This series of articles highlighting specific mental health issues, written by a Family Guidance Center psychiatrist, was published by NJN Publishing as a public service to the residents of Warren County.

Depression

Vincent Van Gogh was haunted by crows over the wheat fields, ominously painting them in oils shortly before he committed suicide. Depression, which effects one out of ten men and one out of five women, was closeted in those days behind shame, ignorance, and ineffective treatments. Today, famous people such as author William Styron, 60 Minutes broadcaster Mike Wallace, and Vice Presidential Wife Tipper Gore are outspoken advocates for mental health treatment. This is because they have suffered from depression themselves and know personally how detrimental mental illness can be.

Despite the enormous advances in treatment since the days of the French impressionists, many people understandably don't recognize depression when they experience it, and still feel stigmatized in seeking treatment for it. This is really a residue from the incorrect notion that mental illness is a weakness or inherent personality flaw. Remarkable advances in research have clearly demonstrated that depression, and other mood disorders, are caused by complex abnormalities in brain neurotransmitters, chemicals that are responsible for thoughts and emotions. These changes can be brought about by a myriad number of stressors, ranging from pivotal life events such as the death of a loved one, or even positive life changes such as promotions or desired geographic moves. Sometimes these chemical changes can occur when there are no obvious environmental stresses at all.

A lead article in the annual Education Life section of the January 2002 New York Times highlighted the extent of depression among college students. This has become such an important topic that the University of Michigan recently sponsored the first ever conference on college student depression. Terrorism, war, fragmented families, the poor economy, and increased competition for jobs are all placing enormous pressures on high school and college students. Many students, who would never have had the mental stability to attend college in the past, are now able to attend due to the sophisticated diagnostic tools and powerful medication treatments available to combat depression.

Depression, like diabetes, high blood pressure, and high cholesterol, is first and foremost a medical condition. There are specific criteria to diagnose depression and a multitude of effective treatments to address it. The symptoms of depression may vary from individual to individual, but usually include a constellation of consistent symptoms. Low energy, decreased interest in outside activities, a significant change in appetite, low sexual drive, withdrawal from friends and family, increased or decreased sleep, awakening early in the morning and being unable to return to sleep, thoughts of death and suicide are all hallmarks of this illness. A particularly dangerous type of depression, postpartum depression, which occurs in women after giving birth, is frequently associated with. severe suicidal thoughts. If left untreated, depression can severely impact an individual's relationships and employment. It can even lead tragically to suicide. This is why it is crucial to seek trained medical attention immediately.

The two most important and highly effective treatments for depression are medication treatment and psychotherapy. Psychotherapy, also known as talking therapy, allows for an in depth evaluation of the psychological forces that might contribute to an individual's depression. While some of these are issues that the individual might recognize, others might be out of one's awareness, and might require a highly skilled therapist to discover and treat. For example, some people with depression might be aware that they are in a self destructive job or relationship. They may not recognize, however, that there is a pattern of repetition to such liaisons, and may need assistance in sorting out what the self destructive motivations are that might contribute to harmful personal and professional encounters. Cognitive therapy, one of the many types of psychotherapies, examines the way an individual thinks about his life, and addresses the distortions that might contribute to depression. Some people, for example, might exaggerate failures unrealistically, subsequently becoming highly self blaming. Reality testing and learning how to put defeats in perspective are skills that being in therapy can strengthen.

The medication treatments involve the prescription of a pill by a trained medical doctor, usually a psychiatrist, who specializes in treating individuals with mood disorders. Since depression is caused by a change in the chemical balance of the neuro, or mood, transmitters, the antidepressants are pills that correct this underlying imbalance and restore the individual to normal mood and functioning. If left untreated, a depression can take upwards of a year or more to spontaneously resolve. With medication treatment, depression usually resolves within two to four weeks. Sometimes longer time periods are required. Once a person's mood has returned to normal, he or she should remain on the medication for an extended period of time that will be discussed with the doctor.
While many medications have side effects, these are usually short term and are often mild. Many individuals don't experience any side effects at all. Interestingly, many of the medications used to treat depression have potential benefits for other conditions. For example, Wellbutrin, an antidepressant that is often helpful for individuals who suffer from low energy and melancholia, is a very effective anti-smoking medication. Antidepressants that increase brain serotonin, a chemical that is sometimes decreased in depression, also often reduce pain syndromes such as migraine headaches or chronic pain. Even sleeping disorders, not associated with the classic symptoms of depression described earlier, often resolve completely with antidepressant medication.

