Challenge: Uncontrollability

“Bipolar disorder can feel uncontrollable,” according to Sheri L. Johnson, Ph.D., professor of psychology at the University of California-Berkeley and director of the Cal Mania (CALM) Program. Symptoms, such as mood changes, can seem to appear suddenly and without provocation. And they can diminish daily functioning and ruin relationships, said Sheri Van Dijk, MSW, a psychotherapist and author of The DBT Skills Workbook for Bipolar Disorder.

Strategies: While bipolar disorder can seem unpredictable, there are often patterns and triggers you can watch out for. And even if you can’t prevent symptoms, you can minimize and manage them.

One way to monitor changes is to keep a mood chart, Van Dijk said. Depending on which chart you use, you can record everything from your mood to the number of hours you slept, your anxiety level, medication compliance and menstrual cycle, she said. (This is a good chart, she said.) For instance, you can anticipate a potential depressive episode if you see that your mood has been progressively sinking in the last few days, Van Dijk said.

Practicing healthy habits is an effective way to lessen the hold emotions have on you. Make it a priority to get enough sleep, going to bed at the same time and waking up at the same time, Van Dijk said. Create a calm bedtime routine, avoid substances such as alcohol – which disrupts sleep – and don’t exercise in the evenings, said Johnson, also co-author of Bipolar Disorder: A Guide for the Newly Diagnosed.

Sleep deprivation can trigger mania, and “it makes you more susceptible to being controlled by your emotions, such as irritability,” Van Dijk said. On the other hand, sleeping too much can cause lethargy and also reduce your ability to manage emotions, she said.

Exercise helps to reduce depressive symptoms. Eliminating caffeine can reduce irritability and anxiety and improve sleep, Van Dijk said. She suggested cutting out caffeine for two weeks and paying attention to any changes. Some people also find that certain foods exacerbate their mood swings. You can check by cutting out specific foods from your diet, and watching the results, she said.

You also can use a variety of strategies to stave off the negative consequences from your symptoms. For instance, if impulsive spending is a problem, gain control by having a low limit on your credit cards, Johnson said. When you’re experiencing early signs of mania, have someone else hold onto your checks and cards, Johnson said. If you do overspend, return your purchases, she said. You can even ask a friend to go with you, she added.

Challenge: Medication

“There is no ‘one size fits all’ medication that helps everyone with bipolar disorder,” Johnson said. Lithium is typically the first line of treatment. But for some people the side effects are especially troublesome, she said. Finding the right medication (or combination of medications) can seem like a daunting process.

Strategies: Learn as much as you can about mood-stabilizing medications, Johnson said, including their potential side effects. “Find a doctor who will work with you to make adjustments based on your experiences with the different medications,” she said. Expect that it might take several tries to figure out the best medications for you.

Many of the side effects dissipate after the first two weeks, Johnson said. Changing the dose schedule helps to minimize side effects. For instance, if you feel groggy, your doctor might suggest taking your medication in the evening, she said.

Support groups are another valuable tool, Johnson said. (She suggested looking at the Depression and Bipolar Support Alliance website for a group.) For instance, individuals in these groups are usually familiar with compassionate doctors in the area, she said.

Challenge: Relationships

Bipolar disorder is hard on relationships. The very symptoms – swinging moods, risky behaviors – often leave loved ones feeling confused, exhausted and like they’re walking on eggshells, Van Dijk said.

She also sees loved ones have difficulty distinguishing between the illness and the person. They might invalidate the person’s feelings and either blame everything on the illness or believe the person is making conscious choices when it is the illness.

Strategies: Bipolar disorder is difficult to understand, Van Dijk said. “Different affective episodes, [such as] depression versus hypomania, result in different symptoms, and one episode of depression or hypomania can be different from the next within the same person,” she said.

So it’s incredibly important for loved ones to get educated about the illness and how it functions. Individual therapy, family therapy and support groups can help. Refer loved ones to self-help resources and biographies or memoirs of people with bipolar disorder, Johnson said.

Getting a handle on your emotions also improves relationships, she said. Working on assertiveness is key, too, she said. Individuals with bipolar disorder tend to have a tough time being assertive. Therapy is a good place to learn assertiveness skills. But if you’d like to practice on your own, Van Dijk suggested using “I statements”: “ I feel _____ when you ______.” She gave the following example: “I feel scared and hurt when you threaten to leave me.”

Challenge: Anxiety

According to Johnson, about two-thirds of people with bipolar disorder also have a diagnosable anxiety disorder.

Strategies: Johnson stressed the importance of using relaxation techniques and not using avoidance behaviors. As Van Dijk explained, “the more you avoid things because of your anxiety, the more your anxiety will actually increase, because you never allow your brain to learn that there’s nothing to be anxious about.”

Psychotherapy is tremendously helpful for managing bipolar disorder and the above challenges. If you’ve been prescribed medication, never stop taking it abruptly – this boosts the risk for relapse – and communicate regularly with your doctor.

These are the top 25 psychiatric medications by number of U.S. prescriptions dispensed in 2011, according to IMS Health. I’ve also provided their 2009 and 2005 ranking (you can view the 2009 list here).

To put the percent changes below into perspective, the U.S. total population rose approximately 1.6 percent from 2009 to 2011. That suggests that anything above 1.6 percent change was driven by other factors — more people seeking treatment, more pharmaceutical advertising and marketing, or some other factor.

The biggest movers and shakers on the list were Celexa — moving up 15 spots to grab the second most-prescribed psychiatric drug in 2011 — and Wellbutrin XL, moving from 22 to 13.

Drugs used to treat attention deficit hyperactivity disorder (ADHD) — generic amphetamine salts and methylphenidate — enjoyed big gains as well.

Notes:

If no percentage change is listed, we did not track it in 2005.

NA – Rank not available for this year.

* – This is not a psychiatric medication, but is often prescribed for a mental health issue.

How This Data is Derived

Information in the National Prescription Audit (NPA) is derived from IMS Health’s Xponent service, one of the most complete, national-level prescription databases in the U.S. Xponent captures roughly 70% Market Share of all prescriptions in the U.S. IMS then uses a patented projection methodology from a stratified and geographically balanced sample to represent 100% Market Share coverage of U.S. prescription activity at retail, mail service, long-term care, and managed care outlets.

While both psychotherapy and medications have been shown to be effective in the treatment of social anxiety disorder, a combination approach to treatment — utilizing both at the same time — may be the most timely and beneficial.

While some people may find relief from some social anxiety symptoms through trying simple self-help techniques, most people with a diagnosed social phobia condition will need professional treatment in order to overcome it.

Psychotherapy for Social Anxiety

Psychotherapy is a very effective method of treatment for social anxiety disorder. Specifically, cognitive behavioral treatments — which include techniques such as exposure therapy, cognitive restructuring without exposure, exposure therapy with cognitive restructuring, and social skills training — appear to be highly effective in treatment social anxiety, in a time-limited manner. Most cognitive-behavioral therapy (CBT) can be administered within 16 sessions (usually one session per week). At the end of treatment, a person’s anxiety symptoms are greatly reduced or even disappear in some cases.

