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What are the symptoms of depression and how is it diagnosed?

Doctors make decisions about diagnosis based on guidance. The main guidance used by NHS doctors is the International Classification of Diseases (ICD-10).

When you see a doctor, like your GP or a psychiatrist, they will look for the symptoms that are set out in the ICD-10 guidance. You do not have to have all of these to be diagnosed with depression – you might have just a few of them.

The symptoms of depression are:
•low mood and feeling sad,
•less energy and feeling less able to do things,
•losing interest in activities you used to enjoy,
•loss of concentration,
•becoming tired easily,
•sleeping and eating less,
•feeling less good about yourself (loss of confidence),
•feeling guilty or worthless,
•losing interest in sex, and
•thoughts of self-harm or suicide, and making suicide attempts.

What is depression?

Everyone has ups and downs – sometimes you might feel a bit low, or experience grief when you lose someone you love. It is common for people to say that they are ‘depressed’ when they are feeling down, but this does not mean that they have depression.

Depression is a long lasting low mood that affects your ability to do everyday things, feel pleasure, or take interest in activities.

Depression is:
•a mental illness that is recognised worldwide.
•common. It affects about one in ten of us.
•something that anyone can get.
•treatable.

Depression is not:
•something you can ‘snap out of.’
•a sign of weakness.
•something that everyone experiences.
•something that lasts forever.

How common is depression?

Depression can affect people of any age, including children, and it is one of the most common mental illnesses. About one in ten people will be diagnosed with depression in their life. The number of people who actually experience depression may be higher than this. More women are diagnosed than men. This could be because women are more likely to seek help.

Agoraphobia

Agoraphobia is an anxiety disorder where you have an intense fear of certain situations, including:
•Leaving your home
•Being in public spaces
•Using public transport
•Being in crowded spaces

You might find that these situations make you feel very distressed, panicked and anxious. You may avoid some situations altogether. This can affect your day-to-day life.

Agoraphobia can make it difficult to make an appointment with your GP to talk about your symptoms. You might not feel able to leave your house or go to the GP surgery. You can always ask for a telephone appointment if you are worried you have symptoms of agoraphobia. A GP will make a diagnosis by asking you questions about your symptoms. You may need to see a specialist doctor called a psychiatrist for further assessment to get a formal diagnosis.

Body dysmorphic disorder (BDD)

If you have body dysmorphic disorder (BDD), you will worry a lot about how you look or a particular part of your body. Although other people may not really notice or see it the same way, it will make you feel very distressed. For example, you may think you have an odd body shape compared to other people or that a scar makes you look unattractive. BDD is not the same as being vain or self-obsessed.
BDD can make you do things that take up a lot of time, like:
•Stare at your face or body in the mirror
•Compare your features with other people’s
•Cover or conceal yourself excessively with makeup
•Consider plastic surgery when you do not need it

BDD can lead to depression. Some people with BDD have suicidal thoughts or feelings.

If you think you have BDD, you should speak to your GP. If they feel you have BDD and this is causing you problems with everyday life, then they should discuss treatment options with you. The GP could arrange for a mental health worker who is experienced in BDD to see you.

Generalised anxiety disorder (GAD)

If you have generalised anxiety disorder (GAD), you can feel worried all the time and this can seem seems out of your control. It may feel as though there is no real reason for your worry. You might feel ‘on edge’ and very alert to your surroundings a lot of the time.

This can affect your day to day life. For example, you might find that it affects your ability to work, travel places or even leave the house. You might also get tired easily or have trouble sleeping or concentrating. You might also experience physical symptoms, such as muscle tension, sweating, feeling sick, stomach cramps (or ‘butterflies’) and a fear of fainting.

It is common to have other conditions such as depression or other anxiety disorders if you have GAD.

It can be difficult to diagnose because it does not have some of the more noticeable symptoms of other anxiety disorders. Your doctor is likely to say you have GAD if you’ve felt anxious most days for over six months.

Hair pulling (Trichotillomania)

Trichotillomania is a condition where you feel the urge to pull out strands of your hair. This can be from your head (usually the top of the scalp) or from other places such as your arms, eyelashes, legs or pubic area. You will find it difficult to stop yourself carrying out this action. It is linked to obsessive compulsive disorder (OCD).

You might experience a build-up of tension, which you relieve by pulling out the strand of hair. You might not even be aware that you’re doing it.

