Mental Health For All

Common Mental Illnesses

Here is a booklet on common mental illnesses posted for public education. The matter has been collected and collated from various sources available online and edited for clarity and relevance. The opinions presented are for educational purposes only and do not substitute formal professional help.

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Major / Clinical Depression 

Outline :

Case Vignette

What is Depression?

Signs and symptoms

Major consequences

What causes depression?

What can we do about it?

Sama's Story

Sama did not go to work today. In fact he is remaining absent from his work for last few months, not going for work regularly for last few months. An active and daring young man as he was he has become a distant shadow of himself lately. Things are not going well for his young family either. He is married to beautiful Sumana and blessed with a gorgeous daughter. His wife stays home and looks after the child. Sumana is under a lot of stress as well. Sama's family had only recently moved house to the end of the village after a long and protracted fight with her in-laws. Family feud resulted in some disputes (disagreement) between the man and wife. Their finances are in ruins and they are in considerable debts. Sama spends most of his time lying around and drinking alcohol.

For last couple of months Sama did not have a good sleep. His eating pattern is quite erratic and he lost more than 5 kilos of weight. He hardly ever talks to people and often seen staring at the empty sky. The thing that pained Sumana the most is that Sama is not even showing any affection towards their daughter. He has often threatened to commit suicide. Sumana had recently sought help from a talisman from the local faith healer pool but that does not seem to work. In fact nothing seems to work with him including her coaxing and cajoling. Sumana is deeply concerned about their future: her daughter's and herself.

They finished their evening meal. While she was finishing her daily house hold chores, Sama went to the his bed for the night. She was rudely awaken by a sudden screeching noise form inside the the bed room. Suman ran inside and found Sama hanging from the ceiling with a noose in his neck. The whole world started crumbling before her eyes as she shouted for help holding his dangling feet.

What is Depression?

Depression is certainly more than just feeling depressed or low. It is a syndrome characterize by persistent low mood, lack of energy and interest in doing things. It is often associated with poor appetite, weight loss, lack of sleep, early morning awakening and easy fatigability.  Most of the symptoms are present at least for several weeks and cause significant problems in social, occupational and personal relationship areas.

The World Health Organisation defines clinical depression as:

· Two weeks of an abnormal depressed mood 

· loss of interest or pleasure in activities that used to be enjoyable 

· Reduced energy, or feeling tired

· Loss of confidence and self-esteem

· Feeling guilty and unworthy

· Recurrent thoughts of death or suicide, or any suicidal/self-harming behaviour

· Reduced ability to think or concentrate 

· Agitated or slow movements

· Disturbed sleep (not enough/too much/poor quality)

· Change in appetite (increase or decrease) with weight change

· Decreased libido

· Unexplained physical symptoms

Minor depression includes 2 of the first three symptoms and at least 2 others.

Moderate depression includes 2 of the first three symptoms and at least 4 others.

Severe depression includes all 3 of the first three symptoms and at least 5 others.

Often depression does not strike out of blue but like Sama it starts slowly leaving subtle yet characteristic clues. It varies from person to person but usually consists of one or more of the following combinations.

Feeling low: This is an essential symptom of depression. It is a persistent and pervasive symptom more intense than usual low mood on a bad day. Very often the low mood is more so in the early hours of the day. Actually it is very painful and some times almost paralyzes every activity of the person. In fact there are researches that compared the intensity of pain due to depression as opposed to pain due to fracture of a bone It was found that depressed pain could be more intense and difficult to endure!

Lack of interest:

This is another ubiquitous sign in depressive disorders. The person lacks interest in the activities he/she used to enjoy earlier including sexual activities. He might be callous and appear very selfish to the outsiders for his lack of concern. In the reality he is unable to experience any pleasure and at times any other emotions. He may view the world pessimistically; have a very low self-esteem and poor opinion regarding others.

Lack of energy and concentration:

People suffering from depression may not have energy to do even the simplest of the jobs and always feel drained. They literally make mountains out of molehills! They find it very difficult to focus attention on the day-to-day chores and perform poorly in occupational and educational activities.

Biological symptoms: As suggested earlier like Sama they sleep less, neglect their health, have poor food intake and tend to lose lots of weight. A disproportionately high number of such people in fact die earlier than those not suffering from depressive illnesses.

Suicidality: Many people suffering from moderate to severe depression are at high risk of committing suicide. Very often they make veiled threats before the actual act and often resort to various self harming behaviour as a prelude to the completed suicide.

Depression Myths

Myths about depression often separate people from the effective treatments now available. Friends need to know the facts. Some of the most common myths follow:

Myth: Depression doesn’t affect me.

Fact: According to a 2004 survey by the American College Health Association, nearly half of all college students report feeling so depressed at some point in time that they have trouble functioning, and 15 percent meet the criteria for clinical depression. This means that someone in your life that you care about (or maybe yourself) could face depression at some point in college or in adulthood.

Myth: Depression is not a real medical problem.

Fact: Depression is a real and serious condition. It is no different than diabetes or heart disease in its ability to impact someone’s life. It can have both emotional and physical symptoms and make life very difficult for those who have it. The medical community has acknowledged the seriousness of depression and recognizes it as a disease. While no one is completely certain what causes depression, we know that genetic and biological factors play a significant role in development of this disease.

Myth: Depression is something that strong people can “snap out of” by thinking positively.

Fact: No one chooses to be depressed, just like no one chooses to have any other health condition. People with depression cannot just “snap out of” their depression any more than someone with diabetes can. It is not a sign of weakness or laziness to be depressed; it is a health problem resulting from changes in brain structure or function due to environmental and biological factors.

Myth: It's normal for teenagers to be moody; teens don't suffer from "real" depression. 

Fact: Depression can affect people at any age or of any race, ethnic, or economic group.

Myth: Talking about depression only makes it worse. 

Fact: Talking through feelings may help a friend recognize the need for professional help. By showing friendship and concern and giving uncritical support, you can encourage your friend to talk to his or her parents or another trusted adult, like a teacher or coach, about getting treatment. If your friend is reluctant to ask for help, you can talk to an adult - that's what a real friend will do.

Myth: Antidepressants will change your personality.

Fact: The thought of taking medicine that changes your brain chemistry can be scary. However, antidepressants are designed to change only certain chemicals that underlie the symptoms of depression, not to change your personality. Most people who take antidepressants are actually happy to feel like themselves again, rather than feeling like a different person. It is best to speak with your doctor about the effects that antidepressants can have.

Myth: Telling an adult that a friend might be depressed is betraying a trust. If someone wants help, he or she will get it. 

Fact: Depression, which saps energy and self-esteem, interferes with a person's ability or wish to get help. And many parents may not understand the seriousness of depression or of thoughts of death or suicide. It is an act of true friendship to share your concerns with a school guidance counselor, a favorite teacher, your own parents, or another trusted adult.

Prevalence of the problem:

Depression appears to be the common psychiatric dosorder in any given community. Lifetime prevalence for this disorder in the general population is 10% to 25% for women and from 5% to 12% for men. In any year, 5% to 9% of women will have this disorder and from 2% to 3% of men will have it. The prevalence rates for this disorder appear to be unrelated to ethnicity, education, income, or marital status. In childhood, boys and girls are equally affected. However, in adolescence and adulthood, this disorder is twice as common in females as in males.

  

Consequences of depression:

Sama and Suman are just the examples of the scourge of depression. It could affect the lives of people either direectly or indirectly. Depression is said to be very pervasive mood disorder affecting the way one feels and thinks regarding himself/herself or towards the world. If you are suffering from depression, the emotional and physical symptoms may be overwhelming. They may keep you from taking part in routine tasks. On a more personal level, they may be causing you to shut yourself off from friends and loved ones. Worldwide it is expected to be the second leading cause of disability after heart disease by 2020.

 Depression also adversely affects the lives of families and friends. It also causes reduction of work productivity and absenteeism on a colossal proportion. Hence depression has a significant negative impact on the economy of any country.

Inspite of this impact it is a bit ironical that depression is very often not diagnosed or treated properly.

Nearly two-thirds of depressed people do not get proper treatment. This could be due to one or more of the following reasons:

· The symptoms are not recognized as depression.

· Depressed people are seen as weak or lazy.

· Social stigma causes people to avoid needed treatment.

· The symptoms are so disabling that the people affected cannot reach out for help. 

· Many symptoms are misdiagnosed as physical problems

· Individual symptoms are treated, rather than the underlying cause.

  

In two-thirds of cases, the Major Depressive Episode ends with complete recovery. For individuals that have only a partial recovery, there is a greater likelihood of developing additional episodes of this disorder and of continuing the pattern of partial interepisode recovery. Individuals that have pre-existing Dysthymic Disorder prior to the onset of this disorder are more likely to have additional Major Depressive Episodes, have poorer interepisode recovery, and have more difficult to treat Major Depressive Episodes. One year after the diagnosis of this disorder, 40% have no mood disorder; 20% are partially recovered; and 40% still have symptoms that are sufficiently severe to meet the criteria for a full Major Depressive Episode. The severity of the initial Major Depressive Episode appears to predict persistence. Chronic general medical conditions are also a risk factor for more persistent episodes. Among those with an onset of depression in later life; there is evidence of subcortical white matter hyperintensities associated with cerebrovascular disease. These vascular depressions are associated with greater neuropsychological impairments and poorer responses to standard therapies.

   

Causes of Depression:

Unfortunately, it is not fully known what exactly causes clinical depression. There are numerous theories about causes such as biological and genetic factors, environmental influences, and childhood or developmental events. However it is generally believed that clinical depression is most often caused by the influence of more than just one or two factors. For instance, a person whose mother had recurrent major depression may have inherited a vulnerability to developing clinical depression (genetic influence). This combined with how the person thinks about him- or herself (psychological influence) in response to the stress of going through a divorce (environmental influence), may put him or her at a greater risk for developing depression than someone else who does not have such influences.

The causes of clinical depression are likely to be different for different people. Sometimes a depressive episode can appear to come out of nowhere at a time when everything seems to be going fine. Other times, depression may be directly related to a significant event in our lives such as losing a loved one, experiencing trauma, or battling a chronic illness.

Related to the discussion of the causes of clinical depression is something called, "risk factors."

Risk Factors For Major Depression-

Gender: Women are about as twice as likely as men to be diagnosed and treated for major depression. Approximately 20-25% of women and 12% of men will experience a serious depression at least once in their lifetimes. Among children, depression appears to occur in equal numbers of girls and boys. However, as girls reach adolescence, they tend to become more depressed than boys do. This gender difference continues into older age.

There are several theories as to why more women than men are diagnosed and treated for depression:

· Women may be more likely than men to seek treatment. They may be more willing to accept that they have emotional symptoms of depressed mood and feelings of worthlessness or hopelessness.

· Men may be less willing to acknowledge their emotional symptoms and more apt to suppress their depression through the use of alcohol or other substances. In such cases depression can be "masked," or viewed only as alcohol or drug dependency/abuse rather than as clinical depression.

· Women may tend to be under more stress than men. In today's society women often have to manage a variety of conflicting roles. They have many responsibilities and full schedules at home and work.

· Women may be more prone to depression because of the possible effects of hormones. Women have frequent changes in their hormone levels, from their monthly menstrual cycles, to the time during and after pregnancy, to menopause. Some women develop a depressive illness around these events.  

Marital factors: Women who are unhappily married, divorced, or separated, have high rates of major depression. The rates are lower for those who are happily married.

Age: While clinical depression usually occurs for the first time when a person is between the ages of 20 and 50, people over the age of 65yrs may be especially vulnerable.

