off to produce a specific protein. Scientists believe epigenetics play a major role in mental disorders and the effects of medications. Some, but not all mutations and epigenetic changes can be passed on to future generations.
Further understanding of genes and epigenetics may one day lead to genetic testing for people at risk for mental disorders. This could greatly help in early detection, more tailored treatments, and possibly prevention of such illnesses.

The Working Brain

Neurotransmitters
Everything we do relies on neurons communicating with one another. Electrical impulses and chemical signals carrying messages across different parts of the brain and between the brain and the rest of the nervous system. When a neuron is activated a small difference in electrical charge occurs. This unbalanced charge is called an action potential and is caused by the concentration of ions (atoms or molecules with unbalanced charges) across the cell membrane. The action potential travels very quickly along the axon, like when a line of dominoes falls.
When the action potential reaches the end of an axon, most neurons release a chemical message (a neurotransmitter) which crosses the synapse and binds to receptors on the receiving neuron’s dendrites and starts the process over again. At the end of the line, a neurotransmitter may stimulate a different kind of cell (like a gland cell), or may trigger a new chain of messages.
Neurotransmitters send chemical messages between neurons. Mental illnesses, such as depression, can occur when this process does not work correctly. Communication between neurons can also be electrical, such as in areas of the brain that control movement. When electrical signals are abnormal, they can cause tremors or symptoms found in Parkinson’s disease.

• Serotonin—helps control many functions, such as mood, appetite, and sleep. Research shows that people with depression often have lower than normal levels of serotonin. The types of medications most commonly prescribed to treat depression act by blocking the recycling, or reuptake, of serotonin by the sending neuron. As a result, more serotonin stays in the synapse for the receiving neuron to bind onto, leading to more normal mood functioning.

• Dopamine—mainly involved in controlling movement and aiding the flow of information to the front of the brain, which is linked to thought and emotion. It is also linked to reward systems in the brain. Problems in producing dopamine can result in Parkinson’s disease, a disorder that affects a person’s ability to move as they want to, resulting in stiffness, tremors or shaking, and other symptoms. Some studies suggest that having too little dopamine or problems using dopamine in the thinking and feeling regions of the brain may play a role in disorders like schizophrenia, or ADHD (attention deficit disorders.

• Glutamate—the most common neurotransmitter, glutamate has many roles throughout the brain and nervous system. Glutamate is an excitatory transmitter: when it is released it increases the chance that the neuron will fire. This enhances the electrical flow among brain cells required for normal function and plays an important role during early brain development. It may also assist in learning and memory. Problems in making or using glutamate have been linked to many mental disorders, including autism,obsessive compulsive disorder (OCD), schizophrenia, and depression.

Brain Regions
Just as many neurons working together form a circuit, many circuits working together form specialized brain systems. We have many specialized brain systems that work across specific brain regions to help us talk, help us make sense of what we see, and help us to solve a problem. Some of the regions most commonly studied in mental health research are listed below.

• Amygdala—The brain’s “fear hub,” which activates our natural “fight-or-flight” response to confront or escape from a dangerous situation. The amygdala also appears to be involved in learning to fear an event, such as touching a hot stove, and learning not to fear, such as overcoming a fear of spiders. Studying how the amygdala helps create memories of fear and safety may help improve treatments for anxiety disorder like phobias or post-traumatci stress disorder (PTSD.)
• Prefrontal cortex (PFC)—Seat of the brain’s executive functions, such as judgment, decision making, and problem solving. Different parts of the PFC are involved in using short-term or “working” memory and in retrieving long-term memories. This area of the brain also helps to control the amygdala during stressful events.
• Anterior cingulate cortex (ACC)— the ACC has many different roles, from controlling blood pressure and heart rate to responding when we sense a mistake, helping us feel motivated and stay focused on a task, and managing proper emotional reactions. Reduced ACC activity or damage to this brain area has been linked to disorders such as ADHD,Schizophrenia, and depresssion.
• Hippocampus—Helps create and file new memories. When the hippocampus is damaged, a person can’t create new memories, but can still remember past events and learned skills, and carry on a conversation, all which rely on different parts of the brain. The hippocampus may be involved in mood disorders through its control of a major mood circuit called the hypothalamic-pituitary-adrenal (HPA) axis.

Brain Basics in Real Life

Brain Basics in Real Life—How Depression affects the Brain

Meet Sarah
Sarah is a middle-aged woman who seemed to have it all. She was happily married and successful in business. Then, after a serious setback at work, she lost interest in her job. She had problems getting to sleep and generally felt tired, listless, and had no appetite most of the time. Weeks later, Sarah realized she was having trouble coping with the stresses in her life. She began to think of suicide because she felt like things weren’t going to get better and that there was nothing she could do about it.
Worried at the changes he saw, Sarah’s husband took her to the doctor, who ran some tests. After deciding her symptoms were not caused by a stroke, brain tumor, or similar conditions, Sarah’s doctor referred her to a psychiatrist, a type of medical doctor who is an expert on mental disorders. Other medical professionals who can diagnose mental disorders are psychologists or clinical social workers.