It can be difficult to stop, which can lead to hair loss. This in turn can make you feel guilty, embarrassed and affect how you feel about yourself.
Your GP may look at the following to diagnose your condition:
•You repeatedly pull your hair out, which causes noticeable hair loss.
•You feel increasing tension before you pull your hair out.
•You feel relief or pleasure when you have pulled your hair out.
•There is no underlying medical condition causing you to pull your hair out, such as a skin condition.
•Pulling your hair out causes you distress or affects your everyday life, such as your relationships or your work.

Obsessive-compulsive disorder (OCD)

An obsession is an unwelcome thought or image that repeatedly enters your mind and is largely out of your control. These can be difficult to ignore. You may not want these thoughts and they can be disturbing, which can make you feel distressed and anxious.

Compulsions are things you think about or do repeatedly to relieve the anxiety from your obsessive thoughts.

You might believe that you or someone close to you might come to harm if you do not do these things. You may realise that your thinking and behaviour is not logical but still find it very difficult to stop.

There are different types of OCD, which include:
•Contamination
•Checking
•Intrusive thoughts
•Hoarding

When you first see a healthcare professional like a GP about your symptoms, he or she will ask you about them. This helps them to find out if you have OCD, how severe your symptoms are and what treatment will be best for you.

Panic disorder (panic attacks)

A panic attack makes you feel anxious and frightened. It happens suddenly and feels intense. You also have physical symptoms. These can vary but can include shortness of breath, feeling sick, sweating, trembling and feeling like you have a fast heartbeat. You may feel so anxious that you think you might be dying or having a heart attack.
For some people, certain situations cause panic attacks. For example, if someone has a fear of small spaces and has to board a plane, they may have a panic attack then.

Panic disorder is where you have regular panic attacks and there is no particular trigger. This can make you worry about when you might have another attack. If this happens, you may get a diagnosis of panic disorder.

Post-traumatic stress disorder (PTSD)

You can develop post-traumatic stress disorder (PTSD) if you experience a traumatic or frightening event. It can develop a short time after the event, or sometimes months or years later. Types of situations that can cause PTSD include:
•Being a victim of serious violent crime
•Witnessing a violent attack on someone else
•Witnessing a death
•Being involved in military combat
•Situations working for the emergency services
•Surviving a severe accident, such as a road traffic accident
•Being held hostage
•Experiencing natural disasters, such as an earthquake

PTSD causes feelings of intense fear, helplessness and horror. You can have panic attacks, nightmares and flashbacks (seeing images or visions of the past event in your mind).

To get a diagnosis of PTSD, you will usually have to show symptoms for more than a month. You may feel less able to socialise, work or carry out everyday activities.

Selective mutism

Selective mutism is an anxiety disorder that stops children being able to speak in social situations. It can also cause problems later on when they become an adult. A doctor may refer a child to a speech therapist for support.

If you still have problems or symptoms as an adult, you should try and make an appointment with your GP. An advocacy service could help. You can find out more about advocacy in section 6 of this factsheet.

You can find more information on selective mutism on NHS Choices.

Skin-picking

Skin-picking is a condition where you will repetitively pick at your skin. This can cause damage to your skin, including bleeding, bruising and sometimes permanent marks. You will usually pick the skin on your face, but might also pick other areas of the body. You will find it difficult to stop yourself doing it.

It seems that skin-picking can relieve tension and stress. However, often the relief is short-lived, and you will feel the urge to continue picking. You may not be aware that you are doing it. It is linked to obsessive compulsive disorder (OCD) and body dysmorphic disorder (BDD) as it shares similar symptoms.

Because skin-picking leaves visible marks, you might go to lengths to hide these using makeup or clothing.

Your GP may arrange for you to see a specialist mental health doctor like a psychiatrist for diagnosis.

Social anxiety disorder

Social anxiety disorder (sometimes known as social phobia), means you will have an intense fear or dread of social or performance situations.

Some common situations where you may experience anxiety are:
•Speaking in public or in groups
•Meeting new people or strangers
•Dating
•Eating or drinking in public

You will be worried that you will do something or act in a way that is embarrassing or humiliating.

You might feel very aware of the physical signs of your anxiety. This can include sweating, a fast heartbeat, a shaky voice and blushing. You may worry that others will notice this or judge you. As a result you might find that you try to avoid such situations completely. You might realise that your fears are excessive, but will find it difficult to control them.