Previous episode: If you have had major depression once before, your chances of developing it again increase. According to some estimates, approximately one-half of those who have developed depression will experience it again.

Heredity: People who have relatives who have had clinical depression have a greater chance of developing it themselves. Also, having a close relative with bipolar disorder may increase a person's chances of developing major depression.

  

 What can we do?

Some people feel embarrassed about getting help for depression. In some cases, people might not even know they are experiencing depression, but may be worried about bodily symptoms, such as headaches or chest pain, which can be the way our body expresses tension and anxiety, as part of a depressive illness.

Getting help for depression is not a sign of weakness. It is important to find ways of getting help to treat it as soon as possible. Any doctor, nurse or mental health professional will be able to advise on the choices you can make about which treatment will suit you best.

If you find it easier, you could always ask a friend or someone from your family or cultural/community group to go with you to your appointment.

Your doctor is often the first place to get help. When making an appointment, it is a good idea to ask for a long appointment. This is so there is time to discuss your situation, complete an assessment and begin treatment.

Most depression will be treated by your local doctors, although sometimes he might involve a specialist, either to provide advice or to take over the treatment for a short period. This might be a psychologist or a psychiatrist or a referral to a local specialist mental health team.

What can you expect from treatment?

It is often hard to know what to expect from treatment for health problems. This guide is based on research evidence. It is a responsibility of health professionals to tell you about those treatments which are more likely to work in most people, and which are likely to benefit you.

The stages of getting professional assessment and treatment for depression usually includes:

• A thorough health and mental health assessment

• Information about the condition and its treatment

• Information about, and choices between, those health professionals who are available to treat depression

• Referral to another professional or specialist if your condition worsens or if treatment seems not to be working

• Information about the condition for your family or partner if this is wanted

• Follow-up to help you prevent a repeat episode of depression. 

What are the treatments for depression?

Choice of treatment depends on many factors: including the severity of depression, availability of treatments, and your own feelings about the use of medication or other therapies.

We suggest the following:

Mild depression: may resolve with exercise, pleasant events scheduling and structured problem solving (see appendix for details).

Moderate depression: medication, or psychotherapy or both

Severe depression: medication initially, which may later be supplemented by psychotherapy to reduce the likelihood of relapse

Severe depression complicated by poor food or fluid intake, or psychotic symptoms: medication or ECT. Whatever the severity of a person’s depression, treatment should include learning new skills like problem solving and changes to lifestyle, like cutting down on stress, increasing exercise and physical fitness and not using alcohol or other drugs.

If you are currently suicidal:

We encourage you to see a health professional as soon as possible.

Taking a medicine (Antidepressant):

Depression involves changes in brain chemistry and can change the way people respond to their world. Antidepressant medicines can correct the imbalance of chemicals in the brain until such time as the natural balance is restored. There are many options with proven effectiveness and a particular medicine can be selected which best meets your needs. Please see the appendix for further details on these medicines.

Psychological therapy:

Talking with a health professional in a structured way has been shown to help relieve depression. This therapy involves a choice of one or more psychological therapies (see cognitive behaviour therapy in appendix). The therapist aims to work with you on the way you react to circumstances and relationships. These therapies should be conducted by professionally trained staff for the best results. Some of these professionals might include psychologists, doctors who have had training in psychological therapies, psychiatrists, social workers or other specialist mental health professionals.

What will happen when you seek treatment for depression?

The following outlines what is likely to happen when you seek help and treatment for depression. When you first visit a GP (local doctor) or counsellor they will ask you questions about your symptoms, your current stresses and current supports, and some aspects of your past history, such as whether you have had a previous episode of depression. After this assessment, they will then provide information about depression and how you can best cope with it. If you wish, they can provide information for your family or friends.

Depending on the severity of your depression, your GP or counsellor will recommend:

• Use of a medicine (eg, an antidepressant)

• Use of a specific psychological therapy

• A mix of both psychological therapy and medicine.

· In severe cases ECT may be considered especially if the patient is psychotic, suicidal or extremely dangerous to others (see appendix for more information on this wonderful but much debatable treatment in psychiatry).

Sometimes your GP may suggest you see a specialist (eg, a psychiatrist or another specialist mental health professional) if you need extra treatment, or recommend admission to hospital for a short period if the depression is severe or if there are concerns about your safety.

Following the initial visit, you should have at least weekly check-ups with your GP, nurse, a psychologist or counsellor (including by telephone). Your health professional will reassess your depression every six weeks for one year, or for three years if the depression is severe or if you have had depression before. These visits are to check on your symptoms and changes in your circumstances and to make any necessary adjustments in your treatment.

While all antidepressants are equally effective in treating depression, they all cause some side effects. These differ between types of antidepressants and, to a lesser extent, between different ones of the same type. It is important to discuss how likely particular side effects are with your doctor when choosing a medication and to discuss your experience of these as your treatment progresses.

What can you do to assist with treatment?

Research has shown that the greatest contribution to a positive outcome from treatment comes from:

• The person and their health professional developing a trusting relationship and working together to find a suitable treatment

• Identifying and working on factors which appear to have contributed to the depression

• Continuing with treatment for as long as is necessary to deal with the issues causing the depression and to make sure that mood remains stable afterwards without risk of relapse (at least one year, but up to two to three years if there has been previous depression or there are significant risks that it will occur again).

Other support during recovery from depression (see appendix for more details including local help):

Maintaining and making good friendships is also very important in recovery from depression. Make the most of family, friends and local community groups. Try not to get isolated.

There are also groups run by people who have experienced a mental illness and who have had successful treatment. These include self-help and mutual support groups or associations, and mental health consumer organisations. Such organisations may run mutual support by telephone or in groups that meet face to face. Some offer website chat rooms. Others provide formal information and referral services for personal support, postal or telephone information for you or for your family or partner, and some may suggest clinics, after-hours crisis lines and information about the treatments available. While not directly treatment services, these organisations may be helpful when you are trying to find the right treatment for you, and may make it easier to remain in treatment to get the best results

Adapted from: www.mayoclinic.com 

Bipolar Affective Disorder

Sama, had an arranged marriage with Sumana, only two years before. The life was just perfect for them. For the last six months Sumana is behaving little strange. She has been awakening at night. Since last three weeks the frequency has gone up. Sama was not that disturbed until he found Sumana is talking too much and asking desperately for some of her favorite food, even at midnight. A week before, the case went further when she left home in broad daylight and took shelter in the local corner shop with the plea that the home is dark and occupied by ghost and she can not go there. When Sama confronted her about the inappropriateness of her behavior, Sumana became furious and accused him of knowingly marrying her to live with his de facto wife and make her life miserable. This fabrication upset Sama even more.

Sumana’s speech was quite rapid. Her ideas jump from one to another. She thinks that she is a special messenger from lord Vishnu to bring world peace and she is Vishnu’s special envoy. Although she is a shy person to talk in public, she does not care to talk in front of the village crowd.

Sama knew very little, all most none, about Sumana’s family history as regard to have any psychiatric illness in the family. He recalled that on one occasion he heard Sumana saying something interesting about her maternal uncle, an excellent mathematics teacher in a private school who often neglected his work and acted as if he was a millionaire.

Introduction

Bipolar disorder, also known as manic-depressive illness, is a brain disorder that causes unusual shifts in a person’s mood, energy, and ability to function. Different from the normal ups and downs that everyone goes through, the symptoms of bipolar disorder are severe. They can result in damaged relationships, poor job or school performance, and even suicide. But there is good news: bipolar disorder can be treated, and people with this illness can lead full and productive lives.

About 5.7 million American adults or about 2.6 percent of the population age 18 and older in any given year, have bipolar disorder. Bipolar disorder typically develops in late adolescence or early adulthood. However, some people have their first symptoms during childhood, and some develop them late in life. It is often not recognized as an illness, and people may suffer for years before it is properly diagnosed and treated. Like diabetes or heart disease, bipolar disorder is a long-term illness that must be carefully managed throughout a person’s life.

What Are the Symptoms of Bipolar Disorder?

Bipolar disorder causes dramatic mood swings—from overly “high” and/or irritable to sad and hopeless, and then back again, often with periods of normal mood in between. Severe changes in energy and behavior go along with these changes in mood. The periods of highs and lows are called episodes of mania and depression.

Signs and symptoms of mania (or a manic episode) include:

· Increased energy, activity, and restlessness

· Excessively “high,” overly good, euphoric mood

· Extreme irritability

· Racing thoughts and talking very fast, jumping from one idea to another

· Distractibility, can’t concentrate well

· Little sleep needed

· Unrealistic beliefs in one’s abilities and powers

· Poor judgment

· Spending sprees

· A lasting period of behavior that is different from usual

· Increased sexual drive

· Abuse of drugs, particularly cocaine, alcohol, and sleeping medications

· Provocative, intrusive, or aggressive behavior

· Denial that anything is wrong

A manic episode is diagnosed if elevated mood occurs with three or more of the other symptoms most of the day, nearly every day, for 1 week or longer. If the mood is irritable, four additional symptoms must be present.

Signs and symptoms of depression (or a depressive episode) include:

· Lasting sad, anxious, or empty mood

· Feelings of hopelessness or pessimism

· Feelings of guilt, worthlessness, or helplessness

· Loss of interest or pleasure in activities once enjoyed, including sex

· Decreased energy, a feeling of fatigue or of being “slowed down”

· Difficulty concentrating, remembering, making decisions

· Restlessness or irritability

· Sleeping too much, or can’t sleep

· Change in appetite and/or unintended weight loss or gain

· Chronic pain or other persistent bodily symptoms that are not caused by physical illness or injury

· Thoughts of death or suicide, or suicide attempts

A depressive episode is diagnosed if five or more of these symptoms last most of the day, nearly every day, for a period of 2 weeks or longer.

A mild to moderate level of mania is called hypomania. Hypomania may feel good to the person who experiences it and may even be associated with good functioning and enhanced productivity. Thus even when family and friends learn to recognize the mood swings as possible bipolar disorder, the person may deny that anything is wrong. Without proper treatment, however, hypomania can become severe mania in some people or can switch into depression.

Sometimes, severe episodes of mania or depression include symptoms of psychosis (or psychotic symptoms). Common psychotic symptoms are hallucinations (hearing, seeing, or otherwise sensing the presence of things not actually there) and delusions (false, strongly held beliefs not influenced by logical reasoning or explained by a person’s usual cultural concepts). Psychotic symptoms in bipolar disorder tend to reflect the extreme mood state at the time. For example, delusions of grandiosity, such as believing one is the President or has special powers or wealth, may occur during mania; delusions of guilt or worthlessness, such as believing that one is ruined and penniless or has committed some terrible crime, may appear during depression. People with bipolar disorder who have these symptoms are sometimes incorrectly diagnosed as having schizophrenia, another severe mental illness.

It may be helpful to think of the various mood states in bipolar disorder as a spectrum or continuous range. At one end is severe depression, above which is moderate depression and then mild low mood, which many people call “the blues” when it is short-lived but is termed “dysthymia” when it is chronic. Then there is normal or balanced mood, above which comes hypomania (mild to moderate mania), and then severe mania.

In some people, however, symptoms of mania and depression may occur together in what is called a mixed bipolar state. Symptoms of a mixed state often include agitation, trouble sleeping, significant change in appetite, psychosis, and suicidal thinking. A person may have a very sad, hopeless mood while at the same time feeling extremely energized.

Bipolar disorder may appear to be a problem other than mental illness—for instance, alcohol or drug abuse, poor school or work performance, or strained interpersonal relationships. Such problems in fact may be signs of an underlying mood disorder.

What Is the Course of Bipolar Disorder?