Individuals from all walks of life can develop depression. It has been historically documented that Presidents Lyndon Johnson and Abraham Lincoln have suffered from depression. Academics, lawyers, doctors, carpenters, salespeople, fathers, mothers, brothers and sisters are all susceptible to developing this sometimes deadly disease. Fortunately, if recognized and treated, an individual can resume his life with the same vitality and ability that preceded the depression. This is why it is so important to seek treatment, and to recommend treatment for friends and loved ones who may not recognize the symptoms alone.

Bi-Polar Disorder

Starting a novel in the morning, incorporating two new businesses by noon, claiming to one’s closest friends the likelihood of being the front runner for United States President in the afternoon, and spending thousands on clothes before supper are actions one equates with a wealthy and powerful Fortune 500 CEO. Such behaviors may also reflect the devastating symptoms associated with the disease known as Bipolar Disorder.

This disease, once called Manic Depression, is an illness that may alternate between what are called manic episodes and depressive symptoms. Bipolar disorder often presents with a manic episode, a symptom cluster characterized by rapid speech, racing thoughts, increased energy, decreased need for sleep, spending sprees, sexually provocative actions, and other risky behavior. Individuals in the initial stages of mania often feel invincible, and believe that they possess unlimited powers or unique abilities. They may lose touch with reality altogether and literally destroy their family life and their work life through extraordinary, self-destructive behavior. It almost always requires hospitalization unless diagnosed early and treated very aggressively. Although mania often feels good to individuals who experience it, mania can also be associated with a subjective sensation of irritability and aggression. Individuals in a manic state may therefore be more prone to act impulsively. Hypomanic episodes may also be a component of bipolar disorder. These episodes are comprised of symptoms similar to manic symptoms, although the degree is not as severe.

The depressive episodes, as described in last week’s column, are often characterized by sadness, withdrawal from friends and family, loss of interest in outside activities, increased or decreased appetite, increased or decreased sleep, awakening early in the morning, decreased ability to concentrate, difficulty with memory, and suicidal thoughts. Not every individual diagnosed with bipolar disorder suffers from these depressive episodes. Sometimes these individuals experience only manic or hypomanic episodes.

The treatment for mania consists of medications known as mood stabilizers. These medications are often the same ones used to treat seizure disorders. That is because manic episodes are thought to be caused by the same electrical discharges in the brain that cause seizures. Depakote, one of the most common medications prescribed for mania, has a known therapeutic level in the bloodstream. It is not normally present in the blood. However, once started on Depakote, psychiatrists monitor for that known therapeutic level. Although blood testing is necessary, usually blood needs to be drawn only twice per year after a therapeutic level is reached. This testing reevaluates whether Depakote is at the therapeutic level, and also checks what are known as liver enzymes and a blood count. Liver enzymes, chemicals produced by the liver, can sometimes be elevated when individuals take Depakote. This is usually only a problem in younger children and in individuals who drink alcohol. Depakote can sometimes lower blood counts, so it is an important baseline test to obtain. The vast majority of individuals tolerate Depakote well.

Other antiepileptic drugs used to treat mania include Trileptal, Carbamazepine, Gabitril, and Topomax. Lamictal, an antiseizure medication currently in use, is being evaluated by the FDA to determine if it is suitable for use in Bipolar disorder. Many of these medications are also effective for the treatment of pain and migraine headaches.

The antiepileptic drugs usually take one to three weeks to stabilize a manic mood. Therefore psychiatrists will often prescribe what is known as a major tranquilizer, or antipsychotic, during the initial stages of mania to more quickly balance the mood disorder. Once the mood is stabilized, and the antiepileptic drug has had an opportunity to become effective, the major tranquilizers are usually tapered and discontinued.

Lithium, another highly effective treatment for bipolar disorder, was once used as table salt before its medicinal properties were known. Like Depakote, Lithium also has a known therapeutic blood level. Many patients have read or heard that a chemical imbalance is responsible for mood changes in depression. Unfortunately, there are no available tests at the present time to check for this imbalance. In addition, an individual who is not already taking Lithium or Depakote for a mood disorder will not have any in their blood stream. These medications can only be measured in people who are taking them. Fortunately, once a person is taking these medications, they can be measured in the blood and the dose can be adjusted based upon the blood levels.

Antidepressant medications are used to treat the depressive component of this illness. Serotonin, a neuro transmitter responsible for thoughts and feelings, is thought to be decreased in the brains of depressed individuals. Medications that increase serotonin, such as Zoloft, Paxil, Celexa, Prozac, and Lexapro are used to treat depression. Other medications, such as Effexor, increase both serotonin and norepinephrine, another neurotransmitter thought responsible for depression. Wellbutrin, a medication that acts on a neurotransmitter called dopamine, is also used to treat depression. One of the primary concerns in treating depression in bipolar patients is the risk of making the manic symptoms worse. This is because an antidepressant may raise an individual’s mood too high, particularly if a mood stabilizer is not being used or if it is at a low level. Trained psychiatrists are expert at knowing how to prescribe antidepressants in bipolar patients, and in using them with the appropriate dose of a mood stabilizer.