Your GP will ask you questions about your symptoms, and might ask you to fill out a questionnaire. This will help them find out what how anxious you feel in social situations.

If you feel that it would be difficult to visit your GP, you can ask for a telephone appointment.

Toilet-related anxiety

This is a fear of using toilets in either your own home, someone else’s home or in public spaces. This can lead to difficulty and embarrassment when needing to use the toilet.

You may fear that other people can hear you using the toilet, worry about the cleanliness of the toilet, or worry about being able to use the toilet at all.

How is psychosis treated?

What treatment should I be offered?
The National Institute for Health and Care Excellence (NICE) issues guidance on how the NHS should treat different health conditions. The NHS does not have to follow this guidance but is has to take it into account.

There are guidelines on:
•young people with psychosis and schizophrenia
•adults with schizophrenia, psychosis or schizoaffective disorder
•young people and adults with bipolar disorder
•adults with depression

You can find all of the NICE guidelines here.

Early intervention teams

If you have your first episode of psychosis, you should be referred to an early intervention team for initial treatment. NICE guidance states this should be the case no matter what age you are. These specialist teams provide treatment and support, and are usually made up of psychiatrists, psychologists, mental health nurses, social workers and support workers. Early intervention services are run differently in different parts of the country. If there is not a service in your area, then you should have access to a crisis or home treatment team.

Medication

Medication known as antipsychotics can help treat symptoms of psychosis. Your doctor should give you information about the benefits and possible side effects of different antipsychotics. You and your doctor should choose the medication together.

Your medication should be reviewed at least annually.

Cognitive behavioural therapy (CBT)

You should also have access to talking treatments such as cognitive behavioural therapy (CBT). CBT can help you understand your hallucinations and any upsetting and worrying thoughts and beliefs, and discuss new ways of thinking about them and dealing with them. CBT doesn’t necessarily get rid of the symptoms or upsetting experiences, but may help you cope better and lessen the distress that some symptoms can cause.

If you have bipolar disorder and experience psychosis, your treatment may be different. For example, your doctor may prescribe you a different medication to stabilise your mood rather offer you an antipsychotic.

As well as specific treatment, you may also get support from mental health services through the Care Programme Approach (CPA). This usually involves having a care co-ordinator who will develop a care plan with you.

Physical health

Research has found that people with severe mental illness, such as schizophrenia, are at higher risk of being overweight, having coronary heart disease and diabetes, among other health issues. This may be due to genetic factors, lifestyle choices (such as smoking and diet) or side effects from medication.

Because of this, NICE recommends that:
•When you start taking antipsychotic medication, you should have a full range of physical health checks, including weight, blood pressure and other blood tests. These checks should be repeated regularly.
•Mental health professionals are responsible for doing these checks for the first year of treatment. Responsibility may then pass to your GP.
•You should be offered a combined healthy eating and physical activity programme by your doctor or mental health team.
•You should be given help to stop smoking, and given support from a healthcare professional.

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What if I am not happy with my treatment?

If you ever feel unhappy with how your treatment or care is being handled, or feel that the relationship between yourself and a professional is not working well, you could call the Patient Advice and Liaison Service (PALS) at your NHS trust. They can try to resolve any problems or questions you have. You can find your local PALS’ details here.

You might find a general/community advocate helpful if you are unhappy with your treatment. Advocacy can help you understand the mental health system and enable you to be fully involved in decisions about your care. An advocate is someone independent from mental health services who can help to make your voice heard when you are trying to resolve problems. They may be able to help with writing letters for you or attending appointments or meetings. You can find more information about advocacy in our ‘Advocacy’ section.

There may be a local advocacy service in your area which you can contact for support. You can search online for a local service.

If you are not happy with your treatment, you can refer to the NICE guidance to see if you are being offered the recommended treatments.

You could also find out more about getting a second opinion, having a choice in your medication or making a complaint.

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Different views on psychosis

Some people think that what is considered a psychotic belief depends on the society around us. They feel that people with delusions and hallucinations are being targeted because their beliefs are out of step with the rest of society. For example, in some cultures hearing voices is seen as a normal part of life. However, in most western countries it is associated with mental illness. Also, beliefs in aliens, ghosts and conspiracy theories are widely held throughout the world by people who are not considered mentally ill.