Episodes of mania and depression typically recur across the life span. Between episodes, most people with bipolar disorder are free of symptoms, but as many as one-third of people have some residual symptoms. A small percentage of people experience chronic unremitting symptoms despite treatment.

The classic form of the illness, which involves recurrent episodes of mania and depression, is called bipolar I disorder. Some people, however, never develop severe mania but instead experience milder episodes of hypomania that alternate with depression; this form of the illness is called bipolar II disorder. When four or more episodes of illness occur within a 12-month period, a person is said to have rapid-cycling bipolar disorder. Some people experience multiple episodes within a single week, or even within a single day. Rapid cycling tends to develop later in the course of illness and is more common among women than among men.

People with bipolar disorder can lead healthy and productive lives when the illness is effectively treated (see “How Is Bipolar Disorder Treated?”). Without treatment, however, the natural course of bipolar disorder tends to worsen. Over time a person may suffer more frequent (more rapid-cycling) and more severe manic and depressive episodes than those experienced when the illness first appeared.⁴ But in most cases, proper treatment can help reduce the frequency and severity of episodes and can help people with bipolar disorder maintain good quality of life.

Can Children and Adolescents Have Bipolar Disorder?

Both children and adolescents can develop bipolar disorder. It is more likely to affect the children of parents who have the illness.

Unlike many adults with bipolar disorder, whose episodes tend to be more clearly defined, children and young adolescents with the illness often experience very fast mood swings between depression and mania many times within a day.⁵ Children with mania are more likely to be irritable and prone to destructive tantrums than to be overly happy and elated. Mixed symptoms also are common in youths with bipolar disorder. Older adolescents who develop the illness may have more classic, adult-type episodes and symptoms.

Bipolar disorder in children and adolescents can be hard to tell apart from other problems that may occur in these age groups. For example, while irritability and aggressiveness can indicate bipolar disorder, they also can be symptoms of attention deficit hyperactivity disorder, conduct disorder, oppositional defiant disorder, or other types of mental disorders more common among adults such as major depression or schizophrenia. Drug abuse also may lead to such symptoms.

For any illness, however, effective treatment depends on appropriate diagnosis. Children or adolescents with emotional and behavioral symptoms should be carefully evaluated by a mental health professional. Any child or adolescent who has suicidal feelings, talks about suicide, or attempts suicide should be taken seriously and should receive immediate help from a mental health specialist.

What Causes Bipolar Disorder?

Scientists are learning about the possible causes of bipolar disorder through several kinds of studies. Most scientists now agree that there is no single cause for bipolar disorder—rather, many factors act together to produce the illness.

Because bipolar disorder tends to run in families, researchers have been searching for specific genes—the microscopic “building blocks” of DNA inside all cells that influence how the body and mind work and grow—passed down through generations that may increase a person’s chance of developing the illness. But genes are not the whole story. Studies of identical twins, who share all the same genes, indicate that both genes and other factors play a role in bipolar disorder. If bipolar disorder were caused entirely by genes, then the identical twin of someone with the illness would always develop the illness, and research has shown that this is not the case. But if one twin has bipolar disorder, the other twin is more likely to develop the illness than is another sibling.

In addition, findings from gene research suggest that bipolar disorder, like other mental illnesses, does not occur because of a single gene. It appears likely that many different genes act together, and in combination with other factors of the person or the person’s environment, to cause bipolar disorder. Finding these genes, each of which contributes only a small amount toward the vulnerability to bipolar disorder, has been extremely difficult. But scientists expect that the advanced research tools now being used will lead to these discoveries and to new and better treatments for bipolar disorder.

Brain-imaging studies are helping scientists learn what goes wrong in the brain to produce bipolar disorder and other mental illnesses. New brain-imaging techniques allow researchers to take pictures of the living brain at work, to examine its structure and activity, without the need for surgery or other invasive procedures. These techniques include magnetic resonance imaging (MRI), positron emission tomography (PET), and functional magnetic resonance imaging (fMRI). There is evidence from imaging studies that the brains of people with bipolar disorder may differ from the brains of healthy individuals. As the differences are more clearly identified and defined through research, scientists will gain a better understanding of the underlying causes of the illness, and eventually may be able to predict which types of treatment will work most effectively.

How Is Bipolar Disorder Treated?

Most people with bipolar disorder—even those with the most severe forms—can achieve substantial stabilization of their mood swings and related symptoms with proper treatment. Because bipolar disorder is a recurrent illness, long-term preventive treatment is strongly recommended and almost always indicated. A strategy that combines medication and psychosocial treatment is optimal for managing the disorder over time.

In most cases, bipolar disorder is much better controlled if treatment is continuous than if it is on and off. But even when there are no breaks in treatment, mood changes can occur and should be reported immediately to your doctor. The doctor may be able to prevent a full-blown episode by making adjustments to the treatment plan. Working closely with the doctor and communicating openly about treatment concerns and options can make a difference in treatment effectiveness.

In addition, keeping a chart of daily mood symptoms, treatments, sleep patterns, and life events may help people with bipolar disorder and their families to better understand the illness. This chart also can help the doctor track and treat the illness most effectively.

Medications

Medications for bipolar disorder are prescribed by psychiatrists—medical doctors (M.D.) with expertise in the diagnosis and treatment of mental disorders. While primary care physicians who do not specialize in psychiatry also may prescribe these medications, it is recommended that people with bipolar disorder see a psychiatrist for treatment.

Medications known as “mood stabilizers” usually are prescribed to help control bipolar disorder. Several different types of mood stabilizers are available. In general, people with bipolar disorder continue treatment with mood stabilizers for extended periods of time (years). Other medications are added when necessary, typically for shorter periods, to treat episodes of mania or depression that break through despite the mood stabilizer.

· Lithium, the first mood-stabilizing medication approved by the U.S. Food and Drug Administration (FDA) for treatment of mania, is often very effective in controlling mania and preventing the recurrence of both manic and depressive episodes.

· Anticonvulsant medications, such as valproate (Depakote^®) or carbamazepine (Tegretol^®), also can have mood-stabilizing effects and may be especially useful for difficult-to-treat bipolar episodes. Valproate was FDA-approved in 1995 for treatment of mania.

· Newer anticonvulsant medications, including lamotrigine (Lamictal^®), gabapentin (Neurontin^®), and topiramate (Topamax^®), are being studied to determine how well they work in stabilizing mood cycles.

· Anticonvulsant medications may be combined with lithium, or with each other, for maximum effect.

· Children and adolescents with bipolar disorder generally are treated with lithium, but valproate and carbamazepine also are used. Researchers are evaluating the safety and efficacy of these and other psychotropic medications in children and adolescents. There is some evidence that valproate may lead to adverse hormone changes in teenage girls and polycystic ovary syndrome in women who began taking the medication before age 20. Therefore, young female patients taking valproate should be monitored carefully by a physician.

· Women with bipolar disorder who wish to conceive, or who become pregnant, face special challenges due to the possible harmful effects of existing mood stabilizing medications on the developing fetus and the nursing infant. Therefore, the benefits and risks of all available treatment options should be discussed with a clinician skilled in this area. New treatments with reduced risks during pregnancy and lactation are under study.

Treatment of Bipolar Depression

Research has shown that people with bipolar disorder are at risk of switching into mania or hypomania, or of developing rapid cycling, during treatment with antidepressant medication.¹⁵ Therefore, “mood-stabilizing” medications generally are required, alone or in combination with antidepressants, to protect people with bipolar disorder from this switch. Lithium and valproate are the most commonly used mood-stabilizing drugs today. However, research studies continue to evaluate the potential mood-stabilizing effects of newer medications.

· Atypical antipsychotic medications, including clozapine (Clozaril^®), olanzapine (Zyprexa^®), risperidone (Risperdal^®), quetiapine (Seroquel^®), and ziprasidone (Geodon^®), are being studied as possible treatments for bipolar disorder. Evidence suggests clozapine may be helpful as a mood stabilizer for people who do not respond to lithium or anticonvulsants. Other research has supported the efficacy of olanzapine for acute mania, an indication that has recently received FDA approval. Olanzapine may also help relieve psychotic depression.

· If insomnia is a problem, a high-potency benzodiazepine medication such as clonazepam (Klonopin^®) or lorazepam (Ativan^®) may be helpful to promote better sleep. However, since these medications may be habit-forming, they are best prescribed on a short-term basis. Other types of sedative medications, such as zolpidem (Ambien^®), are sometimes used instead.

· Changes to the treatment plan may be needed at various times during the course of bipolar disorder to manage the illness most effectively. A psychiatrist should guide any changes in type or dose of medication.

· Be sure to tell the psychiatrist about all other prescription drugs, over-the-counter medications, or natural supplements you may be taking. This is important because certain medications and supplements taken together may cause adverse reactions.

· To reduce the chance of relapse or of developing a new episode, it is important to stick to the treatment plan. Talk to your doctor if you have any concerns about the medications.

Thyroid Function

People with bipolar disorder often have abnormal thyroid gland function. Because too much or too little thyroid hormone alone can lead to mood and energy changes, it is important that thyroid levels are carefully monitored by a physician.

People with rapid cycling tend to have co-occurring thyroid problems and may need to take thyroid pills in addition to their medications for bipolar disorder. Also, lithium treatment may cause low thyroid levels in some people, resulting in the need for thyroid supplementation.

Medication Side Effects

Before starting a new medication for bipolar disorder, always talk with your psychiatrist and/or pharmacist about possible side effects. Depending on the medication, side effects may include weight gain, nausea, tremor, reduced sexual drive or performance, anxiety, hair loss, movement problems, or dry mouth. Be sure to tell the doctor about all side effects you notice during treatment. He or she may be able to change the dose or offer a different medication to relieve them. Your medication should not be changed or stopped without the psychiatrist’s guidance.

Psychosocial Treatments

As an addition to medication, psychosocial treatments—including certain forms of psychotherapy (or “talk” therapy)—are helpful in providing support, education, and guidance to people with bipolar disorder and their families. Studies have shown that psychosocial interventions can lead to increased mood stability, fewer hospitalizations, and improved functioning in several areas. A licensed psychologist, social worker, or counselor typically provides these therapies and often works together with the psychiatrist to monitor a patient’s progress. The number, frequency, and type of sessions should be based on the treatment needs of each person.

Psychosocial interventions commonly used for bipolar disorder are cognitive behavioral therapy, psychoeducation, family therapy, and a newer technique, interpersonal and social rhythm therapy. NIMH researchers are studying how these interventions compare to one another when added to medication treatment for bipolar disorder.

· Cognitive behavioral therapy helps people with bipolar disorder learn to change inappropriate or negative thought patterns and behaviors associated with the illness.

· Psychoeducation involves teaching people with bipolar disorder about the illness and its treatment, and how to recognize signs of relapse so that early intervention can be sought before a full-blown illness episode occurs. Psychoeducation also may be helpful for family members.

· Family therapy uses strategies to reduce the level of distress within the family that may either contribute to or result from the ill person’s symptoms.

· Interpersonal and social rhythm therapy helps people with bipolar disorder both to improve interpersonal relationships and to regularize their daily routines. Regular daily routines and sleep schedules may help protect against manic episodes.

· As with medication, it is important to follow the treatment plan for any psychosocial intervention to achieve the greatest benefit.

Other Treatments

· In situations where medication, psychosocial treatment, and the combination of these interventions prove ineffective, or work too slowly to relieve severe symptoms such as psychosis or suicidality, electroconvulsive therapy (ECT) may be considered. ECT may also be considered to treat acute episodes when medical conditions, including pregnancy, make the use of medications too risky. ECT is a highly effective treatment for severe depressive, manic, and/or mixed episodes. The possibility of long-lasting memory problems, although a concern in the past, has been significantly reduced with modern ECT techniques. However, the potential benefits and risks of ECT, and of available alternative interventions, should be carefully reviewed and discussed with individuals considering this treatment and, where appropriate, with family or friends.