In addition to CBT, other psychological treatments have also been found effective in the treatment of social anxiety. These include cognitive therapy (a form of CBT), social skills training alone, relaxation exercises, exposure therapy alone, behavioral therapy, and some other types of less-practiced forms of psychotherapy.

Exposure therapy is often a primary component of psychotherapy treatment of social anxiety disorder. Exposure therapy involves a person learning to understand the irrational basis for their fears (cognitive restructuring), teaching simple relaxation skills to practice while in the moment, and gradually being “exposed” to the situation which causes the anxiety. The exposure is done first in the safety of the psychotherapy office, imagining the scenario and walking through it with the therapist. As the patient’s confidence grows, he or she will begin to apply the skills they’ve learned in the therapy session to outside world events and environments.

Psychotherapy treatments have been shown to be highly effective in treating social anxiety disorder (Acarturk et al., 2009; Powers et al., 2008). Most people who try psychotherapy with a therapist who has experience in treating social anxiety disorder will find relief from their symptoms.

Medications for Social Anxiety

The primary class of drugs used to treat social anxiety are called selective serotonin reuptake inhibitors (SSRIs). This class of drugs was first developed to treat depression and so are often referred to as antidepressants. Since then, however, they have been found to be effective in the treatment of a wider range of disorders. Common SSRIs include Paxil (paroxetine), Zoloft (sertraline), Prozac (fluoxetine), and Luvox (fluvoxamine).

Another type of antidepressant called Effexor (venlafaxine) may also be prescribed to help with the symptoms of social phobia.

These kinds of medications generally take 6 to 8 weeks in order to start feeling the full therapeutic effects of them. While it may be frustrating to wait during that time and feel little relief, always take all medications as prescribed by your doctor. If you experience any distressing side effects, talk to your doctor immediately.

There is little specific reason to prescribe one antidepressant over another for the treatment of this disorder. Your doctor may choose your medication based upon their own experience in prescribing it, or based upon the typical side effects most people who take it experience. If you are not experiencing relief in 6 to 8 weeks from the first medication prescribed, talk to your doctor. He or she may decide to either up your dose or try a different medication altogether.

Other Medications

In addition to SSRIs, others kinds of medications are occasionally prescribed in the treatment of social anxiety disorder.

Anti-anxiety medications called benzodiazepines are rarely prescribed for social anxiety disorder, because they are extremely habit-forming and act as a sedative. However, because they act quickly in the short-term, they may be prescribed when a specific situation warrants their use — such as an unexpected public speaking engagement that can’t be avoided.

A class of drugs called beta blockers may also be used for relieving social anxiety. Beta blockers work by blocking the flow of epinephrine (more commonly known as adrenaline) that occurs when you’re anxious. This means they can help to control and block the physical symptoms that often accompany social anxiety — at least for a short while. They are primarily used for short-term situations, such as when you need to give a speech. However, like benzodiazepines, they are not generally recommended for the treatment of social anxiety and are rarely prescribed for it.

Jason Eric Schiffman, MD, MA, MBA, a psychiatrist at the UCLA Anxiety Disorders programs and editor of Anxiety.org says it’s one of the paradoxes of anxiety disorders. The severity of the disorder, the fear of being stigmatized, and general mistrust of conventional treatment may create obstacles to seeking help.

What Makes Complementary and Alternative Treatments Attractive Options?

The fear of conventional therapy could explain why complementary and alternative therapies (CAT) — such as vitamin supplements and yoga and meditation — are becoming increasingly popular. There was a time not long ago when we trusted Western medicine more than alternative treatments, but today the opposite is said to be true.

What accounts for this shift? Schiffman identifies four reasons why patients may be leaning toward complementary and alternative techniques to relieve their anxiety.

1. General mistrust of pharmaceutical companies.

The 2010 movie Love and Other Drugs does a good job of explaining patients’ growing mistrust of pharmaceutical companies. In a sentence, the relationship between pharmaceutical companies and physicians has become blurred. While Hollywood exaggerates the issue, the movie raises a legitimate concern: How much influence do pharmaceutical companies have on a doctor’s decision to prescribe certain medications? “The pharmaceutical companies are, by and large, publicly traded health companies, which means they have a fiduciary responsibility to their stockholders to maximize profit and that does not always align with the goal of doing what’s best for the greatest number of people,” says Schiffman. Although there have been recent efforts to prevent bias by limiting the way physicians and pharmaceutical companies interact, the general mistrust has stayed.

2. Side effects from commonly used SSRIs.

Schiffman says there is a correlation between the “amount of desired effects that a medication has and the amount of undesired side effects.” In other words, pharmaceutical treatments used are more effective than nonconventional treatments, but they tend to come with more side effects. In the case of selective serotonin reuptake inhibitors (SSRIs), a class of medications commonly used to treat anxiety disorders, sexual side effects can be perceived as intolerable. A previous post written by Psych Central founder and editor-in-chief John Grohol on Managing the Painful Side Effects of Antidepressants lists several of these common side effects. These reasons may be enough to pique patients’ interest in seeking alternative treatments.

3. No relief from SSRIs or difficulty in treating certain anxiety disorders.

According to Schiffman, “Only somewhere between 30-40% of people respond to their first treatment with SSRI’s.” And for some anxiety disorders, such as severe obsessive compulsive disorder (OCD), conventional treatment approaches may not always work. In fact, he says some patients in a “heroic effort to get relief” have even tried neurosurgery. The truth is that in comparison to Generalized Anxiety Disorder (GAD), OCD patients will require a higher dosage of medication. “If people have tried conventional approaches and are still suffering, it makes sense that they would then be willing to try complementary and alternative approaches.”

4. It’s human nature to believe natural products are better than synthetic.

When you hear the words “all natural” do you immediately associate it with low- or no-risk products? Equating natural products with safety and trust is a common and prevailing misconception with CAT. In fact, Schiffman says, “Natural products can be just as dangerous as synthetic products. Just because something is marketed as a natural supplement doesn’t mean that it is without risks.” In March 2002, the U.S. Food and Drug Administration (FDA) issued a warning about kava kava, a supplement used to treat anxiety, because of its potential negative side effects such as severe liver damage.

Yet, people who take supplements are more likely to trust companies and individuals promoting alternative treatments and supplements than pharmaceutical companies and the FDA. Instead Schiffman says, “the FDA and pharmaceutical companies and the marketers of supplements deserve the same degree of healthy skepticism.”

The Challenge with Seeking Alternative Treatments

It is understandable that individuals suffering from anxiety disorders want to seek alternative therapies — even more so because they can find information about them via the Internet in the comfort of their own homes. But because what’s out there on the World Wide Web isn’t regulated, patients may get misinformation that could have costly consequences.