Some encourage people with psychosis to embrace their symptoms and understand their meanings. The psychologist Rufus May believes that delusions can be symptoms of deeper psychological distress which people should work through. For example, if someone feels their being is being controlled by outside forces, this might stem from feelings of lack of control in their life.

The Hearing Voices Network believes that voices are not just symptoms but can be messages about how a person is feeling. For example, critical voices are suggestive of someone with very low self-esteem. They believe it is possible for people to accept and learn to live with voices by understanding what they mean.

These sorts of approaches are not as widely accepted as alternatives to the medical approaches we have described above.

Psychosis is a medical term. If you have psychosis, you might see or hear things, or hold unusual beliefs, that other people do not. Some people describe it as a “break from reality”. You may also hear terms such as “psychotic symptoms”, “psychotic episode” or “psychotic experience”.

In mental health care, these experiences are viewed as symptoms of mental illness which need treatment. In many cases, if you experience these symptoms you are not aware of this and believe that the sensations are real. About 1 in every 100 people will experience a psychotic episode in their lifetime.

Typical examples of psychosis include:

Hallucinations
Hallucinations describe when you see, hear or physically feel things which are not actually there. For example:
•Hearing voices
•Seeing things which other people do not see
•Feeling someone touching you who is not there
•Smelling things which other people cannot.

Delusions
Delusions are strong beliefs which are unlikely to be true and may seem irrational to others. For example:
•Believing that you are being followed by secret agents or members of the public
•Believing that people are out to get you or trying to kill you. This can be strangers or family members
•Believing that something has been planted in your brain to monitor your thoughts
•Believing you have special powers, are on a special mission or in some cases that you are a God.

What conditions are linked with psychosis?

Psychosis is a set of symptoms, rather than a condition in itself. You might have symptoms if you have one of the following conditions:

Schizophrenia

You are likely to get a diagnosis of schizophrenia if you experience a mixture of ‘positive’ symptoms (so called because they are ‘in addition’ to your normal experience) and ‘negative’ symptoms (which detract from your normal experience).

Positive symptoms include:
•Hallucinations such as hearing voices or seeing things other people do not
•Delusions such as believing that you are being followed by secret agents or that you have special powers
•Disorganised thinking – you might switch from one topic to another with no clear link between the two

Negative symptoms include:
•Lack of motivation
•Not saying much
•Lack of eye contact
•Not interacting much with other people

Due to the combination of negative and positive symptoms, schizophrenia will probably affect your day-to-day life a lot until you access treatment. Although some people recover completely from schizophrenia, it is likely to be a long term condition. But you can manage it with the right treatment and support.

Bipolar Disorder

This is a mood disorder where you switch from extreme highs such as elevated mood and increased activity (mania) to extreme lows, feelings of worthlessness and lack of motivation (depression). If you experience manic symptoms you may also experience psychosis. For example, you may believe you have special powers or are on a special mission. Not everyone with bipolar disorder will experience psychosis.

Schizoaffective disorder

People with schizoaffective disorder have symptoms of bipolar disorder (depression and/or mania) and schizophrenia (psychotic symptoms). Because some of the symptoms of bipolar disorder and schizophrenia overlap, psychiatrists often find it difficult to make a diagnosis of schizoaffective disorder.

Drug induced psychosis

People who use or withdraw from alcohol and drugs can experience psychosis. Sometimes these symptoms will end suddenly as the effects of the alcohol or drugs wear off. In other cases, the symptoms may last longer and lead to a psychotic illness being diagnosed.

Psychotic depression

If you have depression you can feel low, lack motivation and energy, have feelings of guilt and may experience a loss of appetite or sleep. If you have severe clinical depression, you may experience psychotic symptoms which are usually particularly pessimistic and self blaming, such as believing that you are responsible for something when you are not.

Postnatal (puerperal) psychosis

If you have psychotic symptoms after giving birth, this is known as puerperal psychosis. This can happen immediately and also up to three months after birth. The symptoms usually include insomnia, feeling agitated, restless and irritated, feeling depressed or unusually happy, and swinging rapidly between these states of mind. Women with puerperal psychosis may behave strangely, feel very confused, and experience fleeting hallucinations.

Personality disorder

There are some personality disorders where you can experience psychotic symptoms such as borderline personality disorder (BPD) and schizotypal personality disorder.