· Herbal or natural supplements, such as St. John’s wort (Hypericum perforatum), have not been well studied, and little is known about their effects on bipolar disorder. Because the FDA does not regulate their production, different brands of these supplements can contain different amounts of active ingredient. Before trying herbal or natural supplements, it is important to discuss them with your doctor. There is evidence that St. John’s wort can reduce the effectiveness of certain medications. In addition, like prescription antidepressants, St. John’s wort may cause a switch into mania in some individuals with bipolar disorder, especially if no mood stabilizer is being taken.

· Omega-3 fatty acids found in fish oil are being studied to determine their usefulness, alone and when added to conventional medications, for long-term treatment of bipolar disorder.

A Long-Term Illness That Can Be Effectively Treated

Even though episodes of mania and depression naturally come and go, it is important to understand that bipolar disorder is a long-term illness that currently has no cure. Staying on treatment, even during well times, can help keep the disease under control and reduce the chance of having recurrent, worsening episodes.

Do Other Illnesses Co-occur with Bipolar Disorder?

Alcohol and drug abuse are very common among people with bipolar disorder. Research findings suggest that many factors may contribute to these substance abuse problems, including self-medication of symptoms, mood symptoms either brought on or perpetuated by substance abuse, and risk factors that may influence the occurrence of both bipolar disorder and substance use disorders. Treatment for co-occurring substance abuse, when present, is an important part of the overall treatment plan.

Anxiety disorders, such as post-traumatic stress disorder and obsessive-compulsive disorder, also may be common in people with bipolar disorder. Co-occurring anxiety disorders may respond to the treatments used for bipolar disorder, or they may require separate treatment.

How Can Individuals and Families Get Help for Bipolar Disorder

Anyone with bipolar disorder should be under the care of a psychiatrist skilled in the diagnosis and treatment of this disease. Other mental health professionals, such as psychologists, psychiatric social workers, and psychiatric nurses, can assist in providing the person and family with additional approaches to treatment.

Help can be found at:

· University—or medical school—affiliated programs

· Hospital departments of psychiatry

· Private psychiatric offices and clinics

· Offices of family physicians, internists, and pediatricians

· Public community mental health centers

People with bipolar disorder may need help to get help.

· Often people with bipolar disorder do not realize how impaired they are, or they blame their problems on some cause other than mental illness.

· A person with bipolar disorder may need strong encouragement from family and friends to seek treatment. Family physicians can play an important role in providing referral to a mental health professional.

· Sometimes a family member or friend may need to take the person with bipolar disorder for proper mental health evaluation and treatment.

· A person who is in the midst of a severe episode may need to be hospitalized for his or her own protection and for much-needed treatment. There may be times when the person must be hospitalized against his or her wishes.

· Ongoing encouragement and support are needed after a person obtains treatment, because it may take a while to find the best treatment plan for each individual.

· In some cases, individuals with bipolar disorder may agree, when the disorder is under good control, to a preferred course of action in the event of a future manic or depressive relapse.

· Like other serious illnesses, bipolar disorder is also hard on spouses, family members, friends, and employers.

· Family members of someone with bipolar disorder often have to cope with the person’s serious behavioral problems, such as wild spending sprees during mania or extreme withdrawal from others during depression, and the lasting consequences of these behaviors.

· Many people with bipolar disorder benefit from joining support groups such as those sponsored by the National Depressive and Manic Depressive Association (NDMDA), the National Alliance for the Mentally Ill (NAMI), and the National Mental Health Association (NMHA). Families and friends can also benefit from support groups offered by these organizations. A list of locally available organizations is given in the appendix.

What About Clinical Studies for Bipolar Disorder?

Some people with bipolar disorder receive medication and/or psychosocial therapy by volunteering to participate in clinical studies (clinical trials). Clinical studies involve the scientific investigation of illness and treatment of illness in humans. Clinical studies in mental health can yield information about the efficacy of a medication or a combination of treatments, the usefulness of a behavioral intervention or type of psychotherapy, the reliability of a diagnostic procedure, or the success of a prevention method. Clinical studies also guide scientists in learning how illness develops, progresses, lessens, and affects both mind and body. Millions of people diagnosed with mental illness lead healthy, productive lives because of information discovered through clinical studies. These studies are not always right for everyone, however. It is important for each individual to consider carefully the possible risks and benefits of a clinical study before making a decision to participate.

Adapted from - NIMH website and available at http://www.nimh.nih.gov/

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Postpartum depression

Case Vignette:

Ambika is a 28 year old school teacher, a mother of three children, married happily to Prakash. The yougest of the children, Deepika is only 4 months old and quite a handful for her. she screams and does not eat properly. Ambika has not been feeling good ever since Deepika is born. She has frequently had crying spell. Her sleep is all over the place and so also her appetite. It all got unbearable when she had these serous thoughts of suicide lately. She just did not find any reasons to be living. She was worried if it is safe for her to be with her kids alone at home. Often she had fleeting thoughts of hurting the young child as well. She further felt miserable just having had these thought re her own flesh and blood, her dear child! She knew they were the reasons for her living and still paradoxically she had these thoughts. She was wondering what sort of mother she is to have thoughts of killing her child. She thought of seeking help.

On interview by her psychiatrist it was found that Ambika had similar experience almost every time all her children were born. She however had not bothered to take any medical help in the past. To complicate the matter further Prakash was very critical of Deepika as he had expected a boy this time as the other two of their children were girls.

Definition

The birth of a baby can trigger a jumble of powerful emotions, from excitement and joy to fear and anxiety. But it can also result in something you might not expect — depression.

Many new moms experience the baby blues after childbirth. An estimated 10 percent of new moms experience a more severe form of emotional distress known as postpartum depression. Rarely, an extreme form of postpartum depression known as postpartum psychosis develops after childbirth.

Postpartum depression isn't a character flaw or a weakness. Sometimes postpartum depression is simply part of giving birth. If you have postpartum depression, prompt treatment can help you manage your symptoms — and enjoy your baby.

Symptoms

Signs and symptoms of depression after childbirth vary depending on the type of depression.

Baby blues

Signs and symptoms of the baby blues — which last only a few days or weeks — may include:

· Mood swings

· Anxiety

· Sadness

· Irritability

· Crying

· Decreased concentration

· Trouble sleeping

Postpartum depression

Postpartum depression may appear to be the baby blues at first — but the signs and symptoms are more intense and longer lasting, eventually interfering with your ability to care for your baby and handle other daily tasks. Signs and symptoms of postpartum depression may include:

· Loss of appetite

· Insomnia

· Intense irritability and anger

· Overwhelming fatigue

· Loss of interest in sex

· Lack of joy in life

· Feelings of shame, guilt or inadequacy

· Severe mood swings

· Difficulty bonding with the baby

· Withdrawal from family and friends

· Thoughts of harming yourself or the baby

Postpartum psychosis

With postpartum psychosis — a rare condition that typically develops within the first two weeks after delivery — the signs and symptoms are even more severe. Signs and symptoms of postpartum psychosis may include:

· Confusion and disorientation

· Hallucinations and delusions

· Paranoia

· Attempts to harm yourself or the baby

Causes

There's no single cause for postpartum depression. Physical, emotional and lifestyle factors may all play a role.

· Physical changes. After childbirth, a dramatic drop in estrogen and progesterone may contribute to postpartum depression. The hormones produced by your thyroid gland also may drop sharply — which can leave you feeling tired, sluggish and depressed. Changes in your blood volume, blood pressure, immune system and metabolism can lead to fatigue and mood swings.

· Emotional factors. When you're sleep deprived and overwhelmed, you may have trouble handling even minor problems. You may be anxious about your ability to care for a newborn. You may feel less attractive or struggle with your sense of identity. You may feel that you've lost control over your life. Any of these factors can contribute to postpartum depression.

· Lifestyle influences. Many lifestyle factors can lead to postpartum depression, including a demanding baby or older siblings, difficulty breast-feeding, exhaustion, financial problems, and lack of support from your partner or other loved ones.

Risk factors

Postpartum depression can develop after the birth of any child, not just the first. The risk increases if:

· You have a history of depression, either during pregnancy or at other times

· You had postpartum depression after a previous pregnancy

· You've experienced stressful events during the past year, including illness, job loss or pregnancy complications

· You're experiencing marital conflict

· You have a weak support system

· The pregnancy is unplanned or unwanted

The risk of postpartum psychosis is higher for women who have bipolar disorder.

When to seek medical advice

If you're feeling depressed after your baby's birth, you may be reluctant or embarrassed to admit it. But it's important to tell your doctor. If the signs and symptoms of depression don't fade after a few weeks or if they're so severe that they interfere with your ability to complete everyday tasks, call your doctor. Early intervention can speed your recovery.

If you suspect that you're developing postpartum psychosis, seek medical attention immediately. Don't wait and hope for improvement. Postpartum psychosis may lead to life-threatening thoughts or behaviors.

Tests and diagnosis

To distinguish between a short-term case of the baby blues and a more severe form of depression, your doctor may ask you to complete a depression-screening questionnaire. Blood tests can help your doctor determine whether an underactive thyroid is contributing to your signs and symptoms.

Complications

Left untreated, postpartum depression can interfere with mother-child bonding and cause family distress. Children of mothers who have untreated postpartum depression are more likely to have behavioral problems, such as sleeping and eating difficulties, temper tantrums and hyperactivity. Delays in language development are common as well.

Untreated postpartum depression can last up to a year or longer. Sometimes untreated postpartum depression becomes a chronic depressive disorder. Even when treated, postpartum depression increases a woman's risk of future episodes of major depression.

Treatments and drugs

Treatment and recovery time vary, depending on the severity of your depression and your individual needs.

Baby blues

The baby blues usually fade on their own within a few days to weeks. In the meantime, get as much rest as you can. Accept help from family and friends. Connect with other new moms. Avoid alcohol, which can make mood swings worse. If you have an underactive thyroid, your doctor may prescribe thyroid medication.

Postpartum depression

Postpartum depression is often treated with counselling and medication.

· Counselling. It may help to talk through your concerns with a psychiatrist, psychologist or other mental health professional.

· Set realistic expectations. Through counselling, you can find better ways to cope with your feelings, solve problems and set realistic goals. Sometimes, family or marital therapy also is helpful.

· Antidepressants. Antidepressants are a proven treatment for postpartum depression. If you're breast-feeding, it's important to know that any medication you take will enter your breast milk. However, various antidepressants can be used during breast-feeding with little risk of side effects for your baby. Work with your doctor to weigh the potential risks and benefits of specific antidepressants.

· Hormone therapy. Estrogen replacement may help counteract the rapid drop in estrogen that accompanies childbirth, which may ease the signs and symptoms of postpartum depression in some women. Research on the effectiveness of hormone therapy for postpartum depression is limited, however. As with antidepressants, weigh the potential risks and benefits of hormone therapy with your doctor.