Since bipolar disorder is associated with extremes of mood, these patients are at a very high risk of suicide. Many of these patients use drugs or alcohol to self medicate against the symptoms of the illness. Unfortunately, recreational substance use makes the symptoms worse, and creates a vicious cycle of mood swings and self-destructive behavior. Early detection and treatment are mandatory.

Ted Turner, the founder and creator of CNN, has publicly acknowledged that he suffers from bipolar disorder and has been treated with Lithium. Many famous individuals throughout history, including Napoleon, have been diagnosed with bipolar disorder. In part, the manic symptoms of the illness often drive these individuals to seek power or success, and sometimes fuel the energy level necessary to bring dreams to fruition. The danger is that the mania distorts reality and that it is frequently associated with mood crashes that lead one into despair and suicidal depths. Fortunately, modern medicine offers a number of highly effective treatment options for a common psychiatric illness.

Schizophrenia

The cacophony of screams often emanating from behind locked and ominous asylum gates is a classical image from the movies. In such dramatic portraits the patients seem demonized, capable of unspeakable horrors, and so threatening that removal from society is the only viable option. In fact, prior to the introduction of medications in the 1950's, many unfortunate patients were chained and whipped, as if they were criminals in a conspiracy against sanity and reason. Legendary hospitals, such as the Hartford Retreat in Connecticut and the Sheppard and Enoch Pratt Hospital in Baltimore eventually replaced punishment with empathy and compassion. Fortunately, the era of biochemical research has augmented this humanistic approach with powerful new medications that have made institutionalization unnecessary for scores of patients with severe psychiatric disorders.

The images from the earlier times still remain in the public psyche. Even the word Schizophrenia conjures up fear in many people who don't know what it means. Schizophrenia is simply a group of disorders, ranging from mild to more severe, in which patients experience troubling symptoms that interfere with job and relationships. These symptoms often take the form of hearing voices or sounds that aren't there. Symptoms can also develop into visions of people or objects that are not present. The patient with schizophrenia may differentiate what is real from what is not but, unfortunately, continues to experience these symptoms unless treated. Schizophrenia is often associated with a lack of motivation or interest. Sometimes it is defined by the development of delusions, beliefs that are not grounded in reality. For example, an individual may believe that family members and friends are involved in a plot to harm him. All of these symptoms are thought to be due to a chemical imbalance in the brain. One prominent theory is that there is an imbalance of a chemical called dopamine, which is normally produced in the brain, and that patients with schizophrenia produce in excess. If dopamine is injected into a normal individual, that individual could temporarily develop what are called hallucinations, hearing or seeing things that are not there. Some of the medications that are used to treat schizophrenia block the excess dopamine that is produced. Other medications have different or additional mechanisms of action.

Schizophrenia is usually first diagnosed in late adolescence or early adulthood. These years in an individual's life are often associated with great vulnerability, because many people first leave home, go to college, or get their first job during this time. If an individual is at risk of developing this illness, based upon heredity or other genetic factors, these life stressors often lower the threshold for the illness to actually develop. An analogy would be that of a person at risk for a heart attack due to family history, who then experiences a major life stress such as the loss of a spouse or a financial reversal. Such tremendous stresses could predispose that individual to having a heart attack, even though that person may never have experienced such heart trouble if severe stress had not been encountered.

Once an individual develops schizophrenia, the illness persists throughout life. Fortunately, there are a number of new medications that successfully treat the hallucinations (visions and voices), delusions (false thoughts), and lack of motivation that are the hallmark of this disease. Since all five of the senses can be affected, some patients may even feel, taste, or smell things that aren't really there. Newer medications can be helpful in treating all of these symptoms. In the past older medications caused uncomfortable side effects. The new medications have fewer side effects, are often effective at lower dosages, and are more effective for more symptoms than the medications of the past.

One myth about schizophrenia that still persists is that these patients are violent or that they pose a risk to others. Patients with schizophrenia are actually much more likely to harm themselves or attempt to take their own life than they ever would be to harm other people. Their world is frequently one of internal strife, where they are bombarded by troubling and relentless thoughts. Their motivation is frequently to escape from such turmoil by whatever suicidal means might be available. This is why accurate diagnosis and treatment are so essential in these patients. The major fear that I have as a psychiatrist, who has treated countless schizophrenic patients over the last decade and more, is the fear that patients will not come to their appointments or take their medication, and suffer needlessly.

