The reality is that psychiatric conditions are very common- it’s been estimated that almost half of the U.S. adult population will have had a psychiatric condition in their lifetimes, and almost 20% will have had one during the past year-over 60 million people! Most conditions begin during the childhood or teenage years. Approximately 20% of children or teenagers will have had at least a mild psychiatric condition in any year. 10% of teenagers will have a psychiatric condition severe enough to cause significant problems with functioning. Examples of conditions psychiatrists treat include attention deficit hyperactivity disorder, autism spectrum disorder, disruptive mood dysregulation disorder, generalized anxiety disorder, panic disorder, social anxiety disorder, posttraumatic stress disorder, obsessive compulsive disorder, unipolar depression, bipolar disorder, and schizophrenia.
The more scientists learn about psychiatric conditions, the more we see that they are medical conditions just like other illnesses that doctors treat. Studies indicate that brain activity is often different for people suffering from depression, anxiety, attention deficit hyperactivity disorder. and other conditions. Some studies have shown that certain types of counseling and medications can improve this abnormal activity.
You might have experienced the mind/body connection yourself. Have you ever been so nervous about something (giving a talk in front of the class or office, going on a roller coaster for the first time), that your heart pounded and your stomach fluttered? Have you ever had such a hard day at school or work that you came home with a big headache? Those are ways that the mind interacts with the body.
A psychiatrist diagnoses a psychiatric condition after a careful evaluation of the patient. Rating scales and collateral tests can be helpful, but the diagnoses are mainly based on a careful clinical history and mental status examination. The psychiatrist can refer to a colleague such as a psychologist or neurologist for testing to provide additional supporting information if the diagnosis is unclear.
A psychiatric condition occurs when a cluster of emotions interfere with daily life. For example, let’s look at the symptoms of Panic Disorder. These include panic attacks followed by worry about having more panic attacks for at least one month. What is a panic attack? A period of being very nervous or uncomfortable while having some of these sensations: racing heart, sweating, shaking, shortness of breath, choking sensation, chest pain, upset stomach, dizziness, feelings of unreality, fear of losing control, hot or cold flushes, numbness or tingling, fear of dying. Now, if you noticed a snarling bear racing toward you as you were camping in the woods, some of these feelings would be very helpful. You would want your brain to tell you, “Danger- you could be killed by a bear! Get up and run away to safety!” You would want to feel energized as your heart quickly pumped blood through your body. If you remained seated calmly at the campfire toasting your marshmallow, the consequences could be very serious.
However, if you were sitting in a room listening to a lecture, it would not be helpful to experience these sensations. You might spend the lecture fighting the urge to get up and run out of the room. Even if the sensations stopped, you might continue to worry that you would have another panic attack. Your grades might go down because you were paying attention to the panic attacks instead of what was being taught. You might feel the safest at home in your bedroom, and be reluctant to go to school. The panic attacks would be interfering with your ability to function in school, and school is a big part of a young person’s life. If this happened, you would have developed a psychiatric condition called panic disorder. Feelings become psychiatric conditions when they interfere with your functioning in a major area, such as your ability to learn, have fun, work, or interact with other people.
A psychiatrist is a medical doctor who has had extra training to diagnose and treat psychiatric conditions. After graduating from college, psychiatrists attend a 4-year medical school like other medical doctors. In a typical medical school, students spend most of their first two years in classes and labs learning about the normal workings of the human body, about illnesses that affect the
body and mind, and about the various treatments, including medications, to keep the body and mind healthy. In the second two years, they train in different types of hospital departments, such as internal medicine, pediatrics, psychiatry, surgery, and obstetrics/gynecology, to become familiar with all aspects of medicine. If they successfully pass their courses, they graduate from medical school and become physicians. They receive an M.D. degree and may be referred to as “Doctor Smith” instead of “Mr.” , “Ms. , or “Mx” Smith.”
In their last year of medical school, students decide which type of medicine they wish to practice. They apply for residencies, which are like medical apprenticeships. Residency positions are offered by certain hospitals, called training hospitals, which are usually associated with medical schools. In order to have an accredited residency program, the hospitals must periodically pass a detailed inspection by the Joint Commission.
Psychiatry residents learn how to become psychiatrists by evaluating and treating patients while being supervised by experienced psychiatrists. They continue to have some lectures and classes important for psychiatry. They study for a series of national examinations that they must pass to practice medicine after residency.
Residents work long hours and treat many patients. The first year of residency, called an internship, is often the hardest. In addition to their psychiatry rotations, psychiatry interns work in other hospital departments: medicine, pediatrics, neurology, the intensive care unit, and the emergency room. A residency in adult psychiatry lasts for three years after internship and includes rotations on psychiatry inpatient hospital wards and outpatient clinics. Psychiatry residents also work as consultants to other hospital departments, giving advice on psychiatric issues affecting medical or surgical patients (consultation-liason psychiatry). They learn different kinds of counseling techniques, called “psychotherapies,” substance use treatment, and use of psychiatric medications.
Residents subspecialize (receive additional expertise) to treat children and teenagers if they participate in a fellowship in child and adolescent psychiatry. They may begin this after their third or fourth year of adult psychiatry residency (the fourth year of adult residency is optional for a child fellow.) Other psychiatry subspecialties include geriatric (older adult), consultation-liaison, addiction, forensic (legal aspects of psychiatry), and pain medicine.
A child and adolescent psychiatry residency lasts for two years and includes training in pediatric inpatient and outpatient psychiatry, alcohol and drug abuse, counseling techniques, medications, and legal issues that affect children such as divorce or child abuse. (Adult psychiatrists are not prohibited from treating children, but many prefer not to treat those younger than age 16.)
After residency, the graduate is a full-fledged psychiatrist who can treat patients independently. Like other specialists, many psychiatrists chose to become “board-certified.” This means that they must pass an examination given by the American Board of Psychiatry and Neurology (ABPN). A graduate of a child and adolescent psychiatry residency is eligible for subspecialty board certification in child and adolescent psychiatry. They must be re-certified every ten years.
In order to receive a medical license from a particular state, physicians must participate in several hours each year of continued medical education (CME), by attending conferences or reading articles about their fields of medicine.
As you can see, psychiatrists have worked very hard for many years to achieve expertise to help people with psychiatric conditions.
Other health professionals also treat people with psychiatric conditions: Examples are neurologists, psychologists, social workers, and psychiatric nurses. Some of their skills are unique to their professions, and others overlap with those of other providers.
Psychologists have attended graduate school and are referred to as “Doctor” after receiving their doctorate degrees- a Ph.D or Psy.d. They are specially trained to conduct psychological testing. The purpose can be educational- measuring IQ and learning difficulties, or clinical- helping to confirm a psychiatric condition. Psychologists have extensive training in psychotherapy.
Neuropsychologists have additional special training in neurology to identify conditions that may be due to a brain disorder. Neurologists are physicians who have completed a residency in neurology, the study of the nervous system. Neurologists and psychiatrists may medically treat some of the same conditions: tic disorders (a type of movement problem), developmental disorders, or attention deficit hyperactivity disorder. Neurologists prescribe medications but do not conduct psychotherapy.
Social workers may have a bachelor’s degree, master’s degree, or Ph.D. They conduct psychotherapy and have expertise at finding appropriate community programs and resources. They liaison with families on inpatient psychiatric wards and help to find appropriate follow-up care when patients leave the hospital.
Psychiatric nurses have attended graduate school for nursing. They are critical for the day-to-day care of hospitalized psychiatric patients. They can also provide psychotherapy. They may prescribe psychiatric medications under the supervision of a physician.
Other physicians, such as pediatricians, family practitioners, or internists may provide medication for uncomplicated cases of attention deficit hyperactivity disorder, depression, or anxiety.
Often, the different providers work together and consult with each other. A patient might receive medication from a psychiatrist and psychotherapy from a psychologist or social worker. The therapist may initially have begun working with the patient, then consulted the psychiatrist to determine whether the patient would benefit from medication. The psychiatrist may have referred the patient to a psychologist for a certain type of psychotherapy, or for psychological testing to help clarify the diagnosis.
These are fictional examples of how the providers may work together:
“ Taylor”, an 8-year old boy, was referred to a psychiatrist because he refused to attend school. He told the psychiatrist that he was “too nervous” and could not learn. Was Edward nervous because of a learning problem, or did he have a learning problem because he was too nervous to pay attention to the teacher? The psychiatrist referred Edward to a psychologist, who diagnosed a reading disorder. Edward’s anxiety disappeared after he got help for his reading disorder.
A psychiatrist might consult with a neurologist to help determine whether psychiatric symptoms are due to a neurological condition.
“Katie” was referred to a psychiatrist to evaluate for attention deficit hyperactivity disorder. Pamela told the psychiatrist that she often “zoned out.” Her parents and teachers observed that Pamela had “staring spells” during which her eyelids fluttered for brief periods. The psychiatrist referred her to a neurologist, who determined that the “zoning out” spells were actually a type of seizure disorder.
Similarly, a neurologist may refer a patient to a psychiatrist for headaches associated with stress.
The most important part of a psychiatric evaluation is the interview with the patient. An adult patient can expect to spend approximately 45 to 90 minutes with the psychiatrist during the initial evaluation. Usually the patient fills out paperwork before the meeting. This generally includes a questionnaire of basic information such as name, address, phone number, insurance information, and an emergency contact. Some questionnaires ask for the presenting problem (the problem that is bringing the patient to see the psychiatrist). There may be a list of potential symptoms that the patient can check off as applicable, such as “I feel down or blue,” “my appetite is not what it used to be,” “I have trouble sleeping at night.” Sometimes, people feel more comfortable expressing painful feelings in writing, and these types of questionnaires can be a helpful source of information.
The adult patient will be interviewed individually unless s/he wishes to include a spouse, family member, or friend who can provide helpful information. Adults must give consent, or permission for their psychiatrists to speak to others about them. This is to protect the patient’s privacy and confidentiality. The exception to this would be in an emergency, if the patient was at risk of harming himself/herself or others. For example, if a patient told a psychiatrist that he planned to kill himself that evening, the psychiatrist could not keep this confidential and would be obligated to arrange hospitalization. A judge can also subpoena patient records.
During an initial interview, a psychiatrist will typically ask of a series of questions to help determine the underlying problem and how best to treat it. Some of the interview is open-ended, during which the patient says whatever is on his or her mind. However, the psychiatrist must also ask certain specific questions to gather the necessary information to finish the interview in the time provided. Psychiatrists like to start appointments on time and end them on time so that the patients know what to expect, and so that others are not kept waiting.
During the interview, the psychiatrist will look for signs and symptoms of psychiatric conditions. Symptoms are subjective evidence-the feelings experienced by the patient. Signs are objective evidence-that which can be observed by other people. For example, a depressed person may have the symptom of sadness and the sign of tearfulness. An anxious patient may have the symptom of nervousness and the sign of restlessness. If you had strep throat, you would have the symptom of soreness after swallowing and the sign of a bright red throat. (Sometimes, the word “symptoms” is used to signify “signs and symptoms.”
A standard evaluation includes the chief complaint, history of present illness, and past psychiatric, developmental, medical, family and social history, including use of alcohol or recreational drugs. The chief complaint is the presenting problem, generally the answer the patient gives when asked by the psychiatrist, “What brings you in here today?” The history of present illness is a description of the symptoms and problems leading up to the chief complaint. The past psychiatric history includes past psychiatric diagnoses, medications, psychotherapy, and hospitalizations. Medical history includes current and past medical problems, surgeries, medications, and allergies. It is important for a psychiatrist to know about all medications that a patient takes, even over-the-counter and herbal remedies or vitamins, to ensure that they don’t interact with a psychiatric medication that might be prescribed. Social history includes such issues as family life, school, jobs, hobbies, friendships, alcohol and/ or drug use, and any history of trauma or abuse.
There are certain standard questions that psychiatrists must ask during a psychiatric evaluation, whether or not they think that a patient will answer “yes.” Some of my patients, particularly teenagers, have told me that they felt insulted when past health providers asked them these questions. The most frequent offenders are “have you had thoughts of hurting yourself?” “Have you had thoughts of hurting others?” “Have you used alcohol or recreational drugs?” “Have you ever used laxatives or made yourself vomit to lose weight?” “Are you sexually active?” “Have you ever been physically or sexually abused?” “Have you ever heard voices when no one was in the room?” The teenagers feel insulted that the psychiatrist is “assuming” that they must be using drugs or be ill enough to be hallucinate. I explain that psychiatrists ask all new patients these questions because it is important not to miss a “yes” response. People are sometimes reluctant to volunteer information unless they are asked. It would be very harmful not to realize that a patient was feeling suicidal or was at risk for a sexually-transmitted disease.
An evaluation of a child can be conducted in a few different ways. Ideally, the parent(s), guardian(s), and child can be interviewed separately at least once and together at least once. It is preferable that all parents and guardians be interviewed. A telephone interview can be arranged if one parent is out-of-state. The advantage of interviewing the caregivers separately from the child is that it allows them to share information privately. However, a group session is also useful to provide information on how family members communicate with each other. A psychiatrist will try to respect a child’s privacy and give parents feedback in general terms, such as a summary of the assessment and recommendations.
A psychiatrist is legally obligated to obtain written consent from the parents or guardians to talk to other people about the patient. The child does not need to give consent, but the psychiatrist will try to work with the child and explain why talking to others is important. A psychiatrist might wish to talk to a child’s therapist, pediatrician, teacher and/or former clinicians.
The exception to the confidentiality rule is if a clinician suspects that the child is being abused. Clinicians are legally required to report suspected abuse to the Department of Social Services whether or not the guardian gives consent.
Sometimes psychiatrists use semi-structured interviews to diagnose patients. These consist of a series of standardized questions about different possible symptoms. The psychiatrist can hone in on the diagnosis based on the answers given. It is semi-structured (not completely structured) because psychiatrists can ask their own questions in addition to the standard questions. These types of interviews are carefully tested to ensure that they yield accurate diagnoses. A popular interview for children is the K-SADS (Kiddie-Schedule for Affective Disorders and Schizophrenia).