Organic psychosis

Head injury or a physical illness that affects how your brain works can also cause psychosis. People often have memory problems or feel confused as well as having psychotic symptoms.

Delusional disorder

Psychiatrists might say you have a delusional disorder if you have a single firmly held belief that is not true but might not seem particularly bizarre either. For example, you may feel convinced that your partner is deceiving you even if they are not. Hallucinations and negative symptoms are not usually present.

Reaction psychosis/ Brief psychotic episode

You might have psychotic symptoms after a major stressful event in your life, such as a death in the family or change of living circumstances. Symptoms can be severe, but most people who have reaction psychosis make a quick recovery, which can take up to a month.

These pages explain what psychosis is and its possible causes and treatments. You will find them useful if you are affected by psychosis or if you have a friend or family member who is affected.
•Psychosis is a medical term used to describe hearing or seeing things, or holding unusual beliefs that other people do not share.
•Common examples include hearing voices or believing that people are trying to do you harm.
•You can experience psychosis for a wide variety of reasons. For example it can be due to having a mental illness such as schizophrenia or bipolar disorder. It can also be caused by drug use, brain injury or extreme stress.
•There is no one single cause of psychosis but researchers believe that genes, biological factors and environment may play a part.
•In the NHS, you should be offered medication and cognitive behavioural therapy (CBT) to help with your symptoms.
•To access treatment for psychosis, you usually need to have an assessment by specialist mental health services.
•If you are experiencing very severe psychotic symptoms you may need more urgent help such as going into hospital.
•If you are trying to communicate with a person experiencing psychosis there are communication methods you can try.
•There are different perspectives on how we should view and deal with psychosis. This includes listening to the voices or trying to understand the meaning of the unusual beliefs.

Tell yourself: STOP !

Take a Breath

Focusing on your breathing slows down the adrenaline response and the distressing thoughts.

Breathe mindfully and notice the sensations of breathing in your belly. You might find it helpful to count your breaths, or to breath in to a count of 4, and out to a count of 4.

Observe:

Your thoughts & feelings e.g…

I’m anxious

My body’s alarm system has been triggered

My mind is tricking me into believing I’m in danger

I’m feeling really tense and hyped up

Pull Back:

Is this really true or does it just feel that way?

Is this fact or opinion?

What would a friend say about this?

What advice would I tell someone else?

Even though it feels really bad, these physical sensations are a normal body response…it will pass

Practise what works:

Positive self-talk, e.g.

I can get through this – I’ve done it before

I’m stronger than I think I am

This will pass

I can do this

Visualise: Imagine breathing in blue or green, and breathing out red. (Colour breathing exercise). Or use your imaginary outdoor peaceful place

Will my information be kept confidential?

GPs have strict guidelines on confidentiality and information sharing which means they are not allowed to give information about you to third parties without your direct consent.

This means they will not give information to your partner, children or parents as well as your employer or other organizations. If information was shared without your permission, you could potentially take legal action against the GP or doctor.

Guidelines (General Medical Council’s Confidentiality Guidelines, 2009) state that your close relatives can provide information to GPs about you (for example, inform them about your mental health) and the GP could then use this information to inform your treatment and diagnosis. Professionals helping you can also share information about your mental health. Your Community Mental Health Team and your GP could also discuss your health.

Do mental health problems affect me working?

If you are a doctor, nurse, teacher or social worker, you may have to go through fitness to practice tests. If you are studying one of these professions you may need to as well. This is looked at when working in these professions and also when applying for courses to study in these areas.

If you tell your employer, college or university that you have a mental health problem, then your employer or study provider may ask your permission to contact your doctor. They would do this to get more information about your mental health and check that you are fit to practice. They would usually ask for a letter or report from your doctor. Your doctor would only share this information with your permission because of their duty of confidentiality to you. Having a mental health condition does not mean that you are automatically considered unfit to practice. Telling your employer that you have a mental health problem could protect you from illegal discrimination or lead to you getting extra support if you have a disability under the Equality Act 2010.

What if I have problems getting help?

Although all doctors should be trained to deal with mental health, when you go and see your GP they may not always be very understanding or able to see that you have a problem.