The psychiatrist asked Sarah and her husband questions about Sarah’s symptoms and family medical history. Epigenetic changes from stress or early-life experiences may have made it harder for Sarah to recover normally from her low mood. It’s important to remember that everyone gets “the blues” from time to time. In contrast, major depression is a serious disorder that lasts for weeks. Sarah told the doctor that she had experienced long periods of deep sadness throughout her teenage years, but had never seen a doctor about it. She has faced a few bouts since then, but they have never been as bad as her current mood.
The psychiatrist diagnosed Sarah with major depression and gave her a prescription for a type of antidepressant medication called a selective serotonin reuptake inhibitor (SSRI). SSRIs are the most common type of medication used to treat depression.
SSRIs boost the amount of serotonin in the brain and help reduce symptoms of depression. Sarah also has several follow-up visits scheduled with the psychiatrist to check how she’s responding to the treatment. She also begins regular talk therapy sessions with her psychiatrist. In these sessions, she learns how to change the way she thinks about and reacts to things that may trigger her depression. Several months later, Sarah feels much better. She continues taking SSRIs and has joined an online support group. Sharing her experiences with others also dealing with depression helps Sarah to better cope with her feelings.

Brain Research

Modern research tools and techniques are giving scientists a more detailed understanding of the brain than ever before.
Brain Imaging
Using brain imaging technologies such as magnetic resonance imaging (MRI), which uses magnetic fields to take pictures of the brain’s structure, studies show that brain growth in children with Autism appears to peak early. And as they grow there are differences in brain development in children who develop Bipolar Disorder than children who do not. Studies comparing such children to those with normal brain development may help scientists to pinpoint when and where mental disorders begin and perhaps how to slow or stop them from progressing. Functional magnetic resonance imaging (fMRI) is another important research tool in understanding how the brain functions.
Another type of brain scan called magnetoencephalography, or MEG, can capture split-second changes in the brain. Using MEG, some scientists have found a specific pattern of brain activity that may help predict who is most likely to respond to fast-acting antidepressant medications. Currently available antidepressants usually take four to six weeks to reach their full effect, which can be a difficult wait for some people struggling with depression. However, recent research points to a possible new class of antidepressants that can relieve symptoms of the illness in just a few hours. Knowing who might respond to such medications could reduce the amount of trial and error and frustration that many people with depression experience when starting treatment.
Gene Studies
Advanced technologies are also making it faster, easier, and more affordable to study genes. Scientists have found many different genes and groups of genes that appear to increase risk or provide protection from various mental disorders. Other genes may change the way a person responds to a certain medication. This information may someday make it possible to predict who will develop a mental disorder and to tailor the treatment for a person’s specific conditions.
Such brain research help increase the understanding of how the brain grows and works and the effects of genes and environment on mental health. This knowledge is allowing scientists to make important discoveries that could change the way we think about and treat mental illnesses.
.

Glossary

action potential—Transmission of signal from the cell body to the synaptic terminal at the end of the cell’s axon. When the action potential reaches the end of the axon the neuron releases chemical (neurotransmitters) or electrical signals.
amygdala—The brain’s “fear hub,” which helps activate the fight-or-flight response and is also involved in emotions and memory.
anterior cingulate cortex—Is involved in attention, emotional responses, and many other functions.
axon—The long, fiber-like part of a neuron by which the cell sends information to receiving neurons.
cell body—Contains the nucleus and cytoplasm of a cell.
cell membrane—The boundary separating the inside contents of a cell from its surrounding environment.
cytoplasm—The substance filling a cell, containing all the chemicals and parts needed for the cell to work properly.
dendrite—The point of contact for receiving impulses on a neuron, branching off from the cell body.
dopamine—A neurotransmitter mainly involved in controlling movement, managing the release of various hormones, and aiding the flow of information to the front of the brain.
DNA—The “recipe of life,” containing inherited genetic information that helps to define physical and some behavioral traits.
epigenetics—The study of how environmental factors like diet, stress and post-natal care can change gene expression(when genes turn on or off)-without altering DNA sequence.
gene—A segment of DNA that codes to make proteins and other important body chemicals.
glutamate—The most common neurotransmitter in a person’s body, which increases neuronal activity, is involved in early brain development, and may also assist in learning and memory.
hippocampus—A portion of the brain involved in creating and filing new memories.
hypothalmic-pituitary-adrenal (HPA) axis—A brain-body circuit which plays a critical role in the body’s response to stress.
impulse—An electrical communication signal sent between neurons by which neurons communicate with each other.
magnetic resonance imaging (MRI)mdash;An imaging technique that uses magnetic fields to take pictures of the brain’s structure.
mutation—A change in the code for a gene, which may be harmless or even helpful, but sometimes give rise to disabilities or diseases.
neural circuit—A network of neurons and their interconnections.
neuron—A nerve cell that is the basic, working unit of the brain and nervous system, which processes and transmits information.
neurotransmitter—A chemical produced by neurons that carries messages to other neurons.
nucleus—A structure within a cell that contains DNA and information the cell needs for growing, staying alive, and making new neurons.
prefrontal cortex—A highly developed area at the front of the brain that, in humans, plays a role in executive functions such as judgment, decision making and problem solving, as well as emotional control and memory.
serotonin—A neurotransmitter that regulates many functions, including mood, appetite, and sleep.
synapse—The tiny gap between neurons, where nerve impulses are sent from one neuron to another.