· With appropriate treatment, postpartum depression usually goes away within a few months. In some cases, postpartum depression lasts up to a year. It's important to continue treatment after you begin to feel better, however. Stopping treatment too early may only lead to a relapse.
Postpartum psychosis
Postpartum psychosis requires immediate treatment, often in the hospital.
When your safety is assured, a combination of medications — such as antidepressants, antipsychotic medications and mood stabilizers — may be used to control your signs and symptoms. Sometimes electroconvulsive therapy (ECT) is recommended as well. During ECT, a small amount of electrical current is applied to your brain to produce brain waves similar to those that occur during a seizure. The chemical changes triggered by the electrical currents can reduce the symptoms of depression, especially when other treatments have failed or when you need immediate results.
Treatment for postpartum psychosis can challenge a mother's ability to breast-feed. Separation from the baby makes breast-feeding difficult, and some medications used to treat postpartum psychosis aren't recommended for women who are breast-feeding. If you're experiencing postpartum psychosis, a team of health care providers will help you work through these challenges.
Prevention
If you have a history of depression — especially postpartum depression — mention it to your doctor as soon as you find out you're pregnant. Your doctor will monitor you closely for signs and symptoms of depression. Sometimes mild depression can be managed with support groups, counseling or other therapies. In other cases, antidepressants are recommended — even during pregnancy.
After your baby is born, your doctor may recommend an early postpartum checkup to screen for signs and symptoms of postpartum depression. The earlier postpartum depression is detected, the earlier treatment can begin. If you have a history of postpartum depression, your doctor may recommend antidepressant treatment immediately after delivery.
Lifestyle and home remedies
Postpartum depression isn't generally a condition that you can treat on your own — but you can do some things for yourself that build on your treatment plan. In fact, taking good care of yourself can help speed your recovery.

o   Make healthy lifestyle choices. Rest as much as you can. Include physical activity, such as a walk with your baby, in your daily routine. Eat healthy foods — plenty of fruits, vegetables and whole grains. Avoid alcohol. yourself to do everything. Scale back your expectations for the perfect household. Do what you can and leave the rest. Ask for help when you need it.

· Make time for yourself. If you feel like the world is coming down around you, take some time for yourself. Get dressed, leave the house, and visit a friend or run an errand. Or schedule some time alone with your partner.

· Avoid isolation. Talk with your partner, family and friends about how you're feeling. Ask other mothers about their experiences. Ask your doctor about local support groups for new moms or women who have postpartum depression.

Remember, the best way to take care of your baby is to take care of yourself.

Anxiety Disorders

Introduction

Anxiety Disorders affect millions of people causing them to be filled with fearfulness and uncertainty. Unlike the relatively mild, brief anxiety caused by a stressful event (such as speaking in public or a first date), anxiety disorders last at least 6 months and can get worse if they are not treated. Anxiety disorders commonly occur along with other mental or physical illnesses, including alcohol or substance abuse, which may mask anxiety symptoms or make them worse. In some cases, these other illnesses need to be treated before a person will respond to treatment for the anxiety disorder.

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

This chapter will:

· describe the symptoms of anxiety disorders,

· explain the role of research in understanding the causes of these conditions,

· describe effective treatments,

· help you learn how to obtain treatment and work with a doctor or therapist, and

· suggest ways to make treatment more effective.

The following anxiety disorders are discussed below:

· panic disorder,

· obsessive-compulsive disorder (OCD),

· post-traumatic stress disorder (PTSD),

· social phobia (or social anxiety disorder),

· specific phobias, and

· generalized anxiety disorder (GAD).

Each anxiety disorder has different symptoms, but all the symptoms cluster around excessive, irrational fear and dread.

Panic Disorder

Case vignette:

“For me, a panic attack is almost a violent experience. I feel disconnected from reality. I feel like I’m losing control in a very extreme way. My heart pounds really hard, I feel like I can’t get my breath, and there’s an overwhelming feeling that things are crashing in on me.”

“It started 10 years ago, when I had just graduated from college and started a new job. I was sitting in a business seminar in a hotel and this thing came out of the blue. I felt like I was dying.”

“In between attacks there is this dread and anxiety that it’s going to happen again. I’m afraid to go back to places where I’ve had an attack. Unless I get help, there soon won’t be anyplace where I can go and feel safe from panic.”

Panic disorder is a real illness that can be successfully treated. It is characterized by sudden attacks of terror, usually accompanied by a pounding heart, sweatiness, weakness, faintness, or dizziness. During these attacks, people with panic disorder may flush or feel chilled; their hands may tingle or feel numb; and they may experience nausea, chest pain, or smothering sensations. Panic attacks usually produce a sense of unreality, a fear of impending doom, or a fear of losing control.

A fear of one’s own unexplained physical symptoms is also a symptom of panic disorder. People having panic attacks sometimes believe they are having heart attacks, losing their minds, or on the verge of death. They can’t predict when or where an attack will occur, and between episodes many worry intensely and dread the next attack.

Panic attacks can occur at any time, even during sleep. An attack usually peaks within 10 minutes, but some symptoms may last much longer. Panic disorder is twice as common in women as men. Panic attacks often begin in late adolescence or early adulthood, but not everyone who experiences panic attacks will develop panic disorder. Many people have just one attack and never have another. The tendency to develop panic attacks appears to be inherited.

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

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

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

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

 

 

Obsessive-Compulsive Disorder

 

Case vignette:

 

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

“I knew the rituals didn’t make sense, and I was deeply ashamed of them, but I couldn’t seem to overcome them until I had therapy.”

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

People with obsessive-compulsive disorder (OCD) have persistent, upsetting thoughts (obsessions) and use rituals (compulsions) to control the anxiety these thoughts produce. Most of the time, the rituals end up controlling them.

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

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

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

OCD can be accompanied by eating disorders, other anxiety disorders, or depression. It strikes men and women in roughly equal numbers and usually appears in childhood, adolescence, or early adulthood. One-third of adults with OCD develop symptoms as children, and research indicates that OCD might run in families.

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

OCD usually responds well to treatment with certain medications and/or exposure-based psychotherapy, in which people face situations that cause fear or anxiety and become less sensitive (desensitized) to them.

 

Post-Traumatic Stress Disorder

Case vignette:

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

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

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

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

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

People with PTSD may startle easily, become emotionally numb (especially in relation to people with whom they used to be close), lose interest in things they used to enjoy, have trouble feeling affectionate, be irritable, become more aggressive, or even become violent. They avoid situations that remind them of the original incident, and anniversaries of the incident are often very difficult. PTSD symptoms seem to be worse if the event that triggered them was deliberately initiated by another person, as in a mugging or a kidnapping. Most people with PTSD repeatedly relive the trauma in their thoughts during the day and in nightmares when they sleep. These are called flashbacks. Flashbacks may consist of images, sounds, smells, or feelings, and are often triggered by ordinary occurrences, such as a door slamming or a car backfiring on the street. A person having a flashback may lose touch with reality and believe that the traumatic incident is happening all over again.

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

PTSD can occur at any age, including childhood. Women are more likely to develop PTSD than men and there is some evidence that susceptibility to the disorder may run in families. PTSD is often accompanied by depression, substance abuse, or one or more of the other anxiety disorders.

Certain kinds of medication and certain kinds of psychotherapy usually treat the symptoms of PTSD very effectively.

Social Phobia (Social Anxiety Disorder)

Case vignette:

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

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

Social phobia, also called social anxiety disorder, is diagnosed when people become overwhelmingly anxious and excessively self-conscious in everyday social situations. People with social phobia have an intense, persistent, and chronic fear of being watched and judged by others and of doing things that will embarrass them. They can worry for days or weeks before a dreaded situation. This fear may become so severe that it interferes with work, school, and other ordinary activities, and can make it hard to make and keep friends.

While many people with social phobia realize that their fears about being with people are excessive or unreasonable, they are unable to overcome them. Even if they manage to confront their fears and be around others, they are usually very anxious beforehand, are intensely uncomfortable throughout the encounter, and worry about how they were judged for hours afterward.

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

Physical symptoms that often accompany social phobia include blushing, profuse sweating, trembling, nausea, and difficulty talking. When these symptoms occur, people with social phobia feel as though all eyes are focused on them.

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

Social phobia can be successfully treated with certain kinds of psychotherapy or medications.

 

Specific Phobias

Case vignette:

“I’m scared to death of flying, and I never do it anymore. I used to start dreading a plane trip a month before I was due to leave. It was an awful feeling when that airplane door closed and I felt trapped. My heart would pound, and I would sweat bullets. When the airplane would start to ascend, it just reinforced the feeling that I couldn’t get out. When I think about flying, I picture myself losing control, freaking out, and climbing the walls, but of course I never did that. I’m not afraid of crashing or hitting turbulence. It’s just that feeling of being trapped. Whenever I’ve thought about changing jobs, I’ve had to think, ‘Would I be under pressure to fly?’ These days I only go places where I can drive or take a train. My friends always point out that I couldn’t get off a train traveling at high speeds either, so why don’t trains bother me? I just tell them it isn’t a rational fear.”

A specific phobia is an intense fear of something that poses little or no actual danger. Some of the more common specific phobias are centered around closed-in places, heights, escalators, tunnels, highway driving, water, flying, dogs, and injuries involving blood. Such phobias aren’t just extreme fear; they are irrational fear of a particular thing. You may be able to ski the world’s tallest mountains with ease but be unable to go above the 5th floor of an office building. While adults with phobias realize that these fears are irrational, they often find that facing, or even thinking about facing, the feared object or situation brings on a panic attack or severe anxiety.

Specific phobias are twice as common in women as men. They usually appear in childhood or adolescence and tend to persist into adulthood. The causes of specific phobias are not well understood, but there is some evidence that the tendency to develop them may run in families.

If the feared situation or feared object is easy to avoid, people with specific phobias may not seek help; but if avoidance interferes with their careers or their personal lives, it can become disabling and treatment is usually pursued.

Specific phobias respond very well to carefully targeted psychotherapy.

 

 

 

 

Generalized Anxiety Disorder (GAD)

Case vignette:

“I always thought I was just a worrier. I’d feel keyed up and unable to relax. At times it would come and go, and at times it would be constant. It could go on for days. I’d worry about what I was going to fix for a dinner party, or what would be a great present for somebody. I just couldn’t let something go.”

“I’d have terrible sleeping problems. There were times I’d wake up wired in the middle of the night. I had trouble concentrating, even reading the newspaper or a novel. Sometimes I’d feel a little lightheaded. My heart would race or pound. And that would make me worry more. I was always imagining things were worse than they really were: when I got a stomach ache, I’d think it was an ulcer.”

People with generalized anxiety disorder (GAD) go through the day filled with exaggerated worry and tension, even though there is little or nothing to provoke it. They anticipate disaster and are overly concerned about health issues, money, family problems, or difficulties at work. Sometimes just the thought of getting through the day produces anxiety.

GAD is diagnosed when a person worries excessively about a variety of everyday problems for at least 6 months. People with GAD can’t seem to get rid of their concerns, even though they usually realize that their anxiety is more intense than the situation warrants. They can’t relax, startle easily, and have difficulty concentrating. Often they have trouble falling asleep or staying asleep. Physical symptoms that often accompany the anxiety include fatigue, headaches, muscle tension, muscle aches, difficulty swallowing, trembling, twitching, irritability, sweating, nausea, lightheadedness, having to go to the bathroom frequently, feeling out of breath, and hot flashes.

When their anxiety level is mild, people with GAD can function socially and hold down a job. Although they don’t avoid certain situations as a result of their disorder, people with GAD can have difficulty carrying out the simplest daily activities if their anxiety is severe.

GAD affects twice as many women as men. The disorder comes on gradually and can begin across the life cycle, though the risk is highest between childhood and middle age. It is diagnosed when someone spends at least 6 months worrying excessively about a number of everyday problems. There is evidence that genes play a modest role in GAD.

Other anxiety disorders, depression, or substance abuse often accompany GAD, which rarely occurs alone. GAD is commonly treated with medication or cognitive-behavioral therapy, but co-occurring conditions must also be treated using the appropriate therapies.