Another problem is that many psychiatrists are not up to date with the latest research and information on alternative therapies. And if they are, Schiffman says they may be reluctant to comment on them either way. “One of the problems is that these medications have not been evaluated by the FDA [and] they’re fearful of the liability associated with recommending treatment that hasn’t been thoroughly evaluated or approved by the FDA.” As a result, people who are most qualified in terms of training and experience (such as psychiatrists) are less likely to evaluate potential treatments than people who aren’t trained because of the fear of liability issues.

What to Do if You’re Interested in Seeking Complementary and Alternative Therapies

If you think you are experiencing an anxiety disorder, you should always seek treatment from a mental health provider. If you are working with a therapist and are interested in pursuing an alternative route, consider asking them about potential treatments. In addition, a pharmacist or physician may also be able to answer your questions on supplements and provide information on any potential negative interactions with medications you are taking.

And while Schiffman has seen the positive effects of behavioral interventions such as yoga, meditation and deep breathing on anxiety patients, he advises individuals to avoid making decisions based on anecdotal evidence. Sites such as PubMed that publish current and evidence-based research are the best route for obtaining information via the Internet.

If you are suffering from a less severe anxiety disorder such as General Anxiety Disorder, Schiffman suggests “non-pharmalogical approaches first whether those approaches are complementary or alternative approaches like yoga or meditation or conventional approaches like cognitive behavioral therapy.” This is because there is less risk involved and fewer physiological side effects. However, it is important to note that if you are experiencing more severe symptoms or in the moment anxiety as in the case of phobias or panic attacks, CAT may be less effective. Cognitive Behavioral Therapy (CBT) alongside complementary and alternative techniques might work best in those situations.

Knowing all the work and research involved, is it worth seeking complementary and alternative therapies?

Schiffman wholeheartedly says yes. “When someone gets better from anxiety through a practice such as yoga, meditation or through therapy, they get better because they’ve learned something rather than getting better because a pill has made a change or caused a change to their neurochemistry.” Making an effort to change your lifestyle by learning ways to reduce stress and anxiety not only empowers individuals, but creates change that is “much more profound and long-lasting.”

The choice ultimately is yours. But Schiffman leaves us with this final thought to mull over: “If the goal is to increase the quality of life of the person who’s suffering from anxiety, it doesn’t make sense to limit one’s self to either conventional or non-conventional treatment.”

The reality is that it is possible to safely discontinue any medication, including psychiatric ones.

Stop your medication for the right reasons.

“Timing is everything,” according to Dr. Michael D. Banov, medical director of Northwest Behavioral Medicine and Research Center in Atlanta, and author of the book Taking Antidepressants: Your Comprehensive Guide to Starting, Staying On, and Safely Quitting. Just because someone wants to stop taking their medicine doesn’t mean they’re actually ready, he said.

There are many reasons individuals decide to stop taking medicine. For instance, they might feel better and think they don’t need treatment anymore. Their family might be pressuring them to stop, they read something about a drug that scares them, or they’re afraid that the drug will affect their personality, Banov said. Sometimes people want to stop after making major changes in their lives, such as getting a divorce, moving or changing jobs. But, according to Dr. Banov, this is actually “the worst time” to stop.

Also, some mental health conditions require taking medicine indefinitely. Ultimately, how long a person takes a psychotropic drug depends on his or her individual illness, its responses to treatment and their personal situation, according to Dr. Ross J. Baldessarini, professor of psychiatry and neuroscience at Harvard Medical School and director of the psychopharmacology program at the McLean Division of Massachusetts General Hospital. For instance, some individuals struggling with depression may take an antidepressant for nine months to a year and get better; others may need two to five years; and still others, may be “so genetically loaded for depression, that they may need to stay on them indefinitely,” Dr. Banov said.

Don’t stop your medication abruptly.

“Stopping abruptly is especially dangerous,” Baldessarini said.

Depending on the medicine, stopping abruptly or “cold turkey” can cause a variety of distressing reactions, ranging from mild to moderate early discontinuation symptoms with antidepressants, rapid return of the illness being treated, or even potentially life-threatening seizures with a high dose of benzodiazepines.

Consult your doctor before stopping any medicine, and never attempt to do it on your own.

Consider if you’ve received a thorough assessment.

A comprehensive assessment is required prior to stopping medicine. Among other indicators, your doctor needs to consider “your current clinical condition and life circumstances, your past clinical history, reasons to consider stopping versus continuing treatment, side effects and the presence of stressors and supports, as well as the dose and the length of time you’ve been taking a medicine,” Baldessarini said. You and your doctor should talk about these indicators along with how he or she plans to discontinue the drug.

There are no firm, established rules for discontinuing psychiatric medicines. However, there is one major rule of thumb: Reduce the dosage gradually whenever possible. “We still do not know for sure how long is long enough to reduce doses safely,” Baldessarini said. Still, the “slower the dose-reduction, the greater the chances of preventing return of symptoms of the illness for which treatment was started. Very slow discontinuation is especially important when a person has been taking high doses of a medicine over a long time,” he said.

Discontinuing multiple drugs is like peeling an onion, Baldessarini said. He usually leaves the most essential medicine for last. He then reduces doses of one or more optional or supplemental drugs slowly and gradually. Stopping all medicines at once is not safe.

Dealing with small final doses is tricky when dropping from a low dose to nothing. Sometimes doctors decrease the dose to one pill a day or one every two days or split the pill in half, he said. Pill-splitting can be very helpful. You can find pill splitters at your pharmacy.

Don’t expect stopping medication to be a quick process.

Gradually and safely discontinuing a drug doesn’t happen in a few days. Some drugs, including antidepressants, don’t show benefits for several weeks when they’re started; it seems best to avoid discontinuing faster than over several weeks, Banov said.

If you’ve been taking a medicine for years, Banov recommended reducing the dose, stepwise, over at least six weeks. While this may be a conservative practice, he said that “sometimes, you might not detect a change for a few weeks, but later, problems may arise.” Discontinuation symptoms usually occur within days of stopping a medicine, but relapse of the illness being treated can be delayed for weeks after initially feeling well.

In bipolar disorder, Baldessarini and his research team found years ago that the rate of discontinuing ongoing treatment determines the risk and timing of relapse, he said. Initially, their research found that risk for relapse after discontinuing lithium was reduced by one half or more when slow dose-reduction over several weeks was compared to abrupt discontinuation (Baldessarini et al., 2006). Gradual discontinuation of antipsychotic drugs also resulted in lower risk of relapse in schizophrenia (Viguera et al., 1997). In a recent study, he and his colleagues found that stopping an antidepressant abruptly or only over several days resulted in a much greater risk for depression or panic than gradual discontinuation over two weeks or more (Baldessarini et al., 2010).