A psychiatrist may order blood tests since certain medical problems can mimic psychiatric conditions. Low thyroid function can cause poor mood, energy, concentration and motivation, which may be mistaken for depression. Overly high thyroid function can cause restlessness, insomnia, excessive energy, racing heart, and even psychotic thinking. This could look like mania, anxiety or ADHD.
No treatment is 100% safe and 100% free of side-effects. Even a sugar pill can be harmful to a person with Diabetes Mellitus. Counseling can bring up anxious, sad, or angry feelings that had been buried below the surface. The goal of treatment is to provide benefits that outweigh the potential risks. Before any treatment, the potential benefits vs. risks should be carefully determined.
Picture something you want to do that is a little risky. For example, you might go on vacation with friends and have the opportunity to take scuba diving lessons. The benefits of scuba diving include allowing the sensation of swimming freely under water like fish, close to beautiful sea- life. The risks include the “bends,” (a painful and dangerous condition from surfacing too quickly), drowning, or being eaten by a shark. Your friends might not be a strong swimmers and feel instead that snorkeling will give enough enjoyment. They would therefore feel that the risks outweigh the benefits and decide not to learn to scuba-dive. You, however, might be a strong, adventurous swimmer and want to get scuba-diving certification. For you, the benefits outweigh the risks.
Taking medication is not a frivolous decision as scuba diving classes were for me.
However, the decision to take medication is also based on the risks vs. benefits. Let’s look at the risks first:
There have been many news reports about antidepressants being associated with suicidal thoughts in people younger than 25 years old. These are based on reports from the Federal Drug Administration (FDA). In 2004, the FDA issued a “black box warning” of the risks of antidepressants for young people. (A “black box” on a medication’s prescribing label means that the reader must pay careful attention to the warning inside the box. It generally makes doctors more hesitant to prescribe the medication and patients less likely to take it.) FDA scientists analyzed information from several research studies in which some minors were given an antidepressant and some were given a placebo. They found that the risk of having suicidal thoughts on an antidepressant was twice that of a placebo. However, this was a very small number absolute number- 2% of those taking a placebo developed suicidal thoughts, compared to 4% taking an antidepressant.
An important point is that patients with serious suicidal thoughts are often not allowed into research studies. However, this group does not represent the typical population of depressed young people who would be seen in a psychiatric clinic. In a typical clinic, a high percentage of depressed people would be expected to have suicidal thoughts. There is no way to tell from these studies how many young people would have decreased suicidal thoughts as a result of antidepressant treatment (Norman Sussman, Primary Psychiatry, Feb 2007).
None of the minors in the studies actually killed themselves, and to date it does not appear that antidepressants are associated with a greater risk than placebo of actual completed suicide.
To understand this concept, pretend that you’re testing out a new type of marble cleaner to make muddy marbles bright and shiny again. You throw 100 marbles into each of two circles in the dirt. You pour “Marvelous Miracle Marble Mix” onto one set of marbles and water on the other. You find, to your dismay, 4 discolored marbles from the group that was splashed by your mix, versus 2 from the group that received water. Do you conclude that your “Marvelous Miracle Marble Mix” is a bust? Not exactly- it turns out that you only used clean marbles to test your mix. You don’t know what would have happened if you had used your mix on muddy marbles.
Your hope is that more muddy marbles would have been restored to their original, shiny selves.
In fact, there is evidence to support the belief that antidepressants decrease the youth suicide risk. One study, published in 2006, examining health plan records of over 65,000 teenagers and adults, found that the risk of suicide attempts or completed suicide was highest in the month before starting antidepressant treatment, and steady decreased after starting antidepressants Simon et al., The American Journal of Psychiatry, Jan 2006). Another study examining suicide rates in children ages 5-14 across the United States found that counties with higher rates of SSRI prescriptions had lower rates of suicide (Robert Gibbons et. al., American Journal of Psychiatry, Nov 2006). Another group of investigators examined all suicides in people younger than 18 in New York City between 1999-2002. 36 out of the total of 41 youths who had committed suicide had blood test results which allowed the examiners to determine whether they had been taking antidepressants at the time of their deaths. Antidepressants were detected in the bloodstream of only one, a homeless 16-year-old male who died of an intentional drug overdose Leon et al., J. Am. Child Adolesc. Psychiatry, Sept. 2006).
Some people who take antidepressants actually do commit suicide. The most frequent explanation is that they felt suicidal because they were suffering from depression, and the antidepressants they were given unfortunately did not help them. Depression can sadly be a terminal illness, like cancer, and sometimes the best treatments do not help enough. Suicide is a shocking, devastating event for families. It is natural for families to point to the antidepressant as the possible reason. The reality is that the cause of a suicide is far more likely to be the depression than the medicine used to treat it.
Why would an antidepressant increase suicidal thoughts? We don’t know for sure, but there are several possible explanations. Some people, especially minors, can feel more restless and agitated with an antidepressant, particularly during the first few weeks of treatment. (This can sometimes be avoided by starting with a very low dose and increasing slowly.) Some people describe this feeling like “having ants in your pants,” or “an itchy feeling under your skin.” Some people have trouble falling asleep or have poor quality sleep when they start antidepressants.
Uncomfortable side effects from antidepressants may result in suicidal thoughts for some.
Some people who are given antidepressants may actually have a diagnosis of bipolar disorder. This is a more serious type of depression that used to be called manic depression. In addition to “low,” depressed moods, people with bipolar disorder can have “high” or manic moods, with impulsive, irrational behaviors. Bipolar patient who takes antidepressants may develop manic symptoms mixed in with their depression. This results in a particularly toxic form of mania called “mixed mania,” with irritable, agitated mood and impulsive actions. Such symptoms markedly increase the risk for suicidal thoughts and/or actions. (Antidepressants may sometimes safely be given to bipolar patients if they are first treated with types of medication called mood stabilizers.) Young people even without bipolar disorder have been known to become impulsive and disinhibited with antidepressants. This behavioral activation would make them more likely to act on suicidal thoughts at the beginning of treatment.
Depressed patients may have more risk for suicidal thoughts and actions in the early stages of treatment. Most often, their energy level improves before their mood does. Severely depressed people may have thoughts of committing suicide but not the energy to act on them. Therefore, when they begin to improve, they may develop the energy and motivation to commit suicide, before mood and judgement increase enough to see alternatives.
Sometimes, young people stop taking their medication without telling anyone, including the study investigators. If patients stop antidepressants abruptly, they can have withdrawal side effects, which can feel unpleasantly like the flu- agitation, headache, upset stomach, and light- headed sensation. These symptoms are not physically dangerous, but in a vulnerable person can certainly increase suicidal thoughts.
Other side effects of antidepressants can be upset stomach, headache, appetite changes, weight gain or loss, decreased sexual interest or sensation, insomnia or sleepiness, and rarely, easy bruising or bleeding. Rarely, antidepressants can lower the blood sodium level. This is called hyponatremia, and may be characterized by headaches, nausea, confusion, and drowsiness. It usually happens gradually, mostly in elderly people. A sodium level should be checked for people who exhibit these symptoms.
Side effects often go away within the first few weeks of treatment. However, some side effects tend to remain for the duration of the medication treatment. Side effects should stop when the medication is stopped. Because of these concerns, adolescents may best be treated with psychotherapy alone for mild to moderate depression. A minor who starts an antidepressant should meet with his or her health provider at least weekly during the first month of treatment, then every 2 weeks for the next few months.
Many medications are metabolized, or broken down, in the liver, by a system of enzymes called cytochromes, or CYP. Otherwise, the medications would stay in the body until they reached dangerous levels. After being broken down by the liver, the medicines are sent to the kidneys, where they leave the body in urine. Many antidepressants are metabolized by the CYP 2D6 system. Some also inhibit the 2D6 enzymes-they slow down the metabolism of other
medications. The levels of the other medications become higher than expected. Doctors and pharmacists need to keep track of this so they can avoid drug interactions. The antidepressants fluoxetine, paroxetine, and bupropion are strong inhibitors of CYP 2D6 and can raise the levels of many other medications. People taking them should avoid over-the-counter cough medicines containing dextromethorphan, which is metabolized by 2D6. These antidepressants can also increase levels of the Tricyclic antidepressants. Since high levels of TCA’s can cause heart conduction delays, the combination of an SSRI and TCA must be carefully monitored by a physician. Sertraline is a weaker inhibitor the 2D6 system and is less likely to interact with other medications.
Some medications are metabolized by the CYP 3A4 system. This system is inhibited by grapefruit juice. This is why people are often told to avoid grapefruit juice when taking certain medications. Fluoxetine, sertraline, and nefazodone inhibit the 3A4 pathway. Fluovoxamine inhibits the CYP 1A2 pathway. This system breaks down caffeine, and flouvoxamine will intensify the side effects of caffeinated beverages (jitteriness, insomnia, heart palpitations).
Serotonin syndrome is a rare but potentially dangerous combination of excessive serotonin. This was traditionally seen with the oldest class of antidepressants, the MAOI inhibitors, when they were combined with certain medications. The syndrome consists of fever, rapid pulse, agitation, confusion, hypertension, nausea, sweating, diarrhea, incoordination, rigid muscles, and/or excessively strong reflexes. It can progress to coma and death if not treated promptly.
There have been reports of serotonin syndrome with combinations of medications or recreational drugs that increase serotonin.
Stimulants such as Ritalin (methylphenidate) or Adderall (amphetamine/dextroamphetamine) have gotten a lot controversy. These are commonly used to treat Attention Deficit Hyperactivity Disorder or narcolepsy (a neurological condition of excessive sleepiness). They are sometimes used in combination with other medications to help them work better or to combat fatigue.
Many parents express concern about “medicating” their children by putting them on stimulants for ADHD. They have a perception that the schools want to “drug” their children and turn them into “zombies” by keeping them quiet and taking away their personalities so that they don’t cause problems for the school. This is a very unfortunate stereotype that does a grave disservice to the children who most need help. ADHD is a neurological condition in which the prefrontal cortex, the part of the brain that controls attention, impulse control, learning and memory, is less active than normal. ADHD can be helped with medication just like any other medical condition. When the stimulants are doing their job, they are correcting the problems in the prefrontal cortex so that the child can pay attention, learn, and socialize. The “zombie” effect is the result of overmedication. Stimulant dosages tend to have a “window” in which they work optimally. Too little, and they’re only helping a little; too much, and the child will have side effects, such as appearing to “zone out” even more than usual.
Sadly, it is often parents that are least informed on medications that tend to have the most concerns about stimulants and be the least likely to allow their children to try them. (particularly Ritalin, which is no more harmful than any of the other stimulants, but tends to be more notorious). They have the least access to scientific information, and so must rely on rumors and anecdotes. The parents from the highest, most educated socio-economic groups tend to have the least hesitation about their children taking ADHD medication. They want their children to do well in school and be accepted into good colleges. This unfortunately perpetuates the gap between privileged and non-privileged groups.
Stimulants have received a lot of negative press in the past 30 years. There have been sensationalized cases in which a young people committed violent crimes while taking stimulants. At their trials, the defense teams argued that it was the stimulants that caused them to commit crimes. Of course, the likely explanation was that the people committed the crimes because of underlying aggressive tendencies, which stimulants unfortunately failed to improve. In fact, some very good studies have shown that stimulants tends to improve aggressive behavior, even in young people who don’t have ADHD (Klien, RG, Archives of General Psychiatry, 1997).
There were some lawsuits in the 1970’s alleging that Ritalin (methylphenidate) caused tic disorders (abnormal twitches of the face or upper body) in children. We know that stimulants can bring out tics in children who have a tendency to tics or a family history of tics (as many as 24 % of normal children will have temporary tics at some point of their growth that they might not even notice.)(Snider et al, 2002) There is no evidence that stimulants cause permanent, irreversible tics. Tics caused by a stimulant should stop when the stimulant is stopped.
A small percentage of children become more irritable and tearful when taking stimulants.
This can be countered by lowering the dose or changing to a different type of ADHD medication.
There has been concern on and off since the 1970’s that stimulants can stunt growth. We know for certain that they suppress appetite, and it can be difficult to for children to gain weight when they take them. (There are ways to work around this, such as adding calorie-rich foods like peanut butter and cheese.) We also know that children who are malnourished can fail to gain height. There have been several studies trying to clarify the effects of ADHD medications on growth. One study suggested that young teenagers with ADHD tended to be shorter than average regardless whether they took medication. This was felt to be due to a temporary effect of ADHD on growth, since no differences were seen in adults with or without ADHD (Spencer et al, 1996).
There have been recent results from the Multimodal Treatment Study of Children with Attention Deficit Hyperactivity Disorder-abbreviated as MTA. This was a large study conducted by 18 ADHD experts at 6 different medical centers. Almost 600 elementary school children were treated and studied for 14 months. They were divided into 4 groups: 1) children treated with a stimulant (usually methylphenidate) monitored by an expert 2) children treated with behavioral therapy 3) children treated with a combination of 1) and 2), and 4) children treated with “community treatment as usual”-the treatment they would have received if they hadn’t been part of the study. (Group 4 usually received a stimulant from their local health professionals.) Results were first published in 1999, but the children were monitored for side effects for 24 months after the study ended.
In 2004, the MTA group released its findings on growth. They compared children who had received medication continuously for the previous 2 years with those who had never received medication. They found that the group who had never received medication had grown a little more (4.85 inches, or ½ inch above the national average) than the group who had received medication (4.1 inches, or ¼ inch below the national average.) They also gained more weight- 22 lbs. vs. 13.5 lbs. in the medicated group. The investigators recommended weighing the potential effects on growth against the potential problems associated with untreated ADHD, such as academic and relationship difficulties, juvenile delinquency, and substance abuse. They recommended that children taking ADHD medication have their height and weight monitored regularly.
In another study, 178 children receiving long-acting methylphenidate (Concerta) were only 1/10th of an inch shorter than average after 21 months on medication. Decreases in growth occurred mostly in the tallest children. Similarly, weight loss was most common in the children
who were overweight at the beginning of the study (Spencer et al, 2006). Children have continued to be followed since these studies; Later research showed that the growth spurt of puberty may have been delayed by six months but there has been no difference in average height or weight between adults who did or did not take stimulants as children. The latest data, collected in 2019, showed an approximate 1 inch difference in height between those treated continuously for 16 years vs. children without ADHD.