Treatment of Anxiety Disorders

In general, anxiety disorders are treated with medication, specific types of psychotherapy, or both. Treatment choices depend on the problem and the person’s preference. Before treatment begins, a doctor must conduct a careful diagnostic evaluation to determine whether a person’s symptoms are caused by an anxiety disorder or a physical problem. If an anxiety disorder is diagnosed, the type of disorder or the combination of disorders that are present must be identified, as well as any coexisting conditions, such as depression or substance abuse. Sometimes alcoholism, depression, or other coexisting conditions have such a strong effect on the individual that treating the anxiety disorder must wait until the coexisting conditions are brought under control.

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

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

Medications

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

Antidepressants

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

SSRIs

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

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

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

Tricyclics

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

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

MAOIs

Monoamine oxidase inhibitors (MAOIs) are the oldest class of antidepressant medications. People who take MAOIs cannot eat a variety of foods and beverages (including cheese and red wine) that contain tyramine or take certain medications, including some types of birth control pills, pain relievers, cold and allergy medications, and herbal supplements; these substances can interact with MAOIs to cause dangerous increases in blood pressure. The development of a new MAOI skin patch may help lessen these risks. MAOIs can also react with SSRIs to produce a serious condition called “serotonin syndrome,” which can cause confusion, hallucinations, increased sweating, muscle stiffness, seizures, changes in blood pressure or heart rhythm, and other potentially life-threatening conditions.

Anti-Anxiety Drugs

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

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

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

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

Beta-Blockers

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

Psychotherapy

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

 

 

Cognitive-Behavioral Therapy

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

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

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

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

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

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

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

Taking Medications

Before taking medication for an anxiety disorder:

· Ask your doctor to tell you about the effects and side effects of the drug.

· Tell your doctor about any alternative therapies or over-the-counter medications you are using.

· Ask your doctor when and how the medication should be stopped. Some drugs can’t be stopped abruptly but must be tapered off slowly under a doctor’s supervision.

· Work with your doctor to determine which medication is right for you and what dosage is best.

· Be aware that some medications are effective only if they are taken regularly and that symptoms may recur if the medication is stopped.

 

 

 

 

 

How to Get Help for Anxiety Disorders

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

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

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

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

Ways to Make Treatment More Effective

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

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

The family is very important in the recovery of a person with an anxiety disorder. Ideally, the family should be supportive but not help perpetuate their loved one’s symptoms. Family members should not trivialize the disorder or demand improvement without treatment. If your family is doing either of these things, you may want to show them this booklet so they can become educated allies and help you succeed in therapy.

 

 

Role of Research in Improving the Understanding and Treatment of Anxiety Disorders

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

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

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

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

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

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

Adapted from NIMH website at: http://www.nimh.nih.gov/

Appendix-1

ANTIDEPRESSANTS:  MEDICINES FOR DEPRESSION…

Antidepressants are medicines used to help people who have moderate to severe depression.

Antidepressant medicines are designed to assist in lifting depressive symptoms, but are also useful in some disorders in addition to depression. Antidepressants are used most widely for serious depressions, but they can also be helpful for some milder depressions.

Ø    Antidepressants represent one of the most widely prescribed classes of medications in use today.

Ø    With the help of these depression medications, most people can achieve significant recovery from depression. They are, however, one depression treatment option.  

Ø    They were first developed in the 1950s and have been used regularly since then.

Ø    A doctor can only prescribe these. All antidepressant medications require a prescription.

Ø    There are several types of antidepressant medications used to treat depression and conditions that have depression as a component of the disease (like bipolar disorder).

 Ø   The last few years have seen the introduction of a number of new antidepressants. Several of them are called "selective serotonin reuptake inhibitors" (SSRIs).   

The goal of treatment is to obtain complete relief of depressive symptoms, not just partial relief.

Ø      Most physicians begin antidepressant therapy at a relatively low dosage, and patients who have a hard time adjusting to the antidepressants may be treated with a very low dose.

Ø     The dosage is gradually increased as the patient's tolerance and response to the antidepressant increases.

An effective concentration of the antidepressant in the body must be attained before the patient experiences the desired effect.

Ø     Patients should be open with their doctors about how they feel after they begin taking an antidepressant.

If they feel better after three to six weeks, but their symptoms are still present, the doctor will likely increase the dose of the antidepressant they are taking.

If they cannot tolerate a higher dose, the doctor will likely switch to another antidepressant. 

Ø     If symptoms are no better or worse after three or four weeks, the doctor will most likely suggest a different antidepressant. 

Ø     Some people notice improvement in the first couple of weeks; but usually the antidepressant must be taken regularly for at least 6 weeks and, in some cases, as many as 8 weeks before the full therapeutic effect occurs. 

Wait for them to work. They don't work straight away. 

Persevere - stopping too early is the commonest reason for people not getting better and for the depression to return. 

Ø     Most people feel better in four to six weeks. Some of your symptoms might disappear early in your treatment. 

For example, you might feel less tired and be able to sleep better. Other symptoms, such as your sad mood, might take longer to change. Feeling better most likely comes later, over time. 

Ø     In most cases, antidepressants are prescribed for a minimum of several months.  

Treatment can last a year or more. It's important not to stop taking antidepressant medications too soon, even if you feel better. 

Ø     Stopping antidepressant medications too soon is associated with high rates of relapse. That means if you stop taking your antidepressant medications too soon, you could become depressed again. 

Some people have severe depressions over and over again. Even when they have got better, they may need to take antidepressants for several years to stop their depression coming back.

BASIC FACTS ABOUT ANTIDEPRESSANTS …

· Anti-depressants are drugs that relieve the symptoms of depression.

Most depressed people need antidepressant medications to treat their depression.

Several medication options are available to treat depression, depending on your age and tolerance of the medications.

They are used to treat moderate to severe depressive illnesses.

Antidepressants are used most widely for serious depressions, but they can also be helpful for some milder depressions.
 

· The patient and doctor just have to find the one that works best for the individual.
 

· Most people find that antidepressants take 1-2 weeks to start working and may be up to several weeks to give their full effect.

Antidepressants are typically taken for at least 4 to 6 months. In some cases, patients and their doctors may decide that antidepressants are needed for a longer time.

Once the individual is feeling better, it is important to continue the medications for another few months to prevent a recurrence of the depression.

· Some medications must be stopped gradually to give the body time to adjust.

Some people find that their depressions become more frequent and severe as they get older.
For these people, continuing (maintenance) treatment with antidepressants can be an effective way of reducing the frequency and severity of depressions.

Hospitalization of an individual is necessary when that person has attempted suicide or has serious suicidal ideation or plan for doing so.

Antidepressants are not addictive and their effect is not expected to diminish over time.

Adapted from:  www.depressionindiaonline.com

Appendix-2

IF YOU ARE SUICIDAL…

Are you feeling so severely depressed that you are thinking of suicide?

Are you on the edge of a terrible choice.... which to choose, the pain of death or the pain of life…between doing it and not doing it…which is the worst…?

Then we are glad that you found us. We are very pleased that you are here. And let us remind you that there is nothing more important than your life. Nothing,

We value that life more than anything else. Your life is extremely valuable, and we care about you. You're not alone.

These pages are specifically written for you if you are struggling with suicidal urges, while severely depressed and anxious. Please think of us as your spiritual friend and we are writing these messages with all the love that we have for you.

Let us begin by saying if you are here because you are currently thinking about suicide, we ask you to PLEASE stay with us and read these pages.

If you can give us few minutes, we may be able to give you enough information to be able to save your life. We are sure you can afford a few minutes ...

As you continue to do this, we would like you to do is sit back and relax because it's much more relaxing to read that way. Take a few peaceful breaths, and let your shoulders sink comfortably down, towards the chair that supports you, as you continue to read.

We don't know who you are but we do know you must be feeling at bottom's end, if you are reading this.

If it were possible, we would prefer to be there with you at this moment, to sit with you and talk, face to face and heart to heart. But since that is not possible, we will have to make do with this.

First, we want you to know that here is absolutely nothing wrong with you as a person.

Furthermore, people do feel suicidal and severe depression and associated pain makes people act sometimes without thinking things through.

· We understand that if you are really serious about killing yourself, you must be in tremendous pain and you have a lot of real problems that need to be worked out.
Many of our team members have had first hand experience of severe depression so we know what it's like to torture yourself.

We also know that suicide when compared to a lifetime of pain associated with severe depression, doesn't really seem so bad.

We also understand that the following may be just some of the feelings and things you might be experiencing when you are severely depressed and contemplating suicide:

"I can't stop the horrible pain."
"I can't see any way out of this shit."
"I can't make this absolute sadness go away."
"I can't see a future without unbearable pain."
"I can't get out of this terrible depression."
"I can't sleep, eat or work."
“There is no hope that I will ever be well or stable.”
Since you are reading this, we can assume you may even be wondering deep down, do I really want to commit suicide. That is a sign that you are reaching out for help, and we are happy you have.
We would like to ask you to please continue reading these entire pages.

PLEASE GIVE US FEW MORE MINUTES AND WE WILL GIVE YOU SOME ANSWERS.

So, if you are severely depressed (and/or anxious) and as a result suicidal, what specifically are our main goals for you?

1. To keep you alive for a few more minutes.

2. To have you want to keep yourself alive for a few more minutes.

3. To have you want to keep yourself alive long enough to seek appropriate medical help (more specifically psychiatric help) which is very much available and needed in your case.

4. To have you come to a new understanding as you are reading ... to be able to say "Oh, I get it!”… to have that light bulb flash above your head…or I guess just to feel a little better about yourself.

· We want to reassure you, that you are NOT a bad person. You are NOT flawed or strange.
You are dealing with pain of severe depression. Pain, that out weighs your life.

Your feelings of aloneness, fear, unworthiness, and even uncertainty of suicide are normal when a person has been faced with more pain than they can handle.

Right now, you are feeling that the pain associated with your severe depression outweighs the coping mechanisms.
And your feelings are valid. Sometimes pain outweighs everything.

IF YOU ARE EXTREMELY SUICIDAL…

Are you at high risk at this time to kill yourself? Do you have a plan and the means to commit suicide?

If so, seek medical attention RIGHT NOW.

So, we ask again have you called your doctor yet. STOP reading, log off the Internet and call them NOW. You can read the rest of these pages another time. Right now, let's save your life. You are worth saving. Do it now..................................

· Depression is an invisible disease but Depression is treatable and therefore Suicide is preventable.

There is help for you. Call your doctor and wait for help to arrive. Do not hesitate to call. . Please reach out for help. Never act on your thoughts of suicide. Never.
Time is of the essence. Do not delay in seeking help.

Do not be afraid to call your doctor. That one phone call can save your life. We don't want you to die and neither does anyone else.
We want you to get through this horrible time. Know that many of us have felt exactly what you are feeling now. You are not alone!

Instead of reaching for whatever your "death plan" calls for you to do to end your life, reach for the phone.

Contact a doctor, mental health professional or other health care professional or call a hospital or go to your local hospital emergency room.

In the meantime,

· Distance yourself from any means of suicide.

· Promise yourself another 24 hours.

· It's OK to feel bad, but try to separate your emotions from your actions for the moment.

· Suicidal feelings are the result of treatable illnesses. So, try to act as if there are other options, even if you may not see them right now.

· Be persistent. You are there to get help and you are there to get it NOW.

· Finally, take comfort in the fact that help is on the way.

When someone is feeling suicidal, they should talk about their feelings immediately. Don't burden yourself by trying to cope alone.