If you’re switching from one medicine to another, you can be more aggressive than when discontinuing altogether, Banov said. Usually you switch drugs because of ineffectiveness or side effects, and commonly a new drug is introduced as the previous one is gradually removed. This way, there’s little concern about either withdrawal symptoms or relapse, assuming that both drugs have similar effects or belong to the same class, he said. If you’re switching classes, it’s usual to “cross-taper” the medicines: You take both drugs for a while, and then, the doctor reduces the dose of one and ups the dose of the other.

Your doctor may prescribe another medication.

If you’re taking a relatively short-acting antidepressant, such as paroxetine (Paxil) or venlafaxine (Effexor), and you experience bothersome symptoms, “your doctor may prescribe a long-acting antidepressant such as Prozac for a time, and then gradually discontinue the long-acting drug to limit risk of discomfort of withdrawing,” Baldessarini said. “The principal byproduct of the metabolism of fluoxetine has an extraordinarily long half-life or duration of action,” he said, and can take weeks to leave your system.

This method is not well established for discontinuing other classes of psychotropic drugs, including antipsychotics and mood stabilizers, so the best option usually is to “discontinue such drugs gradually, with close clinical monitoring by your doctor,” Dr. Baldessarini said.

Dr. Jacqueline Frayne from the King Edward Memorial Hospital for Women in Perth, Western Australia, says, “Although pregnancy and childbirth can be a time of great joy, for some women and their families it may also be a time of turmoil.” She explains that the rate of serious mental illness, such as schizophrenia, is fairly low but up to one in five women will experience “clinically diagnosable depression or anxiety” during pregnancy and the postpartum period.

Taking medication for these conditions can be a cause of anxiety for both the patient and her physician. The pros and cons of medication to mother and baby need to be considered, alongside many other factors that impact on maternal and fetal wellbeing.

Dr. Frayne recommends that “specialist opinion is sought early and a multidisciplinary approach with access to specialist care offered if possible. Continuity of care, especially in the context of a trusting therapeutic relationship, is optimal,” she adds.

She says the treatment plan during pregnancy should be based on the woman’s current mental state and medication, as well as her history of past mental illness and previous treatment, and family history of mental illness during pregnancy. Her support network, pregnancy-related fears, drug and alcohol use should also be considered.

A recent study found that “medications with potential for fetal harm” were being taken by 16 percent of women treated for depression. There is a lack of pregnancy safety data for many medications. However, stopping treatment suddenly is not recommended as this can cause side effects and possible relapse.

For example, in the case of bipolar disorder, relapse is often due to the discontinuation of preventive drugs. Although mild manic episodes can often be managed without drugs, severe manic episodes need to be treated because the possible consequences of injury, stress, malnutrition, profound sleep deprivation and suicide could pose more risk to the fetus than the side effects of the drug.

Lithium should be avoided in the first trimester of pregnancy, whenever possible, as it has been linked to a small but significantly increased risk of birth defects, particularly of the heart. The normal maintenance dose should be re-established as soon as possible following delivery, or if lithium is the only medication that controls symptoms, it can be re-introduced in the second trimester.

Other bipolar medications such as carbamazepine (Tegretol) and sodium valproate (Depakote) also carry some risks of fetal malformation, but physicians may still consider using these medications on the minimum effective dose, alongside regular monitoring.

For generalized anxiety disorder and panic disorder, low-risk medications are available. As an alternative to drugs, patients should be offered cognitive behavioral therapy or psychotherapy, as should those with obsessive-compulsive disorder or post-traumatic stress disorder.

The selective serotonin reuptake inhibitor (SSRI) antidepressant paroxetine (sold as Seroxat, Paxil) is not considered safe during pregnancy. The prescribing information says, “Epidemiological studies have shown that infants born to women who had first trimester paroxetine exposure had an increased risk of cardiovascular malformations.

“If a patient becomes pregnant while taking paroxetine, she should be advised of the potential harm to the fetus. Unless the benefits of paroxetine to the mother justify continuing treatment, consideration should be given to either discontinuing paroxetine therapy or switching to another antidepressant.”

Antidepressant medications cross the placental barrier and may reach the fetus, but research has shown that most other SSRIs are safe during pregnancy. Birth defects or other problems are possible, but they are very rare.

Tricyclic antidepressants and serotonin-norepinephrine reuptake inhibitors (SNRIs) have not been found to have any serious effects on the fetus, and have been safely used thoughout pregnancy for many years. On the other hand, monoamine oxidase inhibitors (MAOIs) have been associated with increased risk of malformations and may interect with drugs used in labour (e.g., meperidine).

Nevertheless, there have been reports of neonatal withdrawal symptoms after the use of SSRIs, SNRIs, and tricyclics during late pregnancy. These include agitation, irritability, a low Apgar score (physical health at birth) and seizures.

Benzodiazepines should not be used during pregnancy, particularly in the first trimester, as they may cause birth defects or other infant problems. The U.S. Food and Drug Administration has categorized benzodiazepines into either category D or X meaning potential for harm in the unborn has been demonstrated.

If used in pregnancy, benzodiazepines with a better and longer safety record, such as diazepam (Valium) or chlordiazepoxide (Librium), are recommended over potentially more harmful benzodiazepines, such as alprazolam (Xanax) or triazolam (Halcion).

Pregnancy outcomes for antipsychotic medications vary widely depending on the type of drug. Exposure to low-strength antipsychotics during the first trimester is associated with a small additional risk of congenital anomalies overall. Haloperidol (Haldol) has been found not to cause birth defects.

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

Women taking these medications and who intend to breastfeed should discuss the potential risks and benefits with their physicians.

References

Frayne, J. et al. Motherhood and mental illness: Part 1 – toward a general understanding. Australian Family Physician, Vol. 38, August 2009, pp. 594-600.

Cleary, B. J. et al. Medication use in early pregnancy-prevalence and determinants of use in a prospective cohort of women. Pharmacoepidemiology and Drug Safety, Vol. 19, April 2010, pp. 408-17.

Medication, Pregnancy and Breastfeeding

Antenatal Mental Health Problems

Rubinchik, S. M., Kablinger, A. S. and Gardner, J. S. Medications for Panic Disorder and Generalized Anxiety Disorder During Pregnancy. Primary Care Companion to the Journal of Clinical Psychiatry, Vol. 7, 2005, pp. 100-105.

Mental Health Medications

Howard, L., Webb, R. and Abel, K. Safety of antipsychotic drugs for pregnant and breastfeeding women with non-affective psychosis. The British Medical Journal, Vol. 329, October 23, 2004, pp. 933-34.

From her work in primary care settings, Risa Weisberg, Ph.D, assistant professor (research) and co-director of the Brown University Program for Anxiety Research at Alpert Medical School, has seen “firsthand how a great many patients accept a prescription from their provider without asking many questions about it, or often, without even knowing for what symptoms/disorder it is being prescribed.”