A study of Atomoxetine (Strattera, an ADHD treatment that works differently from a stimulant), found that height had dropped to 1.2 cm below expected when children were started on it before puberty but no difference if it was started during or after puberty.
Atomoxetine was given a “black box warning” in 2005 due to a 0.4% rate of suicidal thoughts early in treatment (5/1357) vs. none in the placebo group. One of the 5 attempted suicide but there were no completed suicides. A warning was added in December 2004 after 2 patients (out of 2 million people taking Atomoxetine) developed severe liver disease. (This reversed after Atomoxetine was stopped.) The manufacturer recommends monitoring for symptoms of liver damage (yellow eyes or skin, itching, abdominal pain, dark urine, flu-like symptoms.)
The blood pressure medications Clonidine or guanficine have also been shown to help ADHD.
Stimulants were in the news in 2005 after Adderall XR was temporarily taken off the market in Canada. There had been reports of sudden death in 12 minors who had taken it. 5 of them had pre-existing heart defects, and many of the others had other medical issues at the time of death. (Heat exhaustion, dehydration, near-drowning, heart attack, diabetes mellitus, drug overdose and excessive exercise were listed in the FDA’s 2005 public health advisory.) Per the FDA, the number of deaths did not appear to be different from the number of deaths that would have been expected been in this population regardless of medication use. A warning that Adderall products should be avoided by patients with underlying heart defects was added to Adderall XR’s labeling in 1994.
What was the cause of the deaths for the patients with heart defects? We don’t know for certain. We know that stimulants increase heart rate and blood pressure. A large increase in heart rate and blood pressure can be dangerous for people with weak hearts. They may have developed irregular heart rhythms that caused their hearts to stop.
Obviously, no patient wants to face the possibility of dying from a medication. Remember, the incidence of sudden death from stimulants is extremely small compared to the number of people taking them. There are ways to further minimize the risk. (These are not absolutely necessary. They are precautions for patients or families who are worried about this risk.)
Patients who wished to try stimulants could meet with a cardiologist (a heart doctor) for an examination. They could be tested with an echocardiogram, which measures the heart rhythm at a single point in time. An additional precaution would be a cardiac ultrasound, which can check for heart structure abnormalities. Those who are extremely cautious could wear a 24-hour holter monitor, which measures the heart rhythm for an entire day to catch any irregular rhythm that an EKG could miss. The combination of EKG, cardiac ultrasound, and holter monitor will catch virtually any possible heart condition. (Children will be reassured to know that these tests are painless- they are measured with monitors placed on the chest.) However, after extensive research, the current guidelines are that these tests may not be necessary if risk factors for heart disease are absent. These include having a family or personal history of a heart condition, having chest pain, getting easily winded with exercise, or having fainting spells.
There has also been concern over the use of atypical neuroleptics in minors. These are medications used to treat psychotic conditions such as schizophrenia- conditions in which one has a distorted view of reality, with delusions and/or hallucinations. These medications are therefore sometimes called anti-psychotic medications. They are also sometimes used for serious conditions in which functioning is significantly compromised, such as Bipolar Disorder or severe aggression. In low doses, they may be added to other medications to help them work better for some conditions, such as sever depression or obsessive compulsive disorder. A better name might be dopamine modulators, since they affect a brain chemical called dopamine.
They are called atypical to distinguish them from the older anti-psychotic medications. The older classic or first-generation medications have been used since the 1950’s. They are usually very effective in treating agitation, delusions, and hallucinations, but can have many side effects. A big problem with the neuroleptics has been their association with what extrapyramidal symptoms (abbreviated EPS, named after the part of the nervous system that is affected).
Extrapyramidal symptoms include tardive dyskinesia, dystonias, akathisia, and parkinsonism.
A person who used neuroleptics for years could develop a movement disorder called tardive dyskinesia. Tardive means late- these side effects can show up after long-term use, even after the medication has been stopped. Dyskinesia means movement problem. Tardive Dyskinesia is abnormal movements of the body, usually the face, tongue, lips, trunk, arms or legs. By definition, the soonest they occur after a few months of treatment, but they usually occur after years of use. (If they happen sooner, they’re called acute dyskinesias, which are usually reversible and easier to treat.) Approximately 5% per year of people who take first-generation neuroleptics develop tardive dyskinesia. About a third of people who take these medications lifelong will develop tardive dyskinesia. Risk factors include being female, elderly, having a mood disorder or mental retardation, and having experienced other EPS earlier in treatment.
These reactions are caused by a lack of dopamine in the movement center of the brain, and may not go away even after the medication is stopped. Treatment involves lowering or stopping the medication, if possible, or adding medication that may help counteract the effects.
Monitoring for tardive dyskinesia is recommended every 6 months for first generation neuroleptics and every 12 months for atypical neuroleptics. A popular questionnaire is the Abnormal Involuntary Movement Scale. A patient will be asked to make a series of movements, such as sticking out the tongue or walking across the room.
It is important to monitor for abnormal movements before starting neuroleptics. A small percentage of the population has abnormal movements even without medication, which could be mistaken for tardive dyskinesia. Often the affected person does not notice the movements, but they can look odd to others. (Because serotonin inhibits the production of dopamine, serotonin reuptake inhibiting antidepressants also lower dopamine. There have been rare reports of extrapyramidal symptoms, including tardive dyskinesia with them.)
Dystonias or dystonic reactions are painful, hardened muscle contractions, usually occurring within the first 2-5 days of treatment in approximately 2% of those treated with a first generation neuroleptic. They are more common in younger males. They usually involve the neck, eyes, tongue, or jaw. They are painful conditions but are rarely dangerous. They quickly improve with treatment with anticholinergic medication like Benadryl (diphenydramamine) or Cogentin (benztropine). (Sometimes, anticholinergic medication is as a precaution to prevent dystonias when classic neuroleptics are started.)
Many people who take first generation neuroleptics develop a type of restlessness called akathisia (from the Greek word meaning, “not to sit.”) This is a feeling of inner agitation.
Patients have difficulty sitting still and feel a need to walk around. Sometimes, doctor’s mistake this for agitation from the disease and increase the dose of neuroleptic, making the problem even worse. This condition is treated by lowering the dose or changing to a different medication. If the neuroleptic cannot be changed, medications such as beta-blockers or benzodiazepines are added to counteract the effect.
Pseudoparkinsonism is a side effect from neuroleptics that resembles Parkinson’s Disease. (Neuroleptics decrease dopamine, which mimics Parkinson’s Disease.) This results in tremor, slowed movement, stiff muscles, and limited facial expressions. Anticholinergic medication can also improve this side effect.
A rare but dangerous side effect of neuroleptics is Neuroleptic Malignant Syndrome. This occurs in less than 1% of patients taking first-generation neuroleptics, usually within the first two weeks of treatment. Symptoms include fever, rigid muscles, and confusion. This is a medical emergency requiring supportive care in an intensive care unit.
The atypical neuroleptics generated a lot of excitement when they first came on the market because they seemed to have fewer side effects and work better than the older medications. The first was Clozapine-the gold standard of the atypical neuroleptics. (Gold standard means that it is the medication proven to work the best and newer medications are compared to it.) It worked in a somewhat different way from the classic neuroleptics by more specifically targeting the areas of the brain involved in schizophrenia. Some schizophrenic patients who had not responded to other medications improved tremendously with Clozapine. The classic neuroleptics had improved positive symptoms of schizophrenia-hallucinations, delusions, and agitation. However, Clozapine also improved negative symptoms, such as inactivity, social withdrawal, and poor motivation, as well as suicidal behavior. It seemed to lower the risk of tardive dyskinesia.
Unfortunately, 1% of people who took Clozapine developed agranulocytosis, a dangerous condition in which the bone marrow stops producing white blood cells, putting patients at risk for infections. There have also been cases of heart problems caused by Clozapine, with a recommendation to monitor for symptoms such as chest pain, shortness of breath, rapid pulse, flu-like symptoms. Because of side effects, Clozapine is reserved for patients who have not improved with other medications. Frequent blood tests are required to monitor for agranulocytosis.
Several new atypical neuroleptics have been developed. These seem to have a low risk of tardive dyskinesia and agranulocytosis. They appear to improve positive and negative symptoms of schizophrenia. (possibly not as effectively as Clozapine). They are now used more commonly than the first-generation neuroleptics. Because they are easier to tolerate, they have been prescribed for children more than the classic neuroleptics. Although children with mental retardation tend to be very sensitive to medication side effects, they appear to tolerate the atypical neuroleptics.
However, atypical neuroleptics can cause rapid and excessive weight gain, high cholesterol, and diabetes mellitus. Younger people tend to gain the most weight- as much as 60 lbs. Over the course of several months of treatment. Weight gain usually tapers off after a few months, but the extra weight is generally not lost unless the patient participates in a diet and exercise program, or stops the medication. The atypical neuroleptics vary in their tendencies to cause weight gain.
Clozapine and olanzapine tends to cause the most weight gain, and aripiprazole, and ziprasodone, the least. Weight gain varies by individual-some people don’t gain any weight from these medications. If a person has lost a lot of weight due to psychotic thinking, weight gain might be a desired side effect.
The American Diabetic Association and American Psychiatric Association published guidelines for monitoring atypical neuroleptics in 2004. Recommendations include evaluation of personal and family history of risk factors for heart disease (obesity, high blood pressure, diabetes, heart disease) at baseline (prior to treatment), then once per year; weight for height calculations at baseline, then at weeks 4, 8, 12, 16, and annually; waist size at baseline, then annually; blood pressure at baseline, at 12 weeks, and annually; fasting blood sugar at baseline, 12 weeks, 16 weeks, and annually; and fasting cholesterol profile at baseline, 12 weeks, and annually (J Clin Psychiatry 2004). In addition, patients should be monitored for symptoms of high blood sugar-weakness associated with excessive drinking, eating, and urinating.
Many people receive education on healthy eating habits and begin a diet and exercise program at the same time they start atypical neuroleptics. This often prevents or slows down the weight gain. Sometimes medications are added to control weight gain- metformin, a medication used for Diabetes Mellitus, or topiramate, a medication used to prevent seizures.
Both first and second generation neuroleptics can cause increased production of prolactin. This is a hormone that is normally inhibited by dopamine. When dopamine levels go down, prolactin levels go up. Prolactin is required for lactation, the release of milk from the breast that occurs when a mother feeds her baby. It is normal for both women and men to produce prolactin in small amounts, but neuroleptics can increase this substantially and cause breast enlargement and milk production. This can interfere with menstruation in women and sexual function in men. There is a possible association between chronically elevated prolactin levels and a type of brain tumor.
To check for increased prolactin levels, physicians will question women about any menstrual irregularities and men about any sexual problems. If patients have noted these problems, the doctor will recommend a blood test to check prolactin level. The treatment for elevated prolactin is to change to another neuroleptic less likely to increase prolactin. If this isn’t possible, a medication that lowers prolactin can be added. Of the atypical neuroleptics, risperidone is the most likely to raise prolactin levels, and ariprazole and quetiapine, the least.
Other troublesome side effects can be sleepiness and difficulty concentrating. This can cause problems with learning. Generally, however, this is offset by the positive effects of the medication-the treatment of psychosis and/or agitation that allows the child to stay in school.
Mood stabilizers are medications that do just what their name implies- keep the mood stable. Psychiatrists use them mainly to treat Bipolar Disorder and aggression. They are sometimes used for other conditions, such as schizophrenia. Many are anti-seizure medications, which have been also shown to work for mood disorders. The theory is that the mood swings of bipolar disorder are like “emotional seizures.”
Lithium was the first medication found to work for Bipolar Disorder and continues to be the “gold standard.” Lithium is one of the few medications that have been shown to reduce the suicide rat. It has repeatedly shown to be effective for Bipolar Disorder. In smaller doses, it is used to help antidepressants work better. Lithium is a safe medication when taken and monitored as directed. However, the difference between an effective dose and a dangerous dose can be small. Lithium is dangerous in overdose. leading to nausea, vomiting, tremor, diarrhea, imbalance, stupor, coma, then death if untreated. Lithium level is monitored with frequent blood tests at the beginning of treatment and whenever a dose change is made. After dose has been stable, a lithium level is checked every 6 months.
Lithium is a naturally-occurring salt that dissolves in the bloodstream. The lithium level can increase when the body loses water by vomiting, diarrhea, or dehydration. Losing salt by sweating can also increase lithium levels.
Lithium leaves the system the same way water does-by urination. Needing to urinate more frequently is a common lithium side effect. This is associated with increased thirst. Lithium can damage the kidneys very rarely. Kidney function is monitored with blood tests every 6-12 months to insure that this is not occurring.
Lithium can be taken up by the thyroid gland, which controls metabolism. Thyroid function is normally checked with a blood test every 6 months. Over time, lithium can cause hypothyroidism, or low thyroid function. Untreated, this results in low metabolism- low energy, sleepiness, difficulty concentrating, weight gain. Patients who develop hypothyroidism can correct it by taking thyroid hormone in pill form.
Rarely, lithium can cause problems with heart conduction. An EKG prior to treatment is recommended for elderly patients or those with pre-existing heart problems. Other side effects include tremor, inattention, nausea, diarrhea, weight gain (although usually less than many other agents), and rash.
Pain relievers such as aspirin and ibuprofen can increase lithium levels. Acetaminophen is recommended when pain relief or fever control is needed unless lithium levels are carefully monitored.
We have a lot of information about the safety of antiepilepsy medications for children, since pediatric neurologists have used them to treat seizures for years. Medications that may be prescribed for Bipolar Disorder include valproate, carbamazepine, lamotrigine, and Topiramate. If these medications are discontinued, they should be slowly tapered if possible, since abruptly stopping them may increase the risk of having a seizure.
Common side effects of valproate, or Depakote, are weight gain, sedation, decreased concentration, abdominal upset, and tremor. Some people also experience hair loss. People who receive significant benefit from Valproate often remain on it even if they experience these symptoms.