It is so helpful to talk about your feelings. You can call or inform any of your trusted loved ones in the meantime. Remember, there is no shame in reaching out.

Contact a family member or friend or contact your minister, priest, guru spiritual leader or someone in your faith community or call the police . These are people who can help you through this crisis. Reminder: If you are in immediate danger of harming yourself, DO NOT continue to read now. This is not good for you and will only cause distress.

So, for your health and well being, if you believe there is any chance that you may be going to harm yourself in anyway you need to at least ring your doctor or other health care professional, emergency service or ambulance immediately or get yourself to the nearest hospital.

Adapted from: www.depressionindiaonline.com

Appendix-3

FAST FACTS RE DEPRESSION...

· More people die from suicide than from homicide.

· For young people 15-24 years old, suicide is the third leading cause of death.

· 80% of people that seek treatment for depression are treated successfully.

· The World Health Organisation predicts that by 2020 depression will be the second leading cause of health impairment worldwide.

· Depression is a silent epidemic.

· Depression is currently the leading cause of non-fatal disability in world.

· Depression will be second only to heart disease as the leading medical cause of death and disability within 20 years.

· On average, one in five people will experience depression at some point in their life.

· Depression affects women nearly twice as often as men.  

· Many people with depression do not even realize that they are depressed and initially see their primary care doctor to treat what they believe is a physical disorder.  

· Depression cannot be prevented. However, more than 80 precents of people who have it can be treated successfully with psychotherapy, medical therapy or a combination of both. 

· The risk of depression  may be as high as 25 precents in first-degree relatives (parents, children and siblings) of patients with a history of depression.  

· About one-third of depressed individuals also suffer from some form of substance abuse or dependence, although for some, the depression is a result of the substance abuse problem.  

· As many as 15 precents of patients with depression eventually commit suicide.  

· Depression is one of the leading causes of disability in the United States and internationally.

 Appendix-4

 Electroconvulsive Therapy

Definition

Electroconvulsive therapy (ECT) is a medical treatment for severe mental illness in which a small, carefully controlled amount of electricity is introduced into the brain. This electrical stimulation, used in conjunction with anesthesia and muscle relaxant medications, produces a mild generalized seizure or convulsion. While used to treat a variety of psychiatric disorders, it is most effective in the treatment of severe depression, and provides the most rapid relief currently available for this illness.

Description

The treatment of severe mental illness, such as schizophrenia, using electroconvulsive therapy was introduced in 1938 by two Italian doctors named Cerletti and Bini. In those days many doctors believed that convulsions were incompatible with schizophrenia since, according to their observations, this disease rarely occurred in individuals suffering from epilepsy. They concluded, therefore, that if convulsions could be artificially produced in patients with schizophrenia, the illness could be cured. Some doctors were already using a variety of chemicals to produce seizures, but many of their patients died or suffered severe injuries because the strength of the convulsions could not be well controlled.

Electroconvulsive therapy is among the most controversial of all procedures used to treat mental illness. When it was first introduced, many people were frightened simply because it was called "shock treatment." Many assumed the procedure would be painful, others thought it was a form of electrocution, and still others believed it would cause brain damage. Unfortunately, unfavorable publicity in newspapers, magazines, and movies added to these fears.

Indeed, in those early years, patients and families were rarely educated by doctors and nurses regarding this or other forms of psychiatric treatment. In addition, no anaesthesia or muscle relaxants were used. As a result, patients had violent seizures, and even though they did not remember them, the procedure itself was frightening.

The way these treatments are given today is very different from the procedures used in the past. Currently, ECT is offered on both an inpatient and outpatient basis. Hospitals have specially equipped rooms with oxygen, suction, and cardiopulmonary resuscitation (CPR) in order to deal with the rare emergency.

The treatment is carried out as follows: approximately 30 minutes before the scheduled treatment time, the patient may receive an injection of a medication (such as atropine) that keeps the pulse rate from decreasing too much during the convulsion. Next, the patient is placed on a cot and hooked up to a machine that automatically takes and displays vital signs (temperature, pulse, respiration, and blood pressure) on a television-like monitor. A mild anaesthetic is then injected into a vein, followed by a medication that relaxes all of the muscles in the body so that the seizure is mild, and the risk of broken bones is virtually eliminated.

When the patient is both relaxed and asleep, an airway is placed in the mouth to aid with breathing. Electrodes are placed on the sides of the head in the temple areas. An electric current is passed through the brain by means of a machine specifically designed for this purpose. The usual dose of electricity is 70–150 millivolts for 0.1–0.5 seconds. In the first stage of the seizure (tonic phase), the muscles in the body that have not been paralyzed by medication contract for a period of five to 15 seconds. This is followed by the second stage (clonic phase) that is characterized by twitching movements, usually visible only in the toes or in a non-paralyzed arm or leg. These are caused by alternating contraction and relaxation of these same muscles. This stage lasts approximately 10–60 seconds. The entire procedure, from beginning to end, lasts about 30 minutes.

The total number of treatments a patient will receive depends upon many factors such as age, diagnosis, the history of illness, family support, and response to therapy. Patients with depression, for example, usually require six to 12 treatments. Treatments are usually administered every other day, three times a week.

The electrodes may be placed on both sides of the head (bilateral) or one side (unilateral). While bilateral ECT appears to be somewhat more effective, unilateral ECT is preferred for individuals who experience prolonged confusion or forgetfulness following treatment. Many doctors begin treatment with unilateral ECT, then change to bilateral if the patient is not improving.

Post-treatment confusion and forgetfulness are common, though disturbing symptoms associated with ECT. Doctors and nurses must be patient and supportive by providing patients with factual information about recovery. Elderly patients, for example, may become increasingly confused and forgetful as the treatments continue. These symptoms usually subside with time, but a small minority of patients state that they have never fully recovered from these effects.

With the introduction of antipsychotics in the 1950s, the use of ECT became less frequent. These new medications provided relief for thousands of patients who suffered greatly from their illness. However, there are a number of side effects associated with these drugs, some of which are irreversible. Another drawback is that some medications do not produce a therapeutic effect for two to six weeks. During this time the patient may present a danger to himself or others. In addition, there are patients who do not respond to medicine or who have severe allergic reactions. For these individuals, ECT may be the only treatment that will help.

Adapted from www.answers.com

Appenxix-5

Cognitive behavioural therapy:

Milder depressions have been shown to respond to some simple behavioural techniques.

1) Exercise and Pleasant events scheduling:

Depressed people often find themselves losing enjoyment of their surroundings and activities. The logical response to this is to stop doing things and become socially withdrawn.

The effect of this is twofold: the person loses contact with the anti-depressant effects of the environment, and robs themselves of the possibility of enjoying something and feeling pleasure. Likewise, an isolated person is left alone to think about their unhappiness, thus reinforcing this view of their situation. there are two strategies, exercise and activity scheduling.

Physical exercise relieves depression: 20 minutes a day of brisk walking will do, best if it is done in the morning and in the sunlight.

Pleasant events scheduling involves activating oneself: scheduling in on a daily basis an activity which you had previously enjoyed, or will give you a sense of achievement.

Some researchers have found that regular exercise results in the resolution of mild depression.

2) Structured problem solving:

If you feel your depression is related to problems in your life, this technique offers a framework for attempting to resolve these problems.

The Six-Step Method Of Structured Problem Solving

Step 1: Identifying problems

Gaining a clear definition of the problem or goal is a vital step in problem solving. Defining problems or goals helps to focus thinking on the issue at hand and minimises the possibility of getting side tracked onto other issues. Also defining problems and goals makes it easier to know when the goal has been achieved or the problem solved.

At this stage of problem solving there are some `rules' that will help to suitably define goals or problems. Encourage individuals to:

· Only consider one problem at a time. If other problems arise in the course of the session they should be set aside for a problem solving session in the future.

· Avoid getting side tracked into attempting to solve the problem at this stage.

Step 2: Generating solutions through brainstorming

Brainstorming is a method by which individuals come up with as many alternative solutions as possible. Rather than try to think of the best or ideal solution, the individual can list any ideas that come to mind, including those, which may not be useful or may even be absurd. Encourage individuals to use their imagination! Even though a solution may at first seem ridiculous, the idea may help to generate better solutions than those that are more obvious. At this stage of problem solving there is no discussion of the solutions, they are just listed.

Step 3: Evaluating the solutions

This step involves a brief discussion of the advantages and disadvantages of each solution. There is no need for the individual to write these points down but just quickly run through the list of solutions, noting the strengths and weaknesses of each. No solution will be ideal since every good idea will have some faults, such as requiring time or money, or skills that individuals do not currently possess. However, most bad ideas will also have some advantages as well. For example, they may be easy to apply but may not really solve the problem in the long run.

Step 4: Choosing the optimal solution

In this step the aim is to choose the solution or combination of solutions which will solve the problem or achieve the goal. It is often helpful for the individual to choose a solution that can be readily applied and which is not too difficult to implement, even though this solution may not be the ideal solution. At least individuals can get started right away. Although the problem may not be solved immediately, the `solution' might have made a difference, and what is learned from this attempt might be useful the second time around. This approach is preferable to choosing a solution which is doomed to failure because someone has been overly ambitious.

A detailed plan of action will increase the likelihood that the problem will be solved. Even if the agreed solution is excellent, the solution will not be of any use if it is not put into practice. The most common reason for failure is a lack of planning. Be sure that individuals spend some time on this planning stage. Cues, reminders or rewards may need to be incorporated into the plan. 

The following checklist (adapted from a checklist developed by Ian Falloon applies to any problem and will be helpful in pinpointing any pitfalls or obstacles in the solution plan.

· Does the individual have the necessary resources (e.g., time, skills, equipment, money) or are you able to arrange the necessary resources, or personal or expert help? Expert help may include other members of your team (social work, occupational therapy, psychiatric or clinical psychology consultation).

· Does the individual have the agreement or co-operation of other people who might be involved in the plan?

· Does everyone involved in the problem solving exercise know exactly what they need to do and when they need to do it? Setting specified times or deadlines will minimise the risk of procrastination.

· Have all the steps been examined for possible difficulties? Has the individual planned any strategies for coping with likely difficulties?

· Has the individual planned any strategies for coping with any consequences that may arise? For example, if the individual applies for a job, what happens if he or she does not succeed? Or if they get the new job and have not considered what the demands of that job may entail.

· Have difficult parts of the plan been rehearsed? (e.g., a telephone call, conversation, or interview).

· How will the steps of the plan be monitored? If the plan involves a number of people it will be useful to nominate a co-ordinator to monitor progress and to prompt and remind people when they need to do the things they agreed upon. Include this monitoring as part of the plan so that everyone agrees and is prepared to be reminded.

· Has a time and place been set for a review of the overall progress of the plan?

Step 6: Review

Problem solving is a continuing process since problems are often not resolved nor are goals always attained after the first attempt. Not all possible hitches are considered at the planning stage and so ongoing reviews are necessary to cope with unexpected difficulties. Steps may need to be changed or new ones added. It will also be important to praise all efforts that have been made. If you reward everyone involved for the work that has been done it is more likely that the structured process will be followed and that problems will be solved in the future.

When things do not go as planned:

· What went right?

· What went wrong?

· What alternative strategies could be used?

· Encourage the individual to acknowledge feelings of disappointment, but do not allow disappointment to turn into a catastrophe.

· Difficulties are usually due to a poorly planned strategy rather than personal inadequacy. Everyone does the best they can do.

· Label any attempt as partial success rather than failure.

· Consider partial success as practice and a useful learning experience.

· Encourage the individual to try again as soon as possible.