Such a scenario can stall or sabotage your treatment. Confused, you’re likely left with tons of questions, unaware of what you’re taking and how it’s supposed to help. You may be feeling helpless — a spectator in your own recovery — and hopeless, if the medication doesn’t seem to work or has bad side effects. Your doctor likely is clueless about your real concerns, not having all the information to guide his or her decision-making process.

But you don’t have to feel like a powerless bystander, on the outskirts of your own treatment. In order to become a sharp self-advocate, you just need some information. Here’s some hints for for taking medication safely and effectively. At the end, you’ll also find a basic glossary of common medication-related terms.

1. Haven’t picked a physician yet? Do your homework and conduct an interview. Before you decide on a doctor, whether it’s a primary care physician or a psychiatrist, ask some questions about qualifications and see if he or she is a good fit for you. Questions to get you started: Where did you go to school and do your training? Do you specialize in a specific mental illness? Do you have hospital privileges? Here’s a list of excellent questions to ask a psychiatrist during and after your first appointment. They focus on bipolar disorder, but you can easily adapt them to any disorder.

2. Ask the doctor about your diagnosis. You have the right to know precisely what you’re diagnosed with and how the doctor came to that conclusion. Making a diagnosis doesn’t happen in a 5-minute interview. You want to make sure that the doctor conducted a thorough evaluation. Did the doctor get your medical and mental health history? Did you complete a standardized test? Did the doctor ask about your symptoms and recent experiences?

3. Seek out psychotherapy. Medication isn’t your only option. Depending on the disorder, you may only need psychotherapy or you may take medication and see a therapist. Psychotherapy provides lasting benefits, whereas a medication’s effects stop as soon as you stop taking it. Cognitive-behavioral therapy effectively treats depression, anxiety disorders and bipolar disorder. To find a therapist, you can ask your doctor for a recommendation, browse the Web or check with universities and medical schools. Be sure the therapist specializes in your mental illness. For advice on finding a good therapist, check out this eBook.

Some Web sources for finding a therapist:

• Psych Central’s therapist finder
• The Association for Behavioral and Cognitive Therapy for CBT-trained therapists
• Children and Adults with Attention Deficit/Hyperactivity Disorder
• Anxiety Disorders Association of America
• National Eating Disorder Association

4. Before taking the medication, ask specifics. Peter Roy-Byrne, M.D., professor and chief of psychiatry at the University of Washington at Harborview Medical Center, and Michael R. Liebowitz, M.D., professor of clinical psychiatry at Columbia University and managing director of The Medical Research Network, suggest asking:

• How will I know if this medication is working?
• What are the side effects, and what do I do if I experience them?
• When will the medication start to work?
• How long will I have to take it?
• If I take it for X amount of time, what’s the likelihood of reducing symptoms?
• What are the dose requirements?
• Will you be monitoring me throughout the course of this medication?
• When will you talk to me next?

The Agency for Healthcare Research and Quality has a basic handout with more questions. Here’s a thorough list if your child is taking medication, which you can easily revise for your situation.

5. Unsure about medication? Explore why. Are you on the fence because of potential side effects, the stigma of having a disorder or taking medication, a bad past experience, fears of addiction or uncertainty about the validity of your diagnosis? Talk to the doctor about your concerns before making the decision to take or refuse the medication.

According to Peter J. Norton, Ph.D, Director of the Anxiety Disorder Clinic at the University of Houston and co-author of The Anti-Anxiety Workbook, anxiety disorders have success rates that make other researchers jealous. The key is to get the right treatment and stick with it.

Here’s a look at what effective treatment entails, including the ins and outs of psychotherapy and medication, plus tips for finding a qualified therapist, managing panic attacks and more.

Common Misconceptions

1. Anxiety disorders aren’t that serious. This myth persists because “anxiety is a universal and normative emotion,” said Risa Weisberg, Ph.D, Assistant Professor (research) and Co-Director of the Brown University Program for Anxiety Research at Alpert Medical School. However, anxiety “can be a hugely distressing and impairing symptom.”

2. “I can overcome this on my own.” In her research on anxiety disorders in primary care, Weisberg found that nearly half of primary care patients with anxiety disorders weren’t taking medication or attending therapy. When asked about their reasons for not engaging in treatment, one of the most common answers was that they didn’t believe in receiving these treatments for emotional problems. Anxiety disorders have a chronic course and “the bottom line is that good treatments exist, so there is no reason to suffer on your own,” Weisberg said.
3. Anxiety disorders are a character defect. “Anxiety has a genetic and neurological basis,” said Tom Corboy, MFT, Director of the OCD Center of Los Angeles.
4. “I need medication in order to improve.” Though medication can be effective in treating anxiety disorders, “research suggests that in many cases, cognitive-behavioral therapy (CBT) is better or just as good as CBT plus medication,” said Jon Abramowitz, Ph.D, Associate Professor at the University of North Carolina at Chapel Hill and Director of the UNC Anxiety and Stress Disorders Clinic. CBT teaches patients the skills for lasting benefits.

Disclosing Your Diagnosis

You may be unsure about sharing your diagnosis with others. Corboy suggested discussing your anxiety with individuals you trust, who have your best interests in mind. If you’re considering telling a significant other, wait “until that person has earned your trust,” he said.

Treatment

A great deal of research over the past 10 to 15 years has shown that CBT is the most effective treatment for most anxiety disorders, Corboy said, making it the first line of treatment. Research also has shown that selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants and benzodiazepines are effective in treating anxiety.

Doctors usually prescribe SSRIs and SNRIs first because they’re effective, can treat depression — which often co-occurs — and tend to be better tolerated. According to the scientific literature, there’s a higher rate of relapse with medication, Norton said. The key is to supplement medication with CBT, said Peter Roy-Byrne, M.D., Professor and Chief of Psychiatry at the University of Washington at Harborview Medical Center. In fact, medication is sometimes used to facilitate psychotherapy.

Psychotherapy

The first step in CBT is to understand your anxiety, Abramowitz said. You and the therapist will work together to gain insight into how your thoughts and behaviors fuel your anxiety. “People with anxiety tend to jump to conclusions and overestimate,” he said. Behavior such as regularly rehearsing what you’re about to say actually feeds your anxiety, nourishing the belief that you can’t think on your feet and you’re a poor public speaker.

Cognitive restructuring helps patients identify their thoughts and expectations and modify problematic patterns, Abramowitz said. He pointed out that cognitive restructuring “is not the power of positive thinking; it’s the power of logical thinking.”

In exposure therapy, another CBT technique, therapists help patients face their fears in various contexts in a systematic and safe way. Together, you and your therapist create a hierarchy, listing the least anxiety-provoking situation to the greatest, and work your way up, confronting each situation.

Most CBT programs consist of 8 to 15 weekly sessions, Norton said. When individuals start to experience gains varies. At his clinic, Norton typically sees patients improve the most from the 5th to 7th session of their 12-week program. However, there’s no universal standard for staying in therapy. Weisberg recommended that patients continue with CBT until they fully understand and have mastered the above skills to manage their anxiety.