Polycystic Ovarian Syndrome (PCOS) has been associated with the use of valproate in women and teenage girls. In one study, 40% of women taking valproate to control epilepsy had this syndrome, but it is unknown whether women with epilepsy are more prone to PCOS than women with Bipolar Disorder (T Betts, April 2001, Seizure). This is a condition characterized by excessive male hormone, obesity, ovarian cysts, menstrual irregularities, facial hair, weight gain, male-pattern baldness, acne, and/or diabetes mellitus. Women who experience irregular menstruation and teenage girls who have not gotten their periods as expected should have an endocrinology evaluation for this condition.
Some side effects, while quite rare, are dangerous enough to require immediately stopping valproate and receiving medical attention. Pancreatitis is a rare side effect that should be suspected in those experiencing upper abdominal pain, nausea, fever, and chills. Liver failure is a rare but potentially life-threatening complication. For this reason, patients and families are cautioned to watch for symptoms of hepatitis, such as jaundice, nausea, fatigue, and appetite loss. Valproate may also inhibit the production of platelets, a type of blood cell that prevents bleeding. Patients are warned to watch for excessive bruising and easy bleeding. Blood tests measuring liver and platelet functioning are normally measured every 6-12 months. Valproate levels should be checked with a blood test after each dose increase.
Carbamazepine can also very rarely cause liver problems. Its main side effects are sedation, nausea, and dizziness, rash, and decreased concentration. It may cause weight gain, usually less than valproate or lithium. It can rarely cause a dangerous rash. Its most dangerous (but thankfully) rare potential side effect is suppressing the bone marrow. It can stop the bone marrow from making blood cells, resulting in dangerous bleeding or infections. Patients should report bruising, easy bleeding, pale skin, sore throat, fever, and other symptoms of infection to their doctor. Carbamazepine can speed up the liver’s metabolism and therefore lower the dose of other medications, including birth control pills. At the beginning of treatment, blood levels should be checked frequently, since carbamazepine can speed up its own metabolism
Lamotrigine, or Lamictal, is also treatment for Bipolar Disorder. It has been shown to improve and prevent recurrences of bipolar depression in adults but has not been shown to help acute mania. It is also used to treat unipolar depression that has not responded to antidepressants. It tends to be better tolerated than the other mood stabilizers and does not require blood testing.
However, it is associated with a dangerous, painful rash called Stevens-Johnson syndrome.
This was found in 0.8% of children under 16 and 0.3% of adults who were taking it for seizures. This is less likely to occur when lamotrigine is started at a very low dose and increased very slowly. Patients who develop a rash need to speak to their doctor right away, particularly if they also have hives, fever, swollen lymph glands, lips, or tongue, or painful sores in the mouth or around the eyes. Lamotrigine must be increased even more slowly if it is used with valproate, which raises lamotrigine blood levels. Birth control pills lower lamotrigine blood levels and lamotrigine lowers the effectiveness of the birth control pill.
Topirimate, or Topamax, is one of the few mood stabilizers to be associated with weight loss instead of weight gain. However, it has not been shown to be effective for Bipolar Disorder when used alone. It is sometimes used with mood stabilizers or atypical neuroleptics to prevent weight gain. However, it can be associated with sedation, dizziness, decreased concentration, and word- finding difficulties. Other potential side effects include kidney stones, decreased sweating, and increased body temperature. Side effects of particular concern are glaucoma and metabolic acidosis. Glaucoma is increased eye pressure that can result in blindness if not treated. Patients should contact their doctor if they develop eye pain or vision changes. Metabolic acidosis is increased blood acidity due to lowered bicarbonate levels. Doctors should be notified for associated symptoms of sleepiness, rapid breathing, or irregular pulse. Since mood stabilizers can be associated with birth defects, anyone who could potentially be pregnant should have a pregnancy test before starting one.
Why risk taking these medications at all? The risk of treating a condition must be weighed against the risk of not treating. For people with significant depression or anxiety, potential side effects are a small price to pay for the relief the medication provides. Have you ever taken medicine for a bad headache? Aspirin can have side effects as well-possible upset stomach, bleeding problems, or ulcers. You must weigh the risk of side effects vs. the intense headache relief.
Several studies show that antidepressants can benefit minors. Fluoxetine, sertraline, and citalopram have been shown to improve depression. Fluoxetine, sertraline, citalopram, and fluvoxamine have had demonstrated effectiveness against anxiety disorders. In 2004, the suicide rate for children and teenagers rose for the first time in over 10 years. This corresponded to a 20% drop in antidepressant prescriptions for minors following the “black box warning.” A new study released in April 2007 found that the benefits of antidepressants for minors with anxiety or
depression clearly outweighed the risks. It analyzed information from 27 studies involving over 5000 patients ages 19 and younger. The risk of suicidal thoughts was found to be lower than that in the FDA analysis (Bridge et al).
What are the risks of not treating depression or anxiety? It is impossible to predict this for an individual, but research helps us to make some generalizations. The purpose of psychiatric treatment is to help keep children or teenagers on their growth track-functioning well in important areas such as friendships and school. Like running a race, once a child fall behind, it becomes increasingly harder to catch up to peers. Depressed or anxious children may have difficulty paying attention in class and fall increasingly behind in school. They may be irritable with other children, or withdraw and stop participating in activities, resulting in the loss of friendships.
We know that the body releases cortisol when under stress– a hormone that helps the body get moving in an emergency. There is evidence that excessive amounts of cortisol can damage parts of the brain, such as the hippocampus, an area that influences mood and certain types of memory. (Czeh et al., 2001). Stress also reduces the level of brain-derived neurotrophic factor, or BDNF, a protein that helps the brain’s nerves survive and grow (Smith et al., 1995, Castrén, 2004; Malberg et al., 2000).). (Antidepressants appear to improve nerve growth, particularly in the hippocampus (Castrén, 2004)). There is evidence that stress affects other parts of the body as well, decreasing our ability to fight illness. This makes it important to control stress. Depression has been associated with heart disease, asthma, and other medical conditions. There is also evidence that psychiatric conditions become harder to treat and more likely to recur the longer they are left untreated. For example, a person may first develop depression due to stress, such job loss or divorce. However, the depression may later take on “a life of its own” and return without any apparent outside trigger.
What are the risks of not treating a psychotic condition? These can be very serious. Psychotic people are out of touch with reality and can easily react impulsively and aggressively, feeling that the world is out to get them. The feelings associated with psychosis are very unpleasant- extreme anxiety and agitation. A psychotic person may be tormented by auditory hallucinations– one or more voices making frightening comments such as, “you’re worthless” or “kill yourself.” Sometimes, depression is accompanied by psychotic thinking that is not obvious to others.
Symptoms will improve much more rapidly with antipsychotic medication.
Schizophrenia is a debilitating psychotic condition that often begins during adolescence. There is evidence that treating it early with antipsychotic medication improves the course, and that the more treatment is delayed, the more serious the condition is and the harder to treat (Perkins et al., Am J Psychiatry 2005).
Neuroleptics can often help severe aggression and mood swings, without psychotic thinking. These medications should not be used for the normal moodiness that can accompany the teenage years, or the temper tantrums of young children. They are not appropriate for behavioral problems that can be treated by a therapist, who helps parents to set limits with children.
Neuroleptics should be reserved for agitation and moodiness that could be dangerous. Example include trying to jump out of moving cars, grabbing kitchen knives, and throwing heavy furniture. In these situations, neuroleptics can make the difference in allowing children to stay in school, learn, and make friends. Children who experience such intense mood swings describe them as horrible. They feel uncontrollable rage, and after the rage attack is over, they feel shame
and regret. Having medicine to help control their impulses gives them hope. They feel proud and happy that they can control their aggressive impulses and have improved friendships and grades.
Bipolar Disorder is a very disabling condition that prevents its sufferers from meeting their potential. When they are manic, they risk of acting impulsively, interfering with relationships and finances. When they are depressed, they have difficulty motivating and mobilizing themselves and may have suicidal thoughts. Despite its possible side effects, lithium is life- saving for many Bipolar patients. There is solid evidence in rigorous scientific studies that lithium prevents suicides in patients with unipolar and bipolar depression. Therefore, patients tend to continue lithium even if they develop side effects such as hypothyroidism, choosing to take thyroid replacement hormone rather than risk the return of severe mood swings.
After improving on a medication, my teenage patients often want to stop it prematurely. Why is this? As a teenager, it’s normal to try new things and test limits. Teenagers often want to do things differently from their parents. They may feel that they’re taking medication only because their parents want them to. Often, they want to fit in with their friends, and think that taking medication makes them “different.” Sometimes, their friends pressure them to stop taking medication, making comments such as, “Only crazy people take those kinds of pills.” Sometimes, teenagers find frightening Internet web sites in which people talk about horrible side effects they attribute to the medication. (I caution patients to trust only scientifically-oriented web sites. Some can be very biased- people who have bad reactions to medications are much more likely to report them on a web site than people who have had good reactions.) Teenagers may be experimenting with alcohol or recreational drugs that they know should not be combined with their medications. They may dislike the sexual side effects of their medications if they are becoming sexually active.
I try to avoid pressuring patients to start medication or stay on medication. I educate them on the risks vs. benefits and help them make an educated choice. I try to help teenagers set aside any conflict with their families that may be influencing their decision so that they can make an educated decision based on the facts and not on emotion.
Sometimes, teenagers abruptly stop taking their medication without telling an adult. If they have been taking a type of antidepressant called a serotonin reuptake inhibitor, they may have a discontinuation syndrome within the next 72 hours. They may experience a light-headed sensation, nausea, and/or headache. This is not physically dangerous, but can feel very unpleasant, like the flu. Patients sometimes mistakenly believe either that the syndrome is “proof” that they need to stay on the medications forever, or that the medications are so unpleasant that they never want to try them again. Neither response is based on fact. The discontinuation syndrome can be avoided by very gradually lowering the dose of medicine before stopping it. This should be supervised by a physician.
Many people object to taking medications because they don’t want to be “dependent” on “drugs.” Although medications are sometimes called “drugs,” they are different from the recreational drugs that are abused to “get high.” Although antidepressants improve mood, they don’t artificially elevate mood beyond normal when they are working correctly- they help the brain to function normally. (The exception is when a Bipolar person develops mania from an antidepressant.) People are no more dependent on antidepressants than they are dependent on insulin to treat their diabetes- they need the medication to treat the medical condition. Starting a medication does not mean that you will continue on it indefinitely. Ideally, a patient will learn psychotherapy techniques to prevent further episodes of depression or anxiety. The
recommendation is to stay on an antidepressant for approximately one year after symptoms have improved, then slowly lower the medication to see if it is still needed. (There are some medications that people may remain on for years, such as those for bipolar disorder or schizophrenia, which are often lifelong conditions.)
Patients normally don’t “crave” their antidepressant. They don’t go from doctor to doctor trying to obtain more of it or give up activities because of it. Antidepressants are not addictive.
Some medications are “controlled substances”-they are categorized as having addiction potential by the United States Drug Enforcement Administration (DEA). They have certain rules about how they can be prescribed. Categories range from II (high abuse potential), to V (low abuse potential). Antidepressants are felt to have no abuse potential are not classified as controlled substances.
Some psychiatric medications do have abuse potential. Stimulants are classified as category II controlled substances, although most people use them safely and do not become dependent on them. Long-term studies have shown that children with ADHD who are treated with stimulants are actually half as likely to abuse recreational drugs when they become teenagers and adults than those who were not treated (Wilens, Timothy, 2005).
A small percentage of people will become addicted to stimulants and should not be prescribed them. People most at risk are those who have a history of addiction to other substances. (People who have close family members with substance use problems should be prescribed stimulants cautiously, since substance dependence tends to run in families). This does not mean they are “weak” or “bad” people- the stimulants affect their brains in ways differently from most people. Vulnerable people get a feeling of artificial well-being from stimulants that most people don’t.
They find themselves becoming tolerant to its effects and craving more of it. They use more of it than intended and run out of it prematurely. They may make excuses to their doctors of why they need a new prescription early. There are safe non-addictive ADHD treatments for people who are at risk of stimulant dependence.
Benzodiazapines are another type of controlled substance sometimes used by psychiatrists.
They classified as category IV. Common names are lorazapam, or Ativan; alprazolam, or Xanax, diazepam, or Valium, and clonazapam, or Klonopin. Neurologists commonly use this class of medication to treat children with seizure disorders. Psychiatrists prescribe them for short-term treatment of anxiety or agitation. If benzodiazepines are used regularly (twice a day for long- acting forms; three or four times per day for shorter-acting forms) for more than a few months, they can cause physical dependence. If they are stopped abruptly, they can cause anxiety, jitteriness, nausea, sweating, and rarely, seizures. The dose should be decreased gradually, under the supervision of a physician. They are used more commonly for adults than for children, but can be helpful for some sleep disorders and when rapid alleviation of anxiety is needed.
The Treatment of Adolescents With Depression Study (TADS) provided important information on the outcomes for teenagers treated with psychotherapy and/or medication. This compared 439 patients with Major Depression between ages 12 to 17 who were assigned to either fluoxetine, cognitive behavioral therapy, a combination of both, or placebo. After 12 weeks of treatment, teenagers who were treated with the combination of fluoxetine and CBT improved the most. Those who took fluoxetine alone also improved. CBT alone was not significantly more effective than placebo except for young people from higher income families. About 30% of teenagers had significant suicidal thoughts before they began treatment, which greatly improved as treatment progressed. Teenagers who received combined treatment had the largest decrease. There was a slightly increased risk of suicidality in patients receiving fluoxetine alone compared to those receiving CBT. This was not seen in those receiving combined treatment, and it was speculated that CBT protects against suicidal ideation in patients given fluoxetine. (March et al., Journal of the American Academy of Child and Adolescent Psychiatry, Dec. 2006)
Another study found that citalopram reduced symptoms of depression in 178 children and teenagers. There were no serious side effects. (Wagner, KD et al, American Journal of Psychiatry, June 2004) Two studies found that sertraline improved major depression in children and adolescents. (Wagner, KD et al., JAMA 2003) Another study found that paroxetine improved major depression in adolescents (Keller, MB, et al., J. American Academy of Child and Adolescent Psychiatry 2001). A study of escitalopram found that it improved depression for adolescents (ages 12-17) but not for children (ages 6-11) (Wagner, KD, J. American Academy of Child and Adolescent Psychiatry, March 2006).