The last decade has introduced a number of new medications to treat schizophrenia, medications by the name of Risperdal, Zyprexa, Seroquel, and Geodon. A new medication, Abilify, has just been introduced in the last few months. Research is ongoing and new treatments will continue to be developed to help patients with schizophrenia lead more balanced and more comfortable lives. In fact, it is very possible that the reliable and trusted coworker that you know is being successfully treated for this illness. Countless friends and family members can attest to the benefits medication has brought to their loved ones. Certainly, there are many schizophrenic patients who unfortunately continue to suffer, or who have not obtained as much relief as they would wish for. My hope is that new medications and new research will prove fruitful for them, as it has for so many patients with this illness.

Anxiety Disorders

The sudden onset of chest pain. Difficulty breathing. Profuse sweating. Dizziness and lightheadedness. Patients describe these dreadfully uncomfortable symptoms to me in my office. They tell me that they called an ambulance the night prior and sped to the emergency room, certain that they were dying of a heart attack. After all the appropriate tests were done, the good news was that this was not a heart attack at all. It was a panic attack, one of the anxiety disorders, and it can mimic a heart attack so closely that it is often impossible to tell the difference without going to the hospital. Anyone with these symptoms must, in fact, go to the hospital to be certain they are not having a heart attack.

Panic disorder, like some of the other anxiety disorders, is thought to be caused by a decrease in the brain of the chemical serotonin, one of the same chemicals that modulates mood. Fortunately, the same medications that treat the mood disorders, such as depression, can be used to treat the anxiety disorders as well. These medications include Prozac, Paxil, Celexa, Zoloft, Effexor, and Lexapro.

Another anxiety disorder, obsessive compulsive disorder (OCD), can also be treated with these medications. This disorder is characterized by repetitive checking behaviors. For example, an individual may check their front door repeatedly to make sure it is locked. Many people do this before retiring for the evening. However, people who suffer from OCD may check their door ten, twenty, or more times, never quite believing that they have accurately completed the task. OCD also causes rituals or superstitions that are associated with extreme anxiety unless they are completed. An example might be the old cliché of "stepping on a crack and breaking my mother's back." Someone with OCD who worried about this would literally have to avoid stepping on cracks as they traveled on the sidewalk, and they would experience extreme amounts of anxiety regarding the fear that they might accidentally make an error. OCD patients often frequently have magical numbers that they follow. The patient mentioned above who checked the door repeatedly might have a magic number of 100, and might have to check the door 100 times to ameliorate the anxiety associated with this behavior. That same number might come into play if this patient had to check the stove repeatedly, or check the car door.

This disorder is also associated with troubling and repetitive thoughts that an individual has great difficulty in dismissing. Often these thoughts are nonsensical in nature. An example I remember reading about from my residency training is that of an executive using a fountain pen. The executive became obsessed and worried that he would drink the ink that he dipped his fountain pen into. Even though he knew, on one level, that he would never actually act on such ruminations, they troubled him repeatedly. Another rumination might be the fear that one would yell obscenities in a quiet but crowded auditorium. These compulsions and obsessions can fortunately be treated with medications. Another method of treatment is known as thought blocking, where an individual simply thinks the word "stop" every time that these thoughts occur. Some people even use behavioral conditioning by putting a rubber band around their wrist and snapping it every time an intrusive thought or behavior occurs. It is thought that this type of negative consequence might diminish the likelihood of future unwanted thoughts or compulsions.

Post-Traumatic stress disorder, another anxiety disorder, is characterized by exposure to a serious event where the life of an individual or group is threatened. A recent example might be the New York City firemen who helplessly watched their colleagues perish in the World Trade Center tragedy. The traumatic event is re-experienced either with flashbacks or with recurring or troublesome dreams. An individual will avoid situations that remind them of the traumatic event or that simulate it. This disorder may also be associated with difficulty concentrating or focusing, outbursts of anger and irritability, an exaggerated startle response, difficulty getting to sleep or staying asleep, and being overly aware and focused on one's surroundings. This disorder can also be treated with medications and psychotherapy.

Social phobia, a crippling disorder that impairs individuals from interacting in social situations, is another anxiety disorder. It too can be treated with therapy and medication. Another disorder within this category, generalized anxiety disorder, is characterized by excessive worry about a number of activities or events. A person literally becomes so preoccupied with worries about so many things that sleep is affected, energy level is decreased, and irritability occurs.

The society that we live in is fraught with enormous stressors. War, fragmented families, economic instability, competitive pressures, and future uncertainty all contribute to the anxiety that people experience. These environmental stressors, and the chemical changes that they may induce in the brain, produce a myriad variety of anxiety symptoms. Fortunately, medication treatment and therapy can lead to symptom reduction and help many people lead much more normal lives.