The boundaries between subtypes are often fuzzy, with some overlap of symptoms, and not every depression expert agrees on the classification system. But clinical research suggests that parsing depression into subtypes is useful in guiding treatment and in gauging the long-term outcome for patients.

At a symposium presented at the recent meeting of the American Psychiatric Association, doctors discussed five depression subtypes that together encompass the majority of depressed persons. These include:

• Atypical depression, which studies show accounts for 23% to 36% of all cases and is under-recognized.
• Anxious depression, which afflicts 40% of patients with major depressive disorder and poses many treatment challenges.
• Melancholic depression, a severe form of disorder that is most common among persons hospitalized for depression.
• Vascular depression, a newly recognized variety that reflects the existence of silent cardiovascular disease and is most common among persons over the age of 60.
• Psychotic depression, a severe form of disorder distinguished by mood-congruent delusions and accompanied by specific changes in brain tissue.

The distinctions first emerged several decades ago on the basis of variations in response to then-available treatments. But clinicians and researchers suggest that dissecting depression into subtypes may be even more valuable today. The subtypes may represent distinct biological pathways of disorder and may ultimately provide clues to the multiple ways depression can arise as well as express itself.

Atypical depression can manifest in both bipolar and unipolar depression, psychiatrist Jonathan W. Stewart. M.D., of Columbia University reported. Patients with this variety of disorder — about 10 million Americans — have what physicians label mood reactivity: they can be cheered up at least 50% in response to positive events in their life, albeit temporarily.

In contrast to patients with classical depression, those with atypical depression overeat regularly and binge often, gaining sometimes substantial amounts of weight. They also sleep a lot, and experience a leaden paralysis and overwhelming fatigue for much of the day, feeling as if they cannot even lift themselves out of a chair.

In addition to such physical manifestations, atypical depression is marked by a longstanding pattern of extreme sensitivity to perceived interpersonal rejection that affects functioning at work, in love, and with friends. With a trail of stormy relationships patients are either never married or divorced, and are unemployed or underemployed. Given their fear of rejection, many withdraw from relationships entirely and refuse to go on job interviews.

Drugs for Depression

Although the Phase III pipeline of drugs for the treatment of depression is deep, including several compounds with new mechanisms of actions, none is expected to be approved in 2009. Pristiq (desvenlafaxine, the major metabolite of venlafaxine), Wyeth’s follow- up to Effexor (venlafaxine), was approved for depression in adults by the FDA in March and could gain ground in the clinic next year.

AstraZeneca submitted an sNDA in May for Seroquel XR for the treatment of generalized anxiety disorder, which was the first submission of an atypical antipsychotic medication for this indication. In February, the company submitted an sNDA for Seroquel XR for the treatment of depression.

In September, LaboPharm submitted an NDA for DDS-04A for the treatment of depression. This compound is the well-known antidepressant trazodone a 5-HT2 receptor antagonist, formulated for once-daily administration. The NDA was based on data from five pharmacokinetic studies and a North American study that included more than 400 patients.

New drugs on the horizon for late 2009/2010 U.S. approval include Valdoxan (agomelatine), which is in development by Novartis and Servier, and Saredutant (SR 48968), a Sanofi-Aventis compound. Valdoxan, which has a novel mechanism of action—melatonin (MT1 and MT2) receptor agonist and 5-HT2C receptor antagonist—and an attractive side-effects profile (i.e., no sexual dysfunction or weight gain), is anticipated.

Novartis is currently conducting four large-scale Phase III trials in the United States, all of which are scheduled to complete in 2009. A U.S. NDA might be submitted in 2009. Saredutant, a neurokinin-2 (NK2) receptor blocker, is well tolerated but has produced mixed results in long-term Phase III trials. Sanofi-Aventis will decide on regulatory submissions based on the results of two ongoing trials assessing saredutant in combination with escitalopram and paroxetine, which are scheduled for completion in the first half of 2009.

Drugs for Bipolar Disorder

Longer-acting injectable and oral formulations of approved atypical antipsychotic medications are the focus of late-stage drug development for bipolar disorder.

Janssen is currently marketing Risperdal Consta, a long-acting, injectable formulation of risperidone for the treatment of schizophrenia. The drug was developed by combining risperidone with the Alkermes’ Medisorb delivery system to maintain a therapeutic drug concentration when administered once every two weeks.

In 2008, Janssen submitted two supplemental New Drug Applications (sNDA) for bipolar indications. An sNDA submitted in April seeks approval for adjunctive maintenance treatment to delay the occurrence of mood episodes in patients with frequently relapsing bipolar disorder. A July sNDA submission looks to indicate Risperdal Consta as monotherapy for the maintenance treatment of bipolar I disorder to delay the time to occurrence of mood episodes in adults.

Another long-acting atypical antipsychotic, AstraZeneca’s Seroquel XR (quetiapine extended-release tablets), was approved in October 2008 for acute treatment of depressive episodes associated with bipolar disorder and manic and mixed episodes associated with bipolar I disorder, as well as maintenance treatment of bipolar I disorder as adjunctive therapy to lithium or divalproex.

Drugs for Schizophrenia

Late-stage drug development for schizophrenia includes a new injectable formulation of an approved atypical antipsychotic and two new drug candidates with atypical antipsychotic mechanisms of action.

Janssen developed an injectable formulation of its antipsychotic, Invega (paliperidone extended-release) by combining it with Elan’s NanoCrystal technology to enable administration by intramuscular injection on a once-monthly schedule. In October 2007, the company submitted an NDA for the treatment of schizophrenia and prevention of symptom recurrence. In August 2008, the FDA requested additional data before approving the NDA, but did not require any additional studies. Janssen is currently evaluating the FDA response and will work with the agency to resolve outstanding questions. Potential advantages of Invega over Risperdal Consta include reduced dosing frequency (once monthly vs. once every two weeks) and no need for refrigeration.

In September, Lundbeck’s NDA submission seeking approval for Serdolect (sertindole) for the treatment of schizophrenia was accepted for review by the FDA. Serdolect is a new-generation atypical antipsychotic. It exhibits a higher level of limbic-selective increased dopaminergic activity than other atypical agents, which may contribute to an attractive extrapyramidal side-effect profile. Serdolect has been launched in Europe, South and Central America, Asia and the Middle East and has been administered to more than 70,000 patients.

Schering-Plough’s NDA submission for its new 5-HT2A- and D2 receptor antagonist Saphris (asenapine) was accepted by the FDA in November 2007 and is undergoing a standard review. Saphris is a fast-dissolving, sublingual tablet acquired by Schering-Plough when it combined with Organon BioSciences earlier in November 2007. The NDA seeks approval for schizophrenia and acute or mixed episodes associated with bipolar I disorder. In November 2008, top-line Phase III clinical trial results demonstrated the efficacy of Saphris in long-term schizophrenia relapse prevention. Approval and launch in 2009 are possible.