Psychiatrists, along with other physicians, try to practice evidence-based medicine– to use the treatments supported by the best scientific research. The most convincing studies are double- blind and placebo-controlled. A placebo is a “fake” treatment, such as a pill without active ingredients. Scientists use placebos because people often initially improve based on the just the expectation that they are getting help.
When I was a teenage babysitter, I had a special “treatment” for children’s “boo-boo’s.” I would touch the hurt child with a “magic leaf” plucked from a tree. I explained that the “magic” would take away all the pain. Almost every child touched by the leaf would immediately stop crying and say that the pain was gone. The “magic leaf “ was a placebo- it worked because the child thought it would work. Similarly, patients who gets a psychiatric treatment might improve because they think that they should be improving. (Usually, placebo responses don’t last more than a few weeks.)
Psychiatrists want to make sure that our patients are improving because the treatment actually works. Therefore, when possible, we compare new treatments against placebos. In a double- blind, placebo controlled study, neither the patients (and their families) nor the scientists rating the treatments know who has the active treatment and who has the placebo. Scientists’knowledge of which patients are getting the real treatment could influence how well they rate the treatment as working.
For example, say I’m doing a study on the effectiveness of pop music on my pets’ health. I’m convinced that pop music is bad for animal, and therefore only classical music (my favorite) should be played in our house. To prove my hypothesis, I keep my dog in my daughter’s bedroom while she listens to pop music for an hour, and my cat in my son’s quiet room at the other end of the house. At the end of the day, I examine the pets. I’m convinced that my dog seems a little upset. Don’t his whiskers look a little droopy? Didn’t he hesitate before batting chasing the ball that I offered him? My cat, on the other hand, looks very content to me. Her whiskers seem very perky while she enthusiastically bats at the yarn. Based on my findings, I rate the dog an “8” and the cat a “5” on my Moody Mammal Scale.
Can I use my research to justify that pop music shouldn’t be played in the house because it depresses pets? No, that study wouldn’t fly with scientists. I was a biased observer- I saw what I wanted to see. Similarly, if researchers know which is the active treatment and which is the placebo, they may unintentionally falsely perceive that patients getting the real treatment are the most improved.
Sometimes, decisions are based on open-label studies. These are studies that are not blinded- the patients and researchers know that they are getting the treatment. These are often done prior to the double-blind, placebo controlled studies, since they are easier to do and can help determine if the further research is warranted.
For example, a new antidepressant medication might have already been found to be safe and helpful for adults, but has not yet been evaluated for teenagers. Teenagers admitted to an inpatient psychiatry ward may participate in a study in which half are given the new medication and half are given an older antidepressant that has already been shown to be effective. (Of course, the risks and benefits would have been explained to the patients and their families in advance, and it would be their choice to be in the study. They would in no way be penalized if they declined to be in the study. Patients in these studies are closely monitored with medical assessments.)
It can be harder to draw conclusions from open-label studies, however, since we don’t know if any response is due to placebo. Sometimes, medications that seem effective in open-label studies turn out to be no more effective than placebo when the double-blind, placebo controlled studies are done. All we can say from open-label studies is that a treatment seems promising.
Why would doctors want to do these types of studies, and why would anyone agree to participate in them when there are already treatments proven to work? No treatment has been found that is 100% effective or free of side effects. A treatment that works for one person might not work for another. Researchers are always looking for better treatments. A patient who has tried other treatments with limited success might want to try something new.
You may have heard many different names for the same antidepressant. This can be confusing. All medications have a generic name. This is the scientific name assigned to the medication in the laboratory. Pharmaceutical companies also select a trade name for their new medications. The same medication can have more than one trade name. Usually, the trade name is more recognizable than the generic name due to advertising by the pharmaceutical companies.
However, researchers usually use the generic name when they discuss the medications in lectures or scientific magazines.
Many people have heard of the antidepressant Prozac. In the 1970’s, it was the first serotonin reuptake inhibitor to be developed, by the pharmaceutical company Eli Lily. Prozac is the trade (brand) name for the generic medication, fluoxetine. (Trade but not generic names are capitalized.) Eli Lily also markets the same medication, fluoxetine, as a treatment for Premenstrual Dysphoric Disorder (PMDD), with the trade name of Seraphem. (PMDD is a condition of emotional and physical problems occurring prior to the menstrual period severe enough to impair functioning.) There is also a long- acting form of Prozac called Prozac weekly, which usually only needs to be taken once a week.
Many new medications cannot be purchased in generic form. This is because pharmaceutical companies file patents on medications that they develop so that other companies cannot copy and sell the same medication. Companies spend millions of dollars researching and developing each medication in the hope of making an even bigger profit. If other companies were allowed to copy the medication as soon as they were ready to be sold, the original company would lose a lot of money and stop inventing new medicines. Generally, a patent runs out 30 years after it is filed. Since patents are usually filed early in development, and it can take years of development before a medication is ready to go onto the market, the actual time that a medication can be sold exclusively by the original company may be considerably less than 30 years.
After the patent runs out, other companies can sell generic forms of the medication. These have the same chemical structure (active ingredients) as the original medication and therefore work the same way. However, there may be different inactive ingredients – fillers in the tablet or capsule that surround the active ingredients. Fillers don’t cause any changes to the body, but are required to give the medication its structure, and must be dissolved in order for the active ingredients to work.
The generic medications may therefore be absorbed somewhat differently from the brand name. Some generic medications are slightly less well absorbed than the brand name. Most of the time, this doesn’t make a difference. However, some brand name medications” are highly recommended. Certain brand-name anti-seizure medications are better absorbed than the generic form. This can make a difference for seizure control.
Many antidepressants are now available in generic form. Most insurance companies will not pay for the brand name medication if a generic is available, since generics tend to cost considerably less than the brand name. However, insurance may pay for brand name medication if the physician documents that it is “medically necessary.” An example of the brand name being medically necessary is when a patient has an allergic reaction to an inactive ingredient in the generic.
It takes many years from the time a medication is initially envisioned in a lab to the time it comes on the market, due to extensive testing that must be done. Most medications developed by pharmaceutical companies never actually make it to the market. They may have been found to be either not as effective or not as safe as originally believed.
A medication must go through several stages of research before it is approved for general use. During the pre-clinical phase, the medication is studied in the test tube and in animals. Following this, there are four clinical phases, in which the medication is studied in people who have volunteered to participate. During phase I, the pharmokinetics are determined- how the body handles the medication. The ways the medication is absorbed, distributed in the body, and eliminated from the body are studied. Initial safety information and appropriate dose are established. During phase II, further safety information at the ideal dose established. During phase III, the safety and effectiveness of the medication is compared to standard treatments already on the market. In order to be approved by the Food and Drug Administration (FDA) and be sold on the market, the pharmaceutical company must show that the medication has an advantage over standard treatments.
If the medication is approved by the FDA, it can be prescribed by physicians and sold to the public. Phase IV is the post-marketing phase-additional safety and effectiveness information is obtained from people who have been prescribed the medication. Sometimes, side effects don’t show up until phase IV, when large populations have been exposed to the medication. This is the disadvantage of being one of the “first on the block” to try a new medication- you risk developing a rare side effect that had been previously unknown. Usually, these initially show up as individual “case reports” that doctors report to the FDA. If a trend is found, the FDA may issue a “black box warning” or take the medication off the market altogether. Examples of rare side effects that showed up during post-marketing are liver failure with Nefazadone, an antidepressant, and closed-angle glaucoma with Topamax, an anti-seizure medication sometimes used for Bipolar Disorder.
It is important to report a bad reaction to a medication. The physician who prescribed this information must know about it in order to make appropriate changes. If this a serious or unusual reaction, it is also important for the FDA to know about it so they can investigate further or take action with the manufacturer. Ideally, it is the prescribing physicians who reports this to the FDA, since they can supply the technical information. Patients or family members who wish to report directly to the FDA can obtain directions and forms from the FDA website https://www.accessdata.fda.gov/scripts/medwatch/index.cfm?action=reporting.home (It is important to notify the FDA if both the physician and patient are reporting to clarify that both reports are about the same person.)
Giving disproportionate publicity to medication side effects is doing the public a disservice.
People who may have been helped by the medications may be reluctant to take them. An influential person who had negative experiences with psychiatric medications might tell reporters, “Psychiatric medications are terrible- don’t ever take them.” A person who spends a lot of time on the Internet might write on multiple chat sites, “Don’t ever take medication X- it did terrible things to me.” This frightens people and prevents them from trying medications that could have a lot of benefit.
For example, I once had a bad reaction to an antibiotic I was taking for an infection. I broke out in an itchy, uncomfortable rash from head to toe. It turned out that I had a serious allergic reaction to this medication. I had to go to my doctor right away, stop the antibiotic, and take a different sedating medication to fight the rash.
Do I use my sphere of influence as a physician to tell my patients, “Don’t use antibiotics- they can give you dangerous itchy rashes?” No, that would be irresponsible. Although this antibiotic was harmful to me, it helps many people, and only a small percentage of the population is allergic to it. It should be prescribed to people to whom it is appropriate.
A little anxiety is good for our civilization. If our ancestors had been perfectly content we would never have developed tools, medicine, or technology. We’d just sit outside in the rain until we were eaten by wild animals. A little worry makes us strive to be better. Too much anxiety can overwhelm us and prevent us from functioning.
As I write today, in June of 2020, many people are worried. We are coping with climate change, Corona virus, and political unrest. We fear the future.
The best predictor of what will happen in the future is what has happened in the past. Humans are resilient and have survived for eons. Put in perspective, this is a lucky time to be alive. The average person in the US lives more comfortably than a king in the Middle Ages. Heat, running water, hot showers, the Internet were unheard of and would have seemed like magic. The average life expectancy was under 40 years.
Things improved because people were anxious to live better. Today’s problems will lead to a better future if people are worried enough to cooperate with each other. We will develop methods to improve the environment, lead healthier lifestyles, fight disease, and live in peace with each other.
What kind of anxiety might people experience today? Here are fictional examples in adults:
Jessica always tended to worry but now is never worry-free. She worries about illness, droughts, fires, riots. While driving to work she worries about a deer leaping in front of her car. At work she worries about making a mistake and getting fired. Because of the worry, she can’t concentrate and does make simple mistakes, which make her worry even more. At home she worries something bad will happen to her family. She feels restless, irritable and tired. The muscles in her neck and back feel like hard knots and she has headaches that feel like a band across her forehead. She has trouble falling asleep because she can’t stop worrying.
Jessica suffered from Generalized Anxiety Disorder, a pervasive pattern of worrying about important life situations that make it difficult to function.
Matthew had always been healthy until he suddenly felt as if he were having a heart attack. His chest hurt, he couldn’t breathe, his lips and hands felt numb, he felt faint, and was sure something terrible was happening. He was rushed to the emergency room but his doctors could find nothing wrong with him. He later had a full evaluation by a cardiologist but all tests showed that his heart was healthy. He felt a little better when he learned that he most likely had a panic attack, which was not physically dangerous.
However, the feeling had been so awful that he continued to worry it would happen again. Sure enough, a few weeks later he had a panic attack at work, then again when he was driving home. He had begun experiencing anticipatory anxiety – the fear that he would have a panic attack made him so nervous that it triggered another panic attack. He became scared to leave the house. The more he stayed at home, the harder it was for him to leave.
Mathew had developed Panic Disorder- the fear of having a panic attack caused him to have difficulty functioning. A panic attack is a discrete episode of at least 4 of the following physical sensations: racing or pounding heart, feeling of choking, chills or sweats, dizziness, trembling, sweats. nausea, shortness of breath, trembling, tingling or numbness around hands, fear of losing control or dying, feelings of unreality. Panic attacks can lead
What causes the sensation of having a panic attack? All animals breathe in oxygen and breathe out carbon dioxide. When we are nervous, we may hyperventilate – take quick, shallow breaths that rid our bodies of carbon dioxide too quickly. The physical symptoms of panic attacks are the body’s way of saying, “I need more oxygen-slow down and take deep breaths.” You will not die if you hyperventilate- at the very worst you would pass out and your body would breath normally again. Learning deep breathing techniques is a great treatment for anxiety. You can try the 4-7-8 breathing technique right now. Inhale for 4 seconds, hold your breath for 7 seconds, then breath out for 8 seconds. Don’t you feel more relaxed already?
Jill is an emergency room doctor. She has always been a high achiever, a perfectionist, proud of her ability to work quickly and efficiently. Two months ago, however, the emergency room became inundated with patients with COVID-19, and short-staffed since some of her coworkers became ill. Jill was dismayed that she could not save all of the patients. At first, she was able to put her emotions on hold as she worked long, intense hours and took on extra shifts. However, she gradually became anxious and irritable. She had trouble sleeping even though she was exhausted.
Finally, the cases slowed down and work went back to normal. Instead of feeling relief, Jill felt depleted. She couldn’t stop thinking of the patients who had died and had nightmares about them. She always felt irritable, tense and jumpy, expecting something bad to happen. When riding the elevator, she stood in a corner because she didn’t like the sensation of people standing behind her where she couldn’t see what they were doing. She felt detached and lost interest in socializing. She felt guilty that she survived but others didn’t.
Some of her colleagues had symptoms which gradually decreased over the next few weeks until they felt back to themselves. Jill’s symptoms only increased until she was considering changing to a job in the pharmaceutical industry.
Jill’s colleagues who had only a few symptoms (brief insomnia, worry, irritability, nightmares, fatigue) were having a normal reaction to a stressful situation. Those who had more symptoms that resolved within a month had Acute Stress Disorder. Jill had multiple symptoms that didn’t go away. She had Posttraumatic Stress Disorder, or PTSD, a more serious condition now classified in the ICD 10 (International Classification of Diseases-10th Revision) as a trauma-related disorder instead of an anxiety disorder. Anxiety is a prominent feature, however.