Overview

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

This health topic includes general information on:

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

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

Throughout this document you will only see the generic names for medications. Because information on medications is frequently updated, brand names are not referenced.

How are medications used to treat mental disorders?

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

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

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

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

What medications are used to treat schizophrenia?

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

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

• Chlorpromazine
• Haloperidol
• Perphenazine
• Fluphenazine,

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

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

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

• Risperidone
• Olanzapine
• Quetiapine
• Ziprasidone
• Aripiprazole
• Paliperidone
• Lurasidone

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

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

What are the side effects?

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

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

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

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

• Rigidity
• Persistent muscle spasms
• Tremors
• Restlessness.

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

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

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

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

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

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

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

How do antipsychotics interact with other medications?

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

What medications are used to treat depression?

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

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

• Fluoxetine
• Citalopram
• Sertraline
• Paroxetine
• Escitalopram

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

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

What are the side effects?

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

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

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

Tricyclic antidepressants can cause side effects, including:

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

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

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

How should antidepressants be taken?

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

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

If a medication does not work, it is helpful to be open to trying another one. A study funded by NIMH found that if a person with difficult-to-treat depression did not get better with a first medication, chances of getting better increased when the person tried a new one or added a second medication to his or her treatment.

Are herbal medicines used to treat depression?

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

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

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

FDA warning on antidepressants

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

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

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

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. The study was funded in part by NIMH.

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

What medications are used to treat bipolar disorder?

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

Mood stabilizers

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

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

Atypical antipsychotics

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

Antipsychotics used to treat people with bipolar disorder include:

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

Antidepressants

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

Research on whether antidepressants help people with bipolar depression is mixed. An NIMH-funded study found that antidepressants were no more effective than a placebo to help treat depression in people with bipolar disorder. The people were taking mood stabilizers along with the antidepressants.

What are the side effects?

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

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

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

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

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

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

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

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

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

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

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

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

How should medications for bipolar disorder be taken?

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

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

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

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

What medications are used to treat anxiety disorders?

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

Anxiety disorders include:

• General Anxiety Disorder (GAD)
• Panic Disorder
• Social Anxiety Disorder.

Antidepressants

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

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

MAOIs are also used for anxiety disorders. Doctors sometimes prescribe phenelzine, tranylcypromine, and isocarboxazid. People who take MAOIs must avoid certain food and medicines that can interact with their medicine and cause dangerous increases in blood pressure.

Benzodiazepines (anti-anxiety medications)

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

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

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

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

Clonazepam, listed above, is an anticonvulsant medication.

Beta-blockers

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

What are the side effects?

• Upset stomach
• Blurred vision
• Headache
• Confusion
• Grogginess
• Nightmares.

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

Possible side effects from buspirone include:

• Dizziness
• Headaches
• Nausea
• Nervousness
• Lightheadedness
• Excitement
• Trouble sleeping.

Common side effects from beta-blockers include:

• Fatigue
• Cold hands
• Dizziness
• Weakness.

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

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

What medications are used to treat ADHD?

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

• Methylphenidate
• Amphetamine
• Dextroamphetamine Lisdexamfetamine Dimesylate

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

What are the side effects?

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

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

How are ADHD medications taken?

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

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

Are ADHD medications safe?

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

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

FDA warning on possible rare side effects

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

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

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

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

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

Which groups have special needs when taking psychiatric medications?

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

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

Children and adolescents

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

For these reasons, it is important to watch young people who take these medications. Young people may have different reactions and side effects than adults. Also, some medications, including antidepressants and ADHD medications, carry FDA warnings about potentially dangerous side effects for young people.

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

Older adults

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

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

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

Women who are pregnant or may become pregnant

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

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

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

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

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

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

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

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

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

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

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

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