Drugs for Attention Deficit Disorder (ADHD)

A new drug with a nonstimulant mechanism of action may be approved in 2009 for the treatment of attention-deficit/hyperactivity disorder (ADHD). Intuniv (guanfacine extended-release tablets) is a selective alpha2A-agonist in development by Shire for the once-daily treatment of ADHD. The company submitted an NDA for monotherapy for the treatment of ADHD symptoms throughout the day in children aged 6 to 17 years and received an approvable letter from the FDA in June 2007. The FDA requested additional information, and the company has been conducting additional clinical work related to the drug’s label.

Immediate-release guanfacine, a medication used to treat high blood pressure, also is used off-label in ADHD.

Anticipated advantages of Intuniv over guanfacine include FDA approval specifically for ADHD and maintenance of blood concentration in the therapeutic range, which is problematic with immediate-release formulations. Another potential advantage: Intuniv is not a controlled substance, and is not associated with any known mechanisms for potential abuse or dependence.

An estimated 30% of children with ADHD cannot tolerate stimulant drugs or do not benefit from currently available ADHD medications. Intuniv also might have applications in combination with stimulant drugs to reduce aggression and insomnia associated with stimulants and adult patients. Shire hopes to gain FDA approval and launch Intuniv in the second half of 2009.

After studying records of nearly 225,000 people ages 67 to 84, researchers at McGill University in Montreal found a 45 percent increase in injury-causing car accidents in people who had been taking a long-acting group of benzodiazepines. These drugs often are prescribed to treat anxiety or insomnia. The medications associated with higher accident rates are the long-lasting ones, which can stay in the bloodstream for more than 24 hours.

The drugs associated with the higher accident rates include many popular medications, such as:

• Clonazepam (Klonopin)
• Diazepam (Valium)
• Clorazepate (Tranxene)
• Chlordiazepoxide (Libratabs)
• Flurazepam (Dalmane)

Other benzodiazepines are not as long-lasting. Shorter-acting drugs in this group include:

• Alprazolam (Xanax)
• Lorazepam (Ativan)
• Triazolam (Halcion)

Keep in mind, though, that the shorter-acting drugs also can impair driving and other skills. These medications have their strongest effects in the first hours after you take them.

If you are an older adult taking long-lasting benzodiazepines for insomnia or anxiety, talk with your health care provider. You may want to switch to another medication that is not linked to a higher risk for accidents.

However, do not stop taking medication without talking to your doctor first. Stopping these drugs suddenly can lead to seizures or severe anxiety attacks in some cases.

Anxiety is often manageable and mild. But sometimes it can present serious problems. A high level or prolonged state of anxiety can be very incapacitating, making the activities of daily life difficult or impossible. Besides generalized anxiety, other anxiety disorders are panic, phobia, obsessive-compulsive disorder (OCD) and posttraumatic stress disorder.

Phobias, which are persistent, irrational fears and are characterized by avoidance of certain objects, places and things, sometimes accompany anxiety. A panic attack is a severe form of anxiety that may occur suddenly and is marked with symptoms of nervousness, breathlessness, pounding heart and sweating. Sometimes the fear that one may die is present.

Anti-anxiety medications help to calm and relax the anxious person and remove the troubling symptoms. There are a number of anti-anxiety medications currently available. The preferred medications for most anxiety disorders are the benzodiazepines.

In addition to the benzodiazepines, a non-benzodiazepine, buspirone (BuSpar), is used for generalized anxiety disorders. Antidepressants are also effective for panic attacks and some phobias and are often prescribed for these conditions. They are also sometimes used for more generalized forms of anxiety, especially when it is accompanied by depression. The medications approved by the FDA for use in OCD are all anti-depressants — clomipramine, fluoxetine and fluvoxamine.

The most commonly used benzodiazepines are alprazolam (Xanax) and diazepam (Valium), followed by chlordiazepoxide (Librium, Librax, Libritabs). Benzodiazepines are relatively fast-acting medications; in contrast, buspirone must be taken daily for two or three weeks before its antianxiety effect is felt.

Most benzodiazepines will begin to take effect within hours, some in even less time. Benzodiazepines differ in duration of action in different individuals; they may be taken two or three times a day, or sometimes only once a day. Dosage is generally started at a low level and gradually raised until symptoms are diminished or removed. The dosage will vary a great deal depending on the symptoms and the individual’s body chemistry.

Benzodiazepines have few side effects. Drowsiness and loss of coordination are most common; fatigue and mental slowing or confusion can also occur. These effects make it dangerous to drive or operate some machinery when taking benzodiazepines, especially when the patient is just beginning treatment. Other side effects are rare.

Benzodiazepines combined with other medications can present a problem, notably when taken together with commonly used substances such as alcohol. It is wise to abstain from alcohol when taking benzodiazepines, as the interaction between benzodiazepines and alcohol can lead to serious and possibly life-threatening complications.

Following the doctor’s instructions is important. The doctor should be informed of all other medications the patient is taking, including over-the-counter preparations. Benzodiazepines increase central nervous system depression when combined with alcohol, anesthetics, antihistamines, sedatives, muscle relaxants, and some prescription pain medications.

Particular benzodiazepines may influence the action of some anticonvulsant and cardiac medications. Benzodiazepines have also been associated with abnormalities in babies born to mothers who were taking these medications during pregnancy.

With benzodiazepines, there is a potential for the development of tolerance and dependence as well as the possibility of abuse and withdrawal reactions. For these reasons, the medications generally are prescribed for brief periods of time days or weeks and sometimes intermittently, for stressful situations or anxiety attacks. For the same reason, ongoing or continuous treatment with benzodiazepines is not recommended for most people. Some patients may, however, need long-term treatment.

Consult with the doctor before discontinuing a benzodiazepine. A withdrawal reaction may occur if the treatment is abruptly stopped. Symptoms may include anxiety, shakiness, headache, dizziness, sleeplessness, loss of appetite, and, in more severe cases, fever, seizures and psychosis.

A withdrawal reaction may be mistaken for a return of the anxiety, since many of the symptoms are similar. Thus, after benzodiazepines are taken for an extended period, the dosage is gradually tapered off before being completely stopped.

Although benzodiazepines, buspirone, tricyclic antidepressants, or SSRIs are the preferred medications for most anxiety disorders, occasionally, for specific reasons, one of the following medications may be prescribed: antipsychotic medications; antihistamines (such as Atarax, Vistaril, and others); barbiturates such as phenobarbital; and beta-blockers such as propranolol (Inderal, Inderide). Propanediols such as meprobamate (Equanil) were commonly prescribed prior to the introduction of the benzodiazepines, but today rarely are used.