Sophia had always been described as “quiet” and “shy.” She felt very nervous when meeting new people but was comfortable with her small friendship group. She got good grades in elementary and middle school but they plummeted her first year of high school. There were two high schools in her town and most of her friends had been placed in the other school. She began making tearful excuses to stay home from school. Although invited, she never went to parties. When her school physically closed and she had only online classes due to the Coronavirus, she felt much better but refused to participate in group videoconferences. She refused to return to school when it physically reopened. She told her parents that she would attend online classes only.
With the help of her psychotherapist, Sophia learned she had Social Anxiety Disorder, the fear of being scrutinized by others. A person with social anxiety constantly feels judged and found deficient. Sophia’s social anxiety had worsened during a required public speaking class in high school. As she stuttered and stammered through her first presentation, a few of her classmates had snickered. This confirmed in her mind that she was inferior to her peers and she stopped participating in all classroom discussions. The more she avoided social situations, the harder it was for her to convince herself that normally she spoke okay. She would ruminate on something she had said to a friend the day before, thinking “Why did I say that? That was such a stupid thing to say! I must have hurt her feelings! I’m an idiot!” Her self-esteem plummeted.
Oliver was a fourth grader who was sent to the principal’s office for running out of his school and hiding in the bushes. When the principal tried to talk to him, Oliver would not answer. He began crying, yelling, and throwing things when the principal tried to question him. He finally communicated by shrugging his shoulders. When his parents picked him up, he started speaking normally once they were in their car.
Oliver had selective mutism– intense fear of speaking to others often associated with social anxiety. He was “scared speechless” about talking to unfamiliar people. Children who have selective mutism may be able to speak normally with family members at home, but become mute in other situations such as school, social gatherings, or restaurants. They may be only able to nod, shrug, or point. They may seem irritable and poorly-behaved in school due to crying, tantrums, hiding under their desks, or running out of the room to avoid speaking.
Ava always wanted to leave her third-grade classroom to go to the nurse’s office. She complained of horrible stomach aches and asked to be sent home. She had another condition beginning in childhood, Separation Anxiety Disorder. Fear of being separated from primary caregivers is normal from mid infancy through the toddler years and generally ends by ages 3-4. Children who continues to fear separation from their attachment figures beyond this developmental stage may have Separation Anxiety Disorder. They fear that something bad will happen if they are away from their primary caregivers. They are terrified of being kidnapped or their parents dying. They may complain of illness to avoid going to school or try to sleep in their parents’ bed. If everyone else in the family is on the first floor of the house, they may refuse to be alone on the second floor. They can also present with tantrums, tearfulness, and irritability when they are away from their family.
In my practice, patients often have more than one anxiety disorder. It’s very common to have a mishmash of different symptoms- panic attacks, generalized anxiety, social anxiety, and trauma history all rolled into one. Anxiety is often associated with depression.
Luckily, most of the treatments are similar. Antidepressants work even better for anxiety than they do for depression. However, psychotherapy is very important. The general premise is “face your fears” Cognitive Behavioral Therapy (see Treatments for Depression section) is a great treatment for anxiety and/or depression. People with Generalized Anxiety Disorder learn techniques to decrease their unrealistic fears. Patients with Panic Disorder learn that the sky won’t fall on their heads if they have a panic attack. If they have agoraphobia, they learn how to gradually increase the time and distance they can tolerate away from their homes.
“William” (fictional) was a 10-year-old boy whose behavior changed over the course of several months. In the previous year, his parents had divorced, he had moved to a new town, and started a new school. He lived with his mother during the week and his father on weekends. He became grumpier each day. Things that never bothered him before now got on his nerves. He started getting into fights with kids at school. He told his mother that “no one liked” him. His grades dropped after he stopped doing his homework. He dropped out of soccer and started spending most of his time in his room. He began breaking household rules. When his mother tried to correct him, he would start crying and say things like, “I hate you,” or, “I wish I was dead.”
William illustrates how depression might look in a child. Depression is more than ordinary sadness. Everyone is sad sometimes. After the death of someone we love, for example, we might be very sad for a very long time, but we should still be able to function in important ways. For human beings, important parts of life are relationships with family and friends, work or school, and play. A depressed adult might have trouble with his or her job, whether working in an office or taking care of a home. S/he might spend less time with family or friends, and/or be crabbier and more irritable around them. Adults who are depressed often look depressed- their faces look sad, they feel sad, and they often cry. They often described a “choked-up” feeling in their hearts.
Severe depression is extremely painful on the inside. Sufferers might be so agitated and anxious that they can’t keep still. Severely depressed people can become delusional and hallucinate– for example, they may feel a bad odor is coming from their bodies because they are rotting inside. Depression can be so painful that sufferers want to commit suicide, similar to patients with severe cancer who want to die to escape the pain.
Rarely, adults become so severely depressed that they no longer look depressed – their faces are restricted and show no emotion at all. They can become so shut down that they are barely functioning at all, unable to eat or sleep. At this stage, they might wish to die, but not have the energy to carry out a plan. They are most at risk for committing suicide in the early stages of treatment, when they have gained just enough energy to carry out a plan, but have not yet gained back the hope to see that their lives can improve. People who do not believe that depression is a medical condition have not spent much time with severely depressed people. Depression clearly affects their bodies and minds. It causes more health problems and disability than does cancer.
Depression looks and feels different in a child. (This is probably why health professionals used to believe that children could not get depressed – now we know that even preschoolers can become depressed.) A depressed child is more likely to be irritable than sad, becoming easily frustrated at minor mishaps. Children, especially before adolescence, often have difficulty identifying their feelings and are more apt to act mad than say they are sad. Friendships and schoolwork, major parts of the life of a child, are what tend to suffer. Children can be so depressed that they wish they were dead, but they usually do not try to hurt themselves.
A Major Depressive Episode is a period of at least 2 weeks in which there are at least 5 of the following symptoms occur most of the day, nearly every day: depressed mood, decreased energy, concentration, or interest in almost all activities, appetite or weight changes when not trying to diet, insomnia or hypersomnia (sleeping too much), psychomotor agitation or retardation, feelings of worthlessness or guilt, and/or recurrent thoughts of death. At least one of the symptoms must be either depressed mood or loss of interest. Children and adolescents can have irritable instead of depressed mood, and failure to gain appropriate weight rather than weight loss. Symptoms must not be due to the biological effects of a substance (such as a medication or recreational drug) or medical condition, or be due to bereavement. Clinicians add various features to the diagnosis of Major Depression, such as whether it is a single or repeated episode, whether it is mild, moderate, severe, or whether it has partially or fully remitted (has improved to the point where it no longer meets the definition for depression).
Persistent Depressive Disorder (formerly known as Dysthymia) is a milder but more chronic form of depression. There must be depressed mood most of the day, for most days, for a period of at least two years for adults and one year for children or teenagers. There must also be at least 2 of the following symptoms: increased or decreased appetite or sleep, decreased energy, low self-esteem, poor concentration or indecision, and/or feelings of hopelessness. Symptoms must not be better explained by Major Depression or be due to the biological effects of a substance or medical condition. Persistent Depressive Disorder is typically not as impairing as Major Depression, but may be more difficult to treat. Symptoms tend to wax and wane, depending on current stressors Cognitive Behavioral Therapy is a particularly important treatment for Persistent Depressive Disorder, since “doom and gloom” cognitive distortions are often associated with it.
Some people have what is termed “double depression”- a more severe Major Depression superimposed onto chronic milder depression. A person with chronic depression may not be able to cope with stressful events, make decisions and feel things will never work out. Major Depression may develop as a result. Often, the Major Depression resolves with medication, but the mild chronic depression remains. Persistent Depression can improve with antidepressants, but may be more difficult to treat. Medication treatments for chronic depression are less well-studied than for Major Depression.
Because depressed children are often irritable, a new category was added to added to the Depression category of the DSM V (a classification system for psychiatric conditions), called Disruptive Mood Dysregulation Disorder. Such children have severe and recurrent temper outbursts disproportionate to the situation. Between outbursts, they are mostly irritable or angry, most of the day, nearly every day for at least one year. Because these children are “moody,” in the past they were often mistakenly diagnosed with Bipolar Disorder and given stronger medication than they needed. When these children grew up they tended to be diagnosed with depression or anxiety disorders, which improved with antidepressant medication and psychotherapy.
Health professionals refer to the wish to be dead as suicidal ideation. Suicidal ideation can be passive or active. Passive suicidal ideation is the desire to die, without any intent to act on it and actually hurt yourself, such as wishing a rock would fall on your head or that the plane you were traveling on would crash. Before adolescence, suicidal ideation is usually passive – children may wish they were dead but not actually try to hurt themselves. However, starting at adolescence, people with depression may develop active suicidal ideation. A person with active suicidal ideation not only wishes to be dead, but has a plan to kill himself or herself. Active suicidal ideation is a medical emergency, akin to a heart attack, and requires immediate treatment.
It can be hard for a non-depressed person to understand the mindset of people who want to kill themselves. Depression can cloud judgement and stop the brain from thinking rationally. Depression can feel like being in a deep hole surrounded by darkness, with no way to climb out. Depressed people can forget what it feels like to be happy, like people who forget they are wearing sunglasses, and believe that the world is dark.
Have you ever had a bad case of flu, where you felt nauseous, tired, and achy? When you were in the throes of it, was it hard to remember how it felt to be healthy? Did it feel as if you would never get better? That’s what depression can feel like- an emotional flu.
I use this metaphor for my depressed patients when they start to lose hope. Just like any other medical condition, depression responds to treatment. Patients can be hospitalized with depression so severe that they are barely able to move. However, within a few weeks of appropriate treatment, their mood and activity levels are normal, and they look back with disbelief at how depressed they were.
Depressed patients need to be reminded that suicide is never a good option. You would not hurt yourself because you were in the throes of a bad flu, and you should not hurt yourself in the throes of depression. Your depression will get better just as the flu does. You will climb out of the hole, take off the dark glasses, and see that there is hope. Most people who try suicide don’t really want to die; they want to escape the pain they are feeling.
Unfortunately, teenagers are particularly prone to “copycat” suicides of acquaintances or celebrities. Even suicide prevention programs or TV shows about teenagers committing suicide may create copycat suicides. This is a tremendous waste- teenagers have the potential to be creative and caring and have so much to contribute to the world. One impulsive action destroys this forever and cuts off what would have been a fulfilling and productive life.
A drawing of a tree can illustrate the potential paths of a depressed patient’s life. Following a healthy path (branch), the patient faces their problems and gets treatment for depression. They lead a fulfilling and productive life. The branch bears fruit (accomplishments, children, etc.) which fall on the ground. The fruit seeds grow into new trees, eventually leading to an orchard. (The person leaves a legacy of family and/or good works.) If the tree is chopped down by suicide, the orchard never grows and the ground remains desolate and empty.
Of course, suicide hurts many more than the person who dies- it is devastating to families, who never get over their sorrow and confusion. It creates a bad ripple effect, making family and friends more susceptible to copycat suicides. (Support groups for family and friends of suicide victims can be helpful in alleviating this.)
Suicidal thoughts must always be taken seriously and never dismissed as “manipulative.” Thoughts and actions are two different things- having suicidal thoughts is not the same as acting on them. However, it is impossible for even the most experienced clinician to predict with 100% accuracy whether a person will commit suicide. Studies have shown that the severity of depression and hopelessness are strongly associated with suicide. Using alcohol or recreational drugs is extremely dangerous, since they may remove a person’s inhibitions against self-harm. A person who begins giving away their possessions, discussing the afterlife or funeral arrangements, saying their friends or family would be better off without them, or saying “goodbyes” is obviously in need of immediate intervention.
If you are a young person who suspects that a family member or friend is considering suicide, what should you do? Tell a trusted adult! This is a secret you do not want to keep. The person will thank you later, even if they are angry now. Tell a parent, teacher, guidance counselor, pastor, or police officer. Just like you would get help if you saw someone hit by a car, get help for your friend who is in emotional pain.
Adults should ensure that a suicidal minor gets immediate medical attention, whether from the treating clinician or a hospital emergency room. All guns, rifles, and/or other weapons should be removed from the home of a child or adolescent with suicidal or violent thoughts, and from the homes they have access to. Even if you keep the weapon locked in one place and the ammunition hidden in another place, and are sure that you are the only person who has access to the key, you are putting your child at risk if you allow the weapon to remain in the house. Do not turn it in to grandparents or neighbors next door whose house your child visits daily-make sure it is far away from where it could ever be used impulsively.
If you are having suicidal thoughts, what should you do? Tell an adult! Tell a parent, teacher, guidance counselor, pastor, or family friend. If you don’t get the help you need, tell another adult. You deserve to have a bright future. Draw your own “tree” of how you want your life to turn out. Copy it onto an index card that you keep in your pocket. When you’re feeling down, pull it out and remind yourself of the future that you can have after you work though this depression.
Remember that the brain is still developing during childhood and adolescence. It does not completely mature until early adulthood. As a result, younger people don’t have the ability to step back and see things in perspective that they will have as adults. The things that seem excruciatingly painful now-being bullied by kids at school, arguing with your parents, getting a bad grade, breaking up with a boyfriend or girlfriend-won’t seem important when you are an adult.
ANYONE WHO NEEDS IMMEDIATE HELP OR FEELS THEY MIGHT HURT THEMSELVES SHOULD CALL 911 OR GO TO THE NEAREST EMERGENCY ROOM. THE NATIONAL SUICIDE HOTLINE IS 800-273-TALK (8255) THERE IS ALSO A LIVE
CHAT AT https://suicidepreventionlifeline.org/
Health professionals used to differentiate between “reactive” and “biological” depressions – the former felt to be due to stress, and the latter, to heredity. There is no longer felt to be a meaningful difference. Trying to separate the two is like trying to decide whether the chicken or the egg came first. As with many conditions in psychiatry, depression is felt to be due to a combination of “Nature and Nurture”- the combination of genetics and environment. The stronger the inherited (genetic) tendency to depression, the less stress is required to trigger a depressive episode. Genes are the building blocks of the body. They tell the body how to arrange itself, as an architect’s blueprints tell how to construct a house.