If this happens you should not give up and still try to seek help. You could make an appointment to see a different doctor at the surgery where you are registered who may be more understanding. Or you could speak to your local Patient Advice and Liaison Service (PALS), which is an organisation within the NHS that provides information and support to patients.

You can find your local service using the following link.

http://www.nhs.uk/Service-Search/Patient%20advice%20and%20liaison%20services%20(PALS)/LocationSearch/363

If you can’t get help through the GP and feel that your mental health problems are severe, you could try contacting the Community Mental Health Team (CMHT) yourself and asking for an assessment. Although many CMHTs will only accept referrals from GPs or social services directly, some accept self referrals.

If you can’t get any help or assessment, then you might find an advocate useful. An advocate can help you to understand the mental health system and help you to be fully involved in decisions about your care. An advocate is independent from mental health services and can help to make your voice heard with problems you may come across. They may be able to help with writing letters for you or attending appointments or meetings.

There may be a local advocacy service in your area who you can contact for support. You can search for a local organisation online.

If you continue to have problems getting an assessment or treatment, you could also consider making a formal complaint.

Can I get help without going to see my doctor?

You do not have to go and see your GP if you don’t want to. You can use self help and get treatment without going to see a GP. If you think you are experiencing anxiety and depression you could try:

•Paying for private therapy or counseling yourself

Many therapists operate a sliding scale of charging for treatment for people on lower incomes. It is a good idea to check if a private therapist is registered with an organization that regulates therapists. This means they have had to meet certain standards.

•Getting a private psychiatrist to prescribe medication

Private psychiatrists can be expensive. If you would like to find a private psychiatrist, your GP might know of a psychiatrist privately. Or you could look in a phone directory or online, or through private healthcare providers such as the Priory or Cygnet. You should check that any private psychiatrist is registered with the General Medical Council (you can check here: http://www.gmc-uk.org/doctors/register/LRMP.asp#View).

Self-help tools on the internet include:

http://www.beatingtheblues.co.uk%20– for depression

http://www.fearfighter.com%20– for anxiety

Both are computer based Cognitive Behavioural Therapy (CBT) packages that are available on the internet. They are available free through the NHS, but can also be purchased privately at a cost of around £400.

You could also try:

Get Self Help: http://www.getselfhelp.co.uk/

a free website containing CBT self-help resources

Moodjuice: http://www.moodjuice.scot.nhs.uk/

a free online self-help resource for a variety of mental health problems and symptoms

Moodscope: http://www.moodscope.com

a free, social networking tool that allows people to monitor their mood and receive support.

Living life to the full: http://www.llttf.com

a free internet self-help resource for a variety of issues.

You might be able to get help from a charity community organisation. Many charities offer therapy or one-to-one support. You could try finding out what is available in your area.

At Rethink Mental Illness we often provide psychological therapy, peer support groups or community services. Find out what is available here.

MIND – also provides local services, some of which provide therapy, support groups and other help. You can search for what is available locally.

http://www.mind.org.uk

Tel: 0300 123 3393

Anxiety UK: – Can help with low cost therapies if you have anxiety (you have to join the organisation).

http://www.anxietyuk.org.uk

Tel: 08444 775 774

Moodswings – gives practical support and help to people experiencing mood disorders.

http://www.moodswings.org.uk

Tel: 0845 1236050

If you are experiencing psychotic symptoms then the NHS may be a more effective route as they can offer more specialist NHS services.

If you have psychosis you might:

•See or hear things that other people do not. Doctors call these hallucinations.

•Believe unusual things. You might believe you are being watched or followed

•Have confused and disturbed thoughts

You may not realise that you are experiencing these symptoms. Doctors or professionals often call this ‘lack of insight’.

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Do drugs and alcohol cause mental health problems?

If you use drugs and/or alcohol regularly, this can cause problems with assessing and treating your mental health. This is because:

•Using alcohol or drugs unwisely can trigger mental illness in some people

•People sometimes use alcohol or drugs to help deal with the symptoms of their conditions. Doctors call this self-medication.

Alcohol or drugs can:

•mask mental health problems

•make medication less effective

•Sometimes cause other symptoms.

If you have a mental health problem in addition to alcohol and/or drug misuse, doctors call this dual diagnosis. You will probably need specialist help and treatment.

If you use alcohol or drugs unwisely you will be more likely to become unwell again. If you regularly use drugs or alcohol and believe that you may have a mental health problem discuss this with your doctor as soon as you can.