Before undergoing any treatment for panic disorder, a person should undergo a thorough medical examination to rule out other possible causes of the distressing symptoms. This is necessary because a number of other conditions, such as excessive levels of thyroid hormone, certain types of epilepsy, or cardiac arrhythmias, which are disturbances in the rhythm of the heartbeat, can cause symptoms resembling those of panic disorder.

Several effective treatments have been developed for panic disorder and agoraphobia. In 1991, a conference held at the National Institutes of Health (NIH) under the sponsorship of the National Institute of Mental Health and the Office of Medical Applications of Research, surveyed the available information on panic disorder and its treatment. The conferees concluded that a form of psychotherapy called cognitive-behavioral therapy and medications are both effective for panic disorder. A treatment should be selected according to the individual needs and preferences of the patient, the panel said, and any treatment that fails to produce an effect within six to eight weeks should be reassessed.

Cognitive-Behavioral Therapy

This is a combination of cognitive therapy, which can modify or eliminate thought patterns contributing to the patient’s symptoms, and behavioral therapy, which aims to help the patient to change his or her behavior.

Typically the patient undergoing cognitive-behavioral therapy meets with a therapist for one to three hours a week. In the cognitive portion of the therapy, the therapist usually conducts a careful search for the thoughts and feelings that accompany the panic attacks. These mental events are discussed in terms of the “cognitive model” of panic attacks.

The cognitive model states that individuals with panic disorder often have distortions in their thinking, of which they may be unaware, and these may give rise to a cycle of fear. The cycle is believed to operate this way: First the individual feels a potentially worrisome sensation such as an increasing heart rate, tightened chest muscles, or a queasy stomach. This sensation may be triggered by some worry, an unpleasant mental image, a minor illness, or even exercise. The person with panic disorder responds to the sensation by becoming anxious. The initial anxiety triggers still more unpleasant sensations, which in turn heighten anxiety, giving rise to catastrophic thoughts. The person thinks, “I am having a heart attack” or “I am going insane,” or some similar thought. As the vicious cycle continues, a panic attack results. The whole cycle might take only a few seconds, and the individual may not be aware of the initial sensations or thoughts.

Antidepressants are not habit-forming and are not drugs of abuse.

Do not despair if the first medication does not work. Finding the appropriate medication(s) and dosages may take time. The good news is that many different antidepressants are available.

The most frequent reason for an antidepressant “failure” is that the dose was too low and the duration of treatment too short.

Feeling better is not a good reason for discontinuing or reducing your medications. Individuals often are tempted to stop medication too soon, risking relapse or recurrence. For individuals with bipolar disorder or recurrent major depression, medication may have to become part of everyday life to avoid return of disabling symptoms.

You should never mix medications of any kind—prescribed, over-the counter, herbs, or borrowed—without consulting a doctor. Some drugs, like alcohol, reduce the effectiveness of antidepressants and should be avoided. This includes wine, beer and hard liquor.

Some drugs, which are usually safe when taken alone, can cause severe and dangerous side effects if taken with other drugs. Always tell dentists, pharmacists and other medical specialists that you are taking antidepressants.

If you have been prescribed an MAOI (such as Parnate or Nardil), you will have to avoid certain foods and over-the-counter medications. Be sure to get a complete list of disallowed foods and medications from your doctor and always carry it with you.

Antianxiety drugs, such as diazepam (Valium) or alprazolam (Xanax), are not antidepressants. They are sometimes prescribed along with antidepressant therapy, but should not be taken alone for a depressive disorder.

Scientific studies suggest that patients with three or more episodes of depression or two severe episodes may need to be maintained on antidepressants indefinitely. The maintenance dose should be the same as the dose required to achieve an initial therapeutic response.

Antidepressants work best in most individuals when prescribed alongside a course of psychotherapy. People taking both medication and engaging in psychotherapy generally take less time to feel better and maintain their gains longer than those taking antidepressant medications alone.

Read more about depression now…

Michael Herkov, Ph.D., and Wayne Goodman, M.D. also contributed to this article.

Experiencing anxiety in and of itself does not constitute a disorder. In fact, anxiety is a necessary warning signal of a dangerous or difficult situation. Without anxiety, we would have no way of anticipating difficulties ahead and preparing for them.

Anxiety becomes a disorder when the symptoms become chronic and interfere with our daily lives and our ability to function. People suffering from chronic anxiety often report the following symptoms:

• Muscle tension
• Physical weakness
• Poor memory
• Sweaty hands
• Fear
• Confusion
• Inability to relax
• Constant worry
• Shortness of breath
• Palpitations
• Upset stomach
• Poor concentration

These symptoms are severe and upsetting enough to make individuals feel extremely uncomfortable, out of control and helpless.

Naomi is a bright, highly motivated young woman who works as an executive for a large investment firm and is doing quite well in her career. Although she is well-liked by both colleagues and superiors, Naomi has never told them that she suffers from terrible, unexplained anxieties.

Ever since she was a child, she remembers worrying about things. She would worry about her father getting home safely from work or her sister getting safely to school. She often had the feeling that something dreadful was about to happen.

In her adult years, in addition to her constant worry, Naomi has become increasingly aware of feeling depressed. There are days when, for no apparent reason, she feels extremely “blue,” without energy or ambition, and suffers from low self-esteem. All of this is puzzling, since she continues to be successful at work, just as she had been at school. However, try as she might, she cannot shake these feelings of being down and of continually worrying that something terrible would happen. It was after coming home extremely drunk one night, after being out with friends, that she decided to seek help; nothing was improving and she was aware of an increase in her alcohol use.

Large numbers of people, like Naomi, have their lives disrupted by the interference of unwelcome and unrealistic fears, phobias, and worries. Some individuals attempt to deal with their anxieties by turning to alcohol to gain relief. The result is that the symptoms are further aggravated. Others do everything they can to avoid situations that might cause an increase in symptoms. Whatever it is that people attempt to do to cope with their fears, it is usually unsuccessful because of their inability to stop feeling nervous. For these people, life can become increasingly narrow and restricted.

Things have not changed very much for Naomi since childhood except that her fears and worries have worsened. She feels most comfortable with her set routine and avoids travel, parties, and dining out for fear of introducing something new in her life to worry about. And yet, there are many nights when Naomi is unable to sleep, preoccupied with some problem at work, in her social life, or with her family. None of this has ever prevented her from carrying on with life in general, but it has made her life miserable.

When Naomi referred herself for psychotherapy, she was told that her situation was not unusual; in fact, she was suffering from a common malady called “generalized anxiety disorder” or GAD. She was also told that depression often accompanies this disorder.

The chronic worry that accompanies GAD is impossible for the sufferer to control. The irony is that these worries and fears are not completely unrealistic. There is always the possibility in life that something terrible might, indeed, happen. However, the sufferer feels and thinks as though the fears and worries are well-founded and highly likely to occur. Whether a danger is imminent, remote, or completely unlikely makes no difference to someone with GAD. Not surprisingly, it is often the case that anxiety disorders run in families.