Picture yourself sitting on a mat made of twigs covering a dirt pit. The mat is a family heirloom, passed down from generation to generation. Suddenly, monkeys start throwing coconuts at you. The mat symbolizes your resistance to depression. Coconuts symbolize stressful life events. The mat weakens each time a coconut (stressor) smashes onto it. If the mat breaks, you fall into the pit of depression. Splat! Your best friend moved away. Splat! Your dog died.
Splat! Your parents divorced. A strong inherited mat can withstand several coconuts without
breaking. A weaker mat will take fewer coconuts to break. Of course, if you are very lucky, you inherited a cement mat, and no amount of coconuts will break it-you will not get depressed no matter how much stress you experience. Even if you have a weak mat, you may still be lucky and avoid the pit by not being hit with any coconuts. If you are very unlucky, your mat is very weak, and will break without any coconuts dropping on it-you will get depressed despite no major stressful life events. Treatment for depression is the ladder you build that allows you to climb out of the pit. Psychotherapy techniques are like expert courses in mat making. They teach you the tools to prevent your depression from returning.
A New Zealand study from 2003 may help explain the how the combination of genetics and stress leads to depression. Scientists found that differences in the gene that controls serotonin transportation in the brain were associated with vulnerability to depression. The body carries two copies of each gene, one from each parent. There can be either a “long” or “short” version of the serotonin transporter gene. This gene produces the protein that recycles serotonin from the nerve synapse back into the presynaptic nerve. The short version of the gene makes a less efficient serotonin transporter protein.
The scientists tracked the number of stressful life events of 847 people between the ages of 21 and 26 in 847 people. They found that people who had two “long” versions of the gene (31%) were much less likely to develop depression even if they had gone through many stressful events-only 17% developed depression. People with two copies of the “short” version of the gene (17% of the study population) had the highest incidence of depression when under stress- 43% developed depression. People with one short and one long version of the gene (51%) had an intermediate incidence of depression-33% became depressed (Caspi, et al., Science, July 2003). The “long” versions of the gene are like the strong “mats” that protect against falling into the “pit” of depression.
A common way to determine how much of a condition is inherited and how much is due to the environment is with twin studies. The scientific term for identical twins is monozygotic-they come from the same fertilized egg and share the same genes. Fraternal twins are dizygotic-they come from two different fertilized eggs and share only half of the same genes, the same as if they were regular siblings. (The most information can be obtained from identical twins who were raised apart from each other. Since they have the same genes, any differences between them are due to the environment.) Heritability is calculated by analyzing the difference in frequency that a trait is seen in monozygotic vs. dizygotic twins. The bigger the difference, the bigger the contribution of inheritance.
Suppose that I’ve discovered a trait called Bubblitis-laughing uncontrollably when a soap bubble lands on your nose. I would like to see how much of Bubblitis is due to inheritance, and how much is due to environmental factors. I study groups of twins, and find that if one twin pair has Bubblitis, the other twin also has it in 100% of the cases when the twins are identical.
However, for fraternal twins, if one twin pair has Bubblitis, the other twin has it in only 50% of the cases. This tells me that Bubblitis is strongly inherited, with virtually no influence from the environment. However, if identical twins and fraternal twins both have almost the same incidence of Bubblitis, this tells me that Bubblitis is most likely due to environmental influences with virtually no genetic contribution. Perhaps when the twins were babies, their parents laughed as they blew bubbles onto their noses, teaching them that bubbles on the nose were funny.
A Swedish study found that heritability of major depression was higher for women (42%) than men (29%). However, environmental factors still contributed more than half the risk for depression (Kendler, Kenneth et al., American Journal of Psychiatry, Jan 2006).
Is depression inherited or is it due to stress? Health professionals used to differentiate between “reactive” and “biological” depressions- the former felt to be due to stress, and the latter, to heredity. There is no longer felt to be a meaningful difference. Trying to separate the two is like trying to decide whether the chicken or the egg came first. As with many conditions in psychiatry, depression is felt to be due to a combination of “Nature and nurture”- the combination of genetics and environment. The stronger the inherited (genetic) tendency to depression, the less stress is required to trigger a depressive episode. Genes are the building blocks of the body. They tell the body how to arrange itself, as an architect’s blueprints tell how to construct a house.
Picture yourself sitting on a mat made of twigs covering a dirt pit. The mat is a family heirloom, passed down from generation to generation. Suddenly, monkeys start throwing coconuts at you. The mat symbolizes your resistance to depression. Coconuts symbolize stressful life events. The mat weakens each time a coconut (stressor) smashes onto it. If the mat breaks, you fall into the pit of depression. Splat! Your best friend moved away. Splat! Your dog died.
Splat! Your parents divorced. A strong inherited mat can withstand several coconuts without breaking. A weaker mat will take fewer coconuts to break. Of course, if you are very lucky, you inherited a cement mat, and no amount of coconuts will break it-you will not get depressed no matter how much stress you experience. Even if you have a weak mat, you may still be lucky and avoid the pit by not being hit with any coconuts. If you are very unlucky, your mat is very weak, and will break without any coconuts dropping on it-you will get depressed despite no major stressful life events. Treatment for depression is the ladder you build that allows you to climb out of the pit. Psychotherapy techniques are like expert courses in mat making. They teach you the tools to prevent your depression from returning.
A New Zealand study from 2003 may help explain the how the combination of genetics and stress leads to depression. Scientists found that differences in the gene that controls serotonin transportation in the brain were associated with vulnerability to depression. The body carries two copies of each gene, one from each parent. There can be either a “long” or “short” version of the serotonin transporter gene. This gene produces the protein that recycles serotonin from the nerve synapse back into the presynaptic nerve. The short version of the gene makes a less efficient serotonin transporter protein.
We can see differences in the brain of depressed and non-depressed people through special tests.
One test used for psychiatry research is the PET study-Positron Emission Tomography. This is a machine that measures body tissue metabolism. All body tissues use glucose, a naturally occurring sugar. A person having a PET study is injected with a tiny amount of radioactive glucose. (The amount of radiation is no more than that of an ordinary X ray.) The PET scanner measures how the brain uses the radioactive glucose. The person being tested is awake and alert, lying on a couch with only his or her head in the machine. S/he may be given a task to do, such as looking at pictures or reading a book. This provides a working map of how the brain is functioning.
Another test used in research is functional magnetic resonance imaging (fMRI). MRIs measure magnetism in the body’s molecules. This method takes advantage of the fact that blood flow to the brain changes with brain activity. The blood vessels bring oxygen to the brain and release it into the tissues to provide the brain with energy. Blood with and without oxygen have different types of magnetism that can be measured by the MRI machine. MRI machines use a
PET Scan Images of Depressed vs. Non- Depressed Brain magnetic field to provide detailed pictures of bodily tissues. If a person performs a task while being measured in the fMRI machine, the part of the brain that performs the task can be localized.
An MRI machine is a large magnet shaped like a tube. The patient must lie very still in the tube for several minutes to get an accurate picture. It is not physically painful, but some people become anxious and restless enclosed in a small space for so long. Patients cannot wear metal in the MRI tube due to the strong magnetic field, even heart pacemakers or hair clips.
What parts of the brain are responsible for depression? Studies have found abnormalities in the prefrontal cortex and limbic system (hippocampus, striatum, amygdala, cingulate gyrus and thalamus).
The prefrontal cortex is a very important brain region. It’s located at the very tip of the brain, just behind the eyes and forehead. This is the area of the brain that controls impulses, sexual behavior, language, working memory, and socialization. Executive functioning is contained in this area. This includes the ability to problem-solve, choose the best option among many choices, control impulses, plan, control and perform a behavior, recognize future consequences of current actions, chose between good and bad actions, suppress bad social responses, delay gratification, determine similarities and differences, and adapt to new situations. For example, if I told you to get together a group of friends and plan the party of the century with an egg, a trampoline, and some tissue paper, you would need your executive functioning to carry this off!
The prefrontal area contains many connections with the limbic system, the area buried deep within the brain that regulates emotions, learning, memory and stress response. Areas of the limbic system include the hypothalamus, pituitary gland, hippocampus, amygdala, cingulate
gyrus, and parts of the thalamus. The amygdala is involved in emotions, learning, and memory, particularly fear and anxiety. It is a type of “alarm system” for the body, alerting it of danger. The hippocampus helps to form and store long-term memories. The cingulate gyrus helps process conscious emotional experiences. The thalamus is a “gatekeeper” that receives messages from the senses and transmits the important ones to the cerebral cortex. It also receives information from the cerebral cortex and sends it to the brainstem and other parts of the brain.
The hypothalamus regulates functions such as sleep, appetite, sexual interest, body temperature, and pituitary gland activities. It releases a hormone (corticotropin-releasing hormone, or (CRH)), that causes the pituitary gland to release a second hormone (adrenocorticotrophic hormone (ACTH)) that causes the adrenal glands to release cortisol, the stress hormone we mentioned earlier. Cortisol is part of the body’s “fight or flight” reaction that helps us when we need to move quickly when we are in danger by increasing blood pressure and blood sugar.
Psychotherapy alone is recommended for mild to moderate depression. A combination of psychotherapy and an antidepressant is recommended for severe or psychotic depression, or depression that hasn’t improved despite psychotherapy. Antidepressants are not recommended for minors with a type of bipolar disorder called rapid-cycling (at least four episodes of depression or mania in one year).
After the depression has resolved, patients should remain in treatment for a minimum of 8-12 months to decrease the likelihood of a recurrence. If antidepressants were prescribed, they should be maintained at their current dose.
When should a child or teenager be hospitalized? When it is too dangerous for them to remain in their current environment. This generally means when young people are having serious thoughts of hurting themselves or others, but can also be appropriate when young people repeatedly run away, cut or otherwise mutilate themselves without intent of death, set fires, or need detoxification from alcohol or recreational drugs. Patients and families should know exactly how to contact their clinicians in an emergency. If they are not under the care of a clinician or can’t get in touch with him or her, they should call 911 or go to their nearest emergency room. It is always better to err on the side of caution. Psychiatric hospitalizations are usually very brief, sometimes 72 hours. The purpose is to provide a safe environment while helping the patient to become stable enough for outpatient treatment. There are day treatments or partial hospitalization programs for patients who don’t need to stay in a hospital overnight but need more than weekly or twice weekly psychotherapy. These meet for several hours a day several days per week.
Psychotherapy, or counseling, is an important treatment for depression. One example of a psychotherapy that has been shown to improve depression and anxiety in children through adults is Cognitive Behavioral Therapy (CBT).
How does Cognitive Behavioral Therapy work? The therapist helps the patient to become a detective and uncover underlying themes or schemas-ways of perceiving the world that lead to depression. Certain ways of thinking lead to depression. For example, a basic schema many depressed people have is “I’m a bad person.” “I’m unlikable.” This idea is usually buried in the back of the mind, out of conscious awareness, and becomes a self-fulfilling prophecy- it perpetuates itself. For example, people who think, “nothing will ever work out for me” avoid taking risks and trying new things since they are afraid of failure. Children might not try to make new friends or participate in a sport or the school play. They end up with few friends and few activities. They see other kids having fun and think, “See, everything works out for everybody else. Nothing works out for me.” It’s like going around and round on a merry-go-round (rather, a “sad-go-round”) when you’d rather be riding the go-carts.
These are called cognitive distortions– seeing the world in a distorted way that leads to depression. The treatment is to be a scientist, uncover the schemas, and find alternative beliefs.
Scientists have been unraveling schemas for thousands of years. For example, the belief that the sun revolved around the earth is an idea that existed for thousands of years. It seemed perfectly obvious- the sun can be seen rising above the earth in the morning and dipping below it in the evening. It took Copernicus to ponder, “wait a minute, is there another explanation of why the sun goes over the horizon at night? He did some research and deduced that the earth was not the center of the universe. This was a major shift in belief.
Similarly, therapists will help patients to uncover the schemas that are perpetuating their depressions. For example, “Noah” (fictional) was a 12-year-old boy with the schema, “nothing ever works out for me.” He used the “D” on his spelling test as proof of this. His therapist, Dr. Taylor, helped him with an alternative explanation. It turned out that Noah didn’t study for his spelling test, because he thought, “What’s the use, I’ll just fail anyway because I fail at everything I try.” Dr. Taylor helped him identify the sadness associated with this thought.
Together they came up with examples of things that had worked out for him – a successful social activity, an attractive art project, a good math grade. Hardest of all, he left his session with a homework assignment-to try something new to test the new belief that he could succeed.
The therapist helped him come up with a task he could probably succeed at with a little effort to build up his confidence. His goal was to study for his next spelling test to get a grade higher than a D. Noah studied for his spelling test, and got a B. His schema that nothing ever worked out for him was challenged, and he was developing a new belief, “things can work out for me.” Dr. Taylor also helped him to see that it was okay even if his tasks weren’t always successful.
The sky wouldn’t fall on his head and the world wouldn’t end if he got another D.
The human brain is “wired” to socialize. Humans have always relied on social networks for survival. Before modern technology, people needed to be allied in groups to protect themselves from intruders and divide the work. Modern technology has resulted in an improved quality of living, but also has allowed people to isolate themselves in ways that were not possible for thousands of years. Spending all of your free time with your TV, computer, or video games may be seem like fun, but can cause a lot of problems in the long run, since you’re not getting real human contact. Real human interaction will help depression.
Healthy living strategies are the best treatment for depression, often recommended in addition to other treatments. These include regular exercise, a regular daily schedule, and a Mediterranean-type diet. Sleep hygiene is very important- bedtime at the same time every night, using the bedroom only for sleep or relations with partners, no electronics within 2 hours of bedtime, exercising during day but not close to bedtime, ensuring bedroom is dark and quiet at night. Being exposed to light in the morning and darkness in the evening has also been shown to help depression.
There is some evidence that certain vitamins and supplements can help mood.