3) Cognitive therapy:

Depressed people typically have a negative view of themselves, the world and the future. Cognitive therapy aims at identifying unhelpful patterns of thinking, and replacing these habits with more helpful, realistic thoughts.

Appendix-6:

Hints to Avoid Harmful Stress

1. Work out priorities

Keep a list - make the tasks possible. Prioritise the tasks in order of importance and tick off when done. Include the important people in your life as priorities and attend to these relationships.

2. Identify your stress situations

Make a list of events that leave you emotionally drained, with one or two ways to reduce the stress for each. When they occur, use them as an opportunity to practise your stress reduction techniques, then, keep notes on what works for next time.

3. Learn to ‘reframe’ statements: Don't react to imagined insults

It is a waste of time and energy to be oversensitive to imagined insults, innuendo or sarcasm. Give people the benefit of the doubt, talk over the situation with someone you trust. They may have another spin on what was said.

4. Think before you commit yourself to other people's expectations

We can often perform tasks merely to feel accepted by other people. Practice saying "no" to requests that are unreasonable or more than you can handle at the time - rather than suffer subsequent regrets and stress. Consider whether you should learn to rely less on the approval of others, again, talk this over with someone you trust.

5. Move on: Don't dwell on past mistakes

Feelings of guilt, remorse and regret cannot change the past and they make the present difficult by sapping your energy. Make a conscious effort to do something to change the mood (eg mindfulness technique or something active you enjoy) when you feel yourself drifting into regrets about past actions. Learn from it and have strategies in place for next time. Learn to forgive yourself for past mistakes.

6. Learn to defuse anger and frustrations rather than bottle them up

Express and discuss your feelings to the person responsible for your agitation. If it is impossible to talk it out, plan for some physical activity at the end of the working day to relieve tensions. Let go of grudges –they do not affect the potential victim because he does not necessarily know about them. However, the grudge-bearer pays a price in energy and anxiety just thinking about revenge.

7. Set aside time each day for recreation and exercise

Gentle repetitive exercise such as walking, swimming, cycling are good to relieve stress. Meditation, yoga, pilates and dance are also excellent. The trick is to find what suits you best. Hobbies that focus attention are also good stress relievers. Take up a new activity unrelated to your current occupation, one that gives you a sense of achievement and satisfaction. Establish new friends in your newly found interest. There are handouts with a range of techniques for relaxation and mindfulness on the website that you can use. The daily mood chart can be used to rate the impact of applying new strategies .

8. Take your time: don't let people rush you

Frenzied activities lead to errors, regrets, stress. Request time to orient yourself to the situation. At work, if rushed, ask people to wait until you finish working or thinking something out. Plan ahead to arrive at appointments early, composed and having made allowances for unexpected hold-ups. Practice approaching situations ‘mindfully’.

9. Take your time on the road: Don't be an aggressive car driver.

Develop an "I will not be ruffled" attitude. Drive defensively and give way to bullies. Near misses cause stress and strain, so does the fear of being caught for speeding. If possible avoid peak hour traffic. If caught in it, relax by concentrating on deep (stomach) breathing or ‘mindful driving’ (using mindfulness technique, also available on website). Advanced driving lessons can be useful.

10. Help children and young people to cope with stress

Children need the experience of being confronted with problems to try out, and improve their ability to cope. By being overprotective or by intervening too soon, parents may prevent young people from developing valuable tolerance levels for problems, or from acquiring problem-solving skills.

11. Think positively – you get what you expect

Smile whenever possible –it’s an inexpensive way of improving your looks and how you feel. Try and find something positive to say about a situation, particularly if you are going to find fault. You can visualise situations you have handled well and hold those memories in your mind when going into stressful situations.

12. Cut down on drinking, smoking, sedatives and stimulants

They only offer temporary relief and don’t solve the problem. They can create more problems in terms of physical and mental health. Consider the effects you are looking for (sedation or stimulation) and how else you can achieve them.

 Adapted from :  http://www.blackdoginstitute.org.au

Appendix-7  

Glossary of Terms

· Acute Stress-Induced depression – a type of non-melancholic depression caused by an immediate or sudden stressful event.

· Antidepressant drug – a drug that treats the symptoms of depression by affecting the interaction and level of chemicals in the brain called neurotransmitters.

· Antipsychotic drugs - a class of drugs used to treat the symptoms of psychotic illnesses, most often schizophrenia, but also psychotic symptoms that may occur in other conditions including drug-induced psychoses; mania or depression; Alzheimer's Disease; and schizo-affective and delusional disorders. Also used as mood stabilizers and to augment antidepressant drugs.

· Anxiety - a normal response to stress which generally passes when a tense situation is over. It can become a disabling disorder with excessive, irrational dread of everyday situations.

· Broad action drugs - classes of antidepressants that target several neurotransmitter systems They include the tricyclic and monoamine oxidase inhibitor drugs.

· Chronic Stress-Induced Depression - a type of non-melancholic depression caused by an ongoing external stressor from which there is no perceived psychological escape

· Clinical depression - a term for depression that is severe and impairing.

· Clinical psychologists – psychologists who have additional qualifications to psychologists which enable them to provide psychological services to patients in the assessment, diagnosis and management of psychological conditions and psychiatric disorders.

· Coping-coping is, the process of managing taxing circumstances, expending effort to solve personal and interpersonal problems, and seeking to master, minimize, reduce or tolerate stress or conflict.

· Delusions – false beliefs about the self, others or objects that are untenable to others and that persist despite evidence to the contrary.

· Dementia – an organic mental disorder characterised by impairments of memory, judgment and abstract thinking as well as changes in personality.

· Dual action drugs - a class of antidepressants that targets two neurotransmitter systems (serotonin and noradrenalin). Examples include Duloxetine, Mirtazapine and Venlafaxine.

· ECT – Electroconvulsive Therapy – a treatment that is most effective for melancholic and psychotic depression.

· Grief – a normal, multifaceted response to loss with emotional, physical, cognitive, behavioural and social dimensions.

· Hallucinations - subjectively experienced sensations in the absence of an actual appropriate stimulus, but which are regarded as real.

· Melancholic depression – the biological depressive sub-type that has distinct clinical features, such as slowed movement and an anhedonic and non-reactive mood. It may have a genetic cause and tends to respond preferentially to physical treatments such as medications, and (if needed) ECT.

· Monoamine oxidase inhibitors [MAOIs] - a class of drugs used to treat depression that block the enzyme 'monoamine oxidase' from breaking down certain neurotransmitters in the brain. Examples are Phenelzine and Tranylcypromine.

· Neurotransmitters - chemicals which account for the transmission of signals from one neuron to the next across synapses.

· Narrow action drugs - a class of antidepressants that generally targets one neurotransmitter, usually serotonin, affecting its concentration in the brain.

· Non-melancholic depression – the most common depressive disorder grouping, comprising a range of conditions that usually reflect the interaction between stress and personality style

· Noradrenalin – one of the neurotransmitters found in the brain.

· Panic attacks – sudden periods of intense terror that strike without warning. The feelings of fear and anxiety are generally out of proportion with the situation and may be unrelated to actual events.

· Post-natal depression – a type of depression that develops within the first nine to 12 months following the birth of a baby.

· Psychiatrists – medical graduates with specialist training in mental conditions, who are trained to administer multiple therapies including psychotropic drugs.

· Psychologists - study human behaviour, conduct research and apply research findings in order to reduce distress and behavioural and psychological problems, and to promote mental health and rational behaviour in individuals and groups.

· Psychomotor disturbance – decreased or increased movement. It comprises cognitive processing difficulties, with slowed thoughts and impaired capacity to work or study; and an observable slowing and/or agitation of physical movements.

· Psychosis - a condition of impairment in reality testing characterised by delusions or hallucinations and often incoherent speech or disorganised and agitated behaviour.

· Psychotic depression – in this subtype of depression the depressed person may lose touch with reality and begin to experience psychotic symptoms such as delusions and hallucinations.

· Self-esteem – one’s ongoing sense of self-worth.

· Serotonin – one of the neurotransmitters that regulates mood.

· SSRIs –Selective Serotonin Reuptake Inhibitors – a class of antidepressant drugs that selectively target the neurotransmitter serotonin (one of the chemicals that regulates mood). Examples include Citalopram, Escitalopram, Fluoxetine, Fluvoxamine, Paroxetine, Sertraline.

· Stressor – Any event or interpersonal interaction that causes distress. Stressors can be acute (e.g. the immediate aftermath of an accident) or chronic (e.g. poverty).

· Tricyclics [TCAs] - first generation antidepressant drugs (emerged in the late 1950s) that act on multiple neurotransmitters in the brain. Examples include Amitriptyline, Clomipramine, Dothiepin, Doxepin, Imipramine, Nortriptyline, Trimipramine.

Appendix-8

ABC of Mental Health

Act-Belong-Commit

Good mental health helps us to more fully enjoy and appreciate the people and environment around us. We

respond better to the stresses and challenges of daily life, we are more creative, use our abilities to the

fullest and make the most of opportunities when our mental health is strong.

To build and maintain your mental health there are three things you can do:

Act

-Strive to keep yourself as active as possible, physically, socially and mentally— walk, swim, read…

Belong

–Connect to your community — join a group, chat to a neighbour, meet a friend…

Commit

– Look to the future and have a go — take a challenge, get involved, volunteer…

Activity and exercise has many psychological benefits

It can help reduce anxiety. People who exercise report feeling less stressed or nervous.

Physical exercise helps to counteract the withdrawal, inactivity and feelings of hopelessness that are

a feature of depression.

Moods such as tension fatigue and anger are all positively affected by exercise.

Exercising can improve the way you perceive your physical condition, athletic abilities and body

image.

Exercise can bring you into contact with other people

Mental fitness helps us to achieve and sustain a mentally healthy state 

A realistic attitude gives us a sense of perspective and flexibility, and the resilience we need to

endure shocks, hardship and change that are part of everyone’s life.

Self-esteem and confidence comes from focusing on the qualities we have that makes us a good

friend, a valued colleague, a loving parent or family member.

Emotional support with family and friends builds support networks through which we receive help

and, in turn help others.

Mental activities such as reading a book, solving crosswords or playing a musical instrument can

improve our mental agility and promotes our overall wellness.

Simple ways to practice your ABC

“Act”

Exercise – regular physical activity improves psychological well-being and can reduce depression

and anxiety.

Enjoy hobbies – taking up a hobby brings balance to your life by allowing you do something you

enjoy and it also keeps your brain active.

Treat yourself well – cook yourself a good meal, have a bubble bath, see a movie, call a friend or

relative you haven’t called for ages, sit on a park bench and take in your surrounding.

“Belong”

Invite – ask someone new to come along.

Share a laugh – life often gets too serious, so when you hear or see something that makes you

smile or laugh share it with someone you know.

Do one thing at a time – for example when you are our for a walk or spending time with friends,

turn off your mobile phone and stop making that mental “to do list”.

“Commit”

“Collect” positive emotional moments – recall times when you have experienced pleasure,

comfort, tenderness, confidence, or other positive emotions.

Learn ways to cope with negative thoughts – don’t block negative thoughts but learn how to

interrupt them and not let them take over.

Set personal goals – for example finish that book you started three years ago, walk around the

block every day, learn to knit or play bridge, call your friends instead of waiting for the phone to ring.

Keep a journal (or even talk to the wall!) – expressing yourself after a stressful day can help you

gain perspective, release tension, and even boost your body’s resistance to illness.

Volunteer – volunteering helps others, makes us feel good about ourselves, widens social networks provides new learning experiences, and can bring balance to people’s lives.

Act Belong Commit

Adapted from the the Mental Health Council of Australia website- http://www.mhca.org.au