Medication – choice and managing problems

Medication can play a key role in treating mental illness. Unfortunately, sometimes people have problems with taking this medication that make them feel that it’s not right for them. This section considers ways of trying to resolve problems with medication. Here, the word ‘doctor’ means psychiatrists and general practitioners (GPs).
•Medication is a key part of the treatment of mental illness, but it is not the only treatment. A lot of people find ‘talking treatments’, self-help and complementary therapies helpful.
•People with schizophrenia, bipolar disorder, depression and anxiety disorders are normally offered medication by their doctor. However, not all illnesses are treated this way. For example, people with a sole diagnosis of personality disorder are not normally offered medication.
•Your doctor should explain the risks and benefits of taking your medication before you start taking it.
•You can expect to be given an opportunity to ask questions about your medication and to have these questions answered.
•Unfortunately, all medications carry a risk of side effects. It is important to try to find the right balance between reducing symptoms and managing side effects.
•If you have a problem with your medication, talk to your doctor about it. If you find this difficult, you might wish to ask a friend, relative or advocate to help you.
•You may have to try a few different medicines before you find the one that is right for you.
•If you cannot resolve disputes informally with your doctor you could try writing them a letter about our concerns or making a complaint.

This section covers:
•How do mood stabilisers work?
•Lithium
•Valproate
•Carbamazepine
•Lamotrigine
•Antipsychotics

How do mood stabilisers work?

It is not yet known exactly how mood stabilisers work. They appear to have the effect of stabilising swings between mania (feeling high) and depression.

What different types of mood stabilisers are there?

There are a number of mood stabilisers used both to reduce mania and depression, and in the long-term stabilise mood swings. Mood stabilisers are usually considered during an episode of mania or depression that appears, changes or worsens suddenly (you may hear this referred to as an acute episode). Long-term treatment is considered after two or more acute episodes.

Drugs used as mood stabilisers include:

Lithium

Lithium is widely used for the long-term maintenance and treatment of mania. It reduces both the number and severity of relapses. It is recommended by NICE guidance as a medication to treat episodes of mania and also as long-term treatment in bipolar disorder. If you have an episode of mania that comes on suddenly or becomes worse, lithium would usually only be started if your symptoms were not severe as it can take at least a week to take effect, which is slower than the other options available. Lithium has been found to reduce the risk of suicide.

In order for the lithium therapy to work, you must have a certain level in your blood stream. To make sure that the lithium is working properly and is not at a dangerous level, it is recommended you have regular blood tests to check the lithium levels in your blood every 3 months.

Lithium is sodium based, so changes to salt levels in the body can cause an imbalance. This can lead to increased levels of lithium. These levels can increase to a point where they are toxic to the body and cause poisoning. This risk can be increased by going on low salt diets, becoming dehydrated and interactions with certain medications. If you would like more advice about this, then please talk to your doctor.

Valproate

Valproate is an anti-convulsant medication used in epilepsy. In the UK, it is widely used in the form of sodium valproate, although it can come in other forms. It is licensed to treat mania.

NICE guidance for bipolar disorder recommends valproate as a first choice to treat episodes of mania and also for long-term treatment. However, it is not recommended to be prescribed to women of child bearing age (please see the section on Pregnancy).

You will also need regular tests, as valproate can affect how your liver works. NICE guidance recommends testing the functioning of your liver at the start of treatment and every 6 months after that.

Carbamazepine

Carbamazepine is an anticonvulsant medication used in epilepsy. In the UK, it is licensed to treat bipolar disorder in people who do not respond to lithium. NICE guidance does not recommend it as a first option to treat episodes of mania or as a long-term treatment. In order to be effective, carbamazepine has to reach a given level in the blood.

Lamotrigine

Lamotrigine is also an anti-convulsant medication used in epilepsy. In bipolar disorder, it may be used where depression is the main problem. NICE guidance does not recommend it to treat episodes of mania, or as a first option for long-term treatment of bipolar disorder.

Antipsychotics

As well as their antipsychotic effect, antipsychotic medication can also have mood stabilising properties. Some of the newer antipsychotics (sometimes referred to as atypical) can be used in bipolar disorder. In the UK, olanzapine, risperidone, quetiapine, aripiprazole and asenapine are licensed to treat mania. Olanzapine is probably the most widely used for this purpose.