Other non-medication treatments include phototherapy, Repetitive Transcranial Magnetic Stimulations (rTMS), and Electroconvulsive Therapy (ECT). Phototherapy is a mild but often effective treatment involving sitting in front of a light box for approximately 30 minutes every morning. The light box must be at least 10,000 lux (a measure of brightness). This is a common treatment for Seasonal Affective Disorder, a type of depression that tends to get worse in the fall and winter and better in the spring and summer. Seasonal Affective Disorder can be unipolar or bipolar. Patients with bipolar disorder may become manic or hypomanic in the spring and summer. Phototherapy is a common treatment for seasonal bipolar disorder since it is less likely to trigger mania than antidepressants do. If mania occurs phototherapy must be stopped.
rTMS is a fairly new, safe procedure in which magnetic pulses are applied to the prefrontal cortex of the brain, in the area thought to involve depression. Treatments are typically given 5 days per week for 4-6 months. Sessions usually last 30-45 minutes and have minimal side effects. The most common are temporary headache or face tingling. Rare side effects are temporary hearing loss (minimized by earplugs) or seizures. Because of the magnets, people with any metal in their head or necks (excluding braces or fillings) should not receive this treatment. Side effects are usually so minimal some people schedule sessions on the way to work. Because of the expense, rTMS is unlikely to be covered by insurance without 2 failed medication trials.
Electroconvulsive Therapy can be an extremely effective but frequently misunderstood treatment in which seizures are induced in the brain. The body is relaxed and does not manifest the seizure. The main risks are from the general anesthesia required. Despite its scary portrayal in old movies, it is usually very safe. The biggest side effect that I have seen is memory loss during the period it is given. During my inpatient psychiatry residency, it was a life-saving treatment for severely depressed patients. People would be hospitalized so depressed they could barely eat or move. Within a few ECT sessions, they would appear bright, motivated, and back to themselves.
Avoiding recreational drugs and excessive alcohol is another way to avoid depression and anxiety. Alcohol is a central nervous system depressant and can cause depressed mood and increased anxiety if consumed excessively. The recommendation of the. Is no more than one alcoholic drink per day and no more than 7 per week total for women and no more than two per day and no more than 14 total per week for men. Alcohol is spread throughout the bloodstream and can have ill effects on the brain, liver, kidneys, gut, and any other of the body’s organs.
People who abstain from alcohol can notice their mood improving within 2 weeks. People who drink excessively daily should be monitored by a physician since stopping abruptly can be dangerous for a heavy drinker.
Although marijuana is often labeled as “medicinal,” uses are still being investigated and there is no concrete evidence to date that it helps with any psychiatric condition.
There is also no data showing it to be safe when combined with medication. It can cause weight gain and poor motivation and concentration. Products are usually more highly concentrated than they were in the 1970s and therefore more addictive, with a strong withdrawal syndrome. People who use marijuana then abruptly stop can soon feel the opposite of how they felt when high- irritable, anxious, agitated, unable to eat or sleep. They consider this evidence that the marijuana has been helping them, not realizing their symptoms are part of a withdrawal syndrome. Marijuana is thought to be very harmful to brain development of youth under age 25.
A psychiatrist treating a patient for depression must make sure the depression is unipolar, or garden-variety depression, and not bipolar, in which episodes of mania also occur. This is a fictional example of a patient with bipolar disorder:
“Liam” was a 19-year-old college student who was arrested for shoplifting. He had walked out of a department store with a shopping cart full of TV sets. He explained to police in rapid- fire speech that it was okay for him to take the TVs because he was going to make millions of dollars for the department store by writing, directing, and starring in a movie that featured the store. The TVs were for distribution to his future adoring fans, who would watch the movie on TV. He had stayed awake for the past 3 nights writing the script. The “script” that he handed the police had illegible scribbles and symbols written all over it. However, his enthusiasm was so infectious, that the police almost believed him and were half-ready to release him.
Liam’s history was significant for an episode of depression five months prior, shortly after starting an out-of-state college. He had been sad and homesick, and spent most of his time crying in bed. He had stopped going to classes or talking to his friends. He had even considered suicide. He eventually saw a campus doctor, but did not tell him that his mother had taken Lithium for Bipolar Disorder, because this had always been a source of embarrassment for him. He was given an antidepressant. Over the next several days, his depression had improved so much that he stopped his medication and did not show up for his mental health appointments. Now he was feeling “marvelous-never better.”
Liam illustrates the case of a person with classic bipolar disorder- distinct episodes of depression and mania. You may have heard depression referred to as a mood or affective disorder. Mood refers to the way a person feels inside. Affect refers to the expression on a person’s face. Since depression deeply influences mood and facial expression, affective disorder and mood disorder are both appropriate classifications for it.
Depression is not the only condition that affects mood or facial expression. Some scientists believe that mood exists on a spectrum. At one end of the spectrum, or pole is depression. What would be at the opposite pole? Instead of a “down,” depressed mood, there exists an extreme of “up,” elevated, elated mood, called euphoria. These “up” moods are called mania. A person who experiences only depression is said to have Unipolar Depression. People who experience mania suffer from Bipolar Disorder. They have the potential to experience both poles- extreme sadness or euphoria. A normal, healthy, stable mood that is neither depressed nor manic is termed euthymia. (If Goldilocks had Bipolar Disorder, euthymia would be the “just right” mood.) Unfortunately, research has indicated that many people with Bipolar Disorder spend relatively little time euthymic and the majority of the time depressed.
What’s wrong with feeling euphoric? Nothing, if you’re riding a roller coaster or just got a puppy for your birthday. In those situations, it’s normal to feel elated. However, if you’re supposed to be sitting in math class learning long division, breaking out in uncontrollable laughter because you feel euphoric can cause problems for you.
Unfortunately, mania is associated with more than euphoric mood. In many cases, particularly in younger people, a manic mood is not euphoric but extremely irritable and unpleasant. This feeling is often called dysphoria.
Just as depressed people may feel slowed down, apathetic, and unmotivated, manic people feels speeded up and restless. Their thoughts and speech are rapid, their energy and activity levels are increased, and their need for sleep is decreased. It may be difficult to understand them as their speech struggles to keep up with their thoughts. They may quickly change topic in mid-sentence and go off on a tangent-indicating tangential thinking. They are often grandiose-they have an inflated belief in their skills and accomplishments. Unfortunately, they tend to act impulsively with risky behaviors, heedless of the consequences. A manic adult may spend excessive money, have unprotected sex with multiple partners, or race a car well above the speed limit. A person with irritable, dysphoric mania is at risk for arguments and physical fights. A person with severe mania may develop disorganized thinking and become delusional and psychotic. They may hear voices and/or falsely think that there is a special plan in place for them, whether arranged by G-d, space aliens, or the FBI.
It is very important to distinguish unipolar from bipolar depression. People with bipolar depression can become manic if they take antidepressants. They must take a different type of medicine, mood stabilizers (lithium, certain anti-seizure medications, and/or neuroleptics) to treat mania. Antidepressants may be considered later if they still have depression despite their mania having resolved on a good dose of a mood stabilizer. A patient presenting to a psychiatrist with depression will be carefully screened for bipolar disorder to ensure the right type of medication is given.
Some people have a perception that doctors are in the hands of “big business” and conspire with pharmaceutical companies to create psychiatric conditions and put patients on medication for profit. (Psychiatrists in particular may be portrayed rubbing their hands together with glee, eager to experiment on children with “mild-altering” drugs.) There is little concrete evidence to support this. Think of the mindset of a doctor who goes into research. Although most physicians make comfortable salaries, there are far more profitable ways to earn a living. It takes a particular personality to make it through the rigors of medical school. One must enjoy science and have a strong measure of self-discipline. Despite the cliché, most people who graduate from medical school genuinely want to help people and take pride in seeing patients improve under their care.
It takes a very special person to go even further by giving up the comforts of a clinical practice in favor of academic research. It is well known that the scientist sacrifices salary for the opportunity to make new discoveries and aid research. People who are primarily interested in financial profit would be foolish to attempt a research career. Discoveries are slow to occur, and any profit goes to the institution supporting the research. Scientists are curious about how the world works and are much more interested in discovering the truth. Because their academic reputations are critical to their careers, they guard them painstakingly.
It is also an unfortunate fact that funding for research from government institutions has been cut dramatically over the past several years. Most researchers by necessity must rely on support from pharmaceutical companies for their research. They are typically on multiple panels from different companies with competing medications. This is disclosed during academic presentations and in journal articles. Researchers who changed their research findings to make profits for pharmaceutical companies would almost certainly be discovered and discredited.
Their academic careers would be over.
Of course, some unethical people do become physicians, just as they become teachers, police officers, lawyers, business people, and any other type of professional. It is these people who tend to be highlighted in the media, and not the millions of hard-working, caring individuals who quietly go about their lives trying to make a positive difference for others.
“I have the boss from hell,” Kara told her psychotherapist at the beginning of treatment. Kara had been experiencing poor self-esteem, sleeplessness, and constant worry since she started her new job as an assistant to Mr. E, a junior vice president. On her first day, he greeted her with “My old assistant was completely incompetent. She couldn’t take the heat. I hope you’ll do better. I’m the star of this company and I’m so good I can make anyone shine. Most of the assistants I’ve trained moved on to top positions-
Apple, Google, Amazon, you name it.”
Kara became demoralized and bewildered working with Mr. E. Not only was she not shining, it seemed she couldn’t do anything right. Mr. E constantly criticized her, saying, “My 2 year old could do a better job!” Once, he became enraged at a typo and ripped up her presentation, screaming, “Are you deliberately trying to make me look bad- how dare you give me this crap!” When he wasn’t yelling, he would stare at her chest rather than look her in the eye and make her do tasks that weren’t in her job description, like cleaning his bathroom. When she tried to protest, he’d say, “You’re not one of those snowflake millennials, are you? Don’t bother to complain to HR. You’ll be the one who gets fired. I’m much too valuable to this company.”
This is a fictional composite of a supervisor with narcissistic personality disorder, an unhealthy coping strategy with the theme, “Be better than the peasants.” People with narcissistic personality disorder make others feel small so they can seem tall. True narcissists never developed a healthy ego in early childhood to give them an internal sense that they are okay. Deep in their subconscious, they feel damaged, inferior, empty. To avoid this feeling, they frantically try to prove that they are superior beings to whom ordinary rules don’t apply.
The definition of narcissism is self-love. Narcissus was a character from Greek mythology who was so entranced with his reflection in a pool of water that he pined away in despair because it could never be his lover. His lasting contribution was the yellow narcissus flower that sprang up where his body withered and died. Narcissistic personality disorder is similarly self-destructive.
Some narcissism is healthy and normal. Having a feeling of self-worth helps us to survive and thrive. Humans are born narcissistic. Babies are aware only of themselves. They perceive that their environment exists solely to fulfill their needs. When they are hungry they cry and get fed. When they are wet, their diapers are changed. Other humans are not real; they are mechanisms to feed and comfort them.
As children age, they become increasingly aware that others exist independently, with their own needs. Their narcissism decreases, but is still present and adaptive. Children at the pool who yell to their parents, “Look at me! Watch me do a handstand!” are unknowingly using narcissism in a healthy way. If adults didn’t notice them, they could drown, or in ancient times, be dragged away by a wolf.
Teenagers tend to grow less narcissistic and more altruistic. Significant brain changes normally occur during puberty to allow the concept of helping others because it is the right thing to do rather than for personal gain or to obey the law. However, healthy narcissism still plays a role. Teenagers tend to feel that they are special people with a special destiny. Confidence in their abilities motivates them to strive to make the world a better place, sparking the drive to become writers, scientists, innovators, healers.
Narcissism becomes a disorder when it is an adult’s go-to coping strategy, harming relationships with coworkers, family, and friends. Malignant narcissism, the most severe form, includes antisocial behavior such as treating people like suckers to be swindled, and conversely, fearing that others will swindle them. Malignant narcissists may obtain business success because they cut corners, break rules, and take advantages that more ethical people would not. It can be very difficult to work with narcissists since they deprecate and exploit underlings and become enraged with perceived criticism. They take credit for other’s accomplishments, and blame others for their own failures.
Malignant narcissists lack the ability to care what others feel. People are tools to exploit. They view their children not as real people but as narcissistic extensions of themselves, and try to force them into roles meant to bring glory to the family. They become harsh, critical, and rejecting if their children fail to do so.
Beyond immediate family, they feel good only in relation to making other people seem inferior. They thrive on praise, admiration, and applause. If not readily attained, they may tell outrageous exaggerations or outright lies to appear superior. It doesn’t matter if it isn’t true, as long as it makes them seem better than others. For example, if narcissists learn where their colleagues went to college, they may say that they were accepted to that same college with a full scholarship, but turned it down because their own college begged them to attend to be captain of the tennis team. If they learn that someone else’s child scored an A on a math test, they will claim that their child does college level calculus. They also find ways to denigrate others’ accomplishments: “So what if he got a Purple Heart – it doesn’t mean he was brave, just that he got injured.”
A malignant narcissist is an emotional vampire, sucking up all the good will in the room. Being exposed to a narcissist, even if only listening in on the conversation, may leave one feeling emotionally exhausted, vulnerable and frustrated. Narcissists may have spent the conversation bragging about themselves and making emotional digs at others. If they sense vulnerability, they will attack further. For example, if a colleague says, “I must be getting old; I’m so winded walking up the stairs,” they might reply, “Really? It was so easy for me; I could do it ten more times and still be bursting with energy.”
What happens if their sense of superiority is threatened? The same thing that happens when a balloon bursts- it flies randomly across the room, creating noise and chaos. Malignant narcissists will become enraged and try to do as much damage as possible to prop up their sinking egos. If fired from a job, they may try to sabotage the work environment for their successor to prove that they were the better employee.
If unable to salve their ego, they become deflated balloons. They experience inverse narcissism- they are a special person with special problems no one else could possibly comprehend, a misunderstood genius, with the world against them; if only they worked in a better environment where their accomplishments could have been truly appreciated. They withdraw and become depressed and anxious.
Ironically, in this state, they can most be helped. It is normally very difficult to motivate narcissists to change their behaviors. They perceive that the rest of the world, not them, has the problem. However, they may seek treatment to help with the painful feelings of depression, anxiety, and isolation that resulted from their narcissism. They cannot be directly confronted- they will become enraged and storm out of treatment. A skilled psychotherapist can ideally teach them to feel good about themselves without making others feel badly. Optimally, they can be convinced of the advantages of following social norms and treating others with respect. If not helped, narcissists will eventually repeat the same maladaptive patterns and find a new venue and audience, like a seductive vampire seeking fresh blood.