Oxford Handbooks offer up-to-date, critical reviews of original research by leading figures in the discipline. Despite the comprehensive and highly academic nature of “The Oxford Handbook of Traumatic Stress Disorders,” it is well organized to make it easy to locate key findings, summaries and abstracts. An extensive index and references are included, and it is all searchable online.

The tome aimed at professionals dealing with the diagnosis and treatment of traumatic stress disorders provides an extremely thorough and detailed look at all aspects and issues surrounding the disorders.

In “Defining Traumatic Events: Research Findings and Controversies,” the editors examine the history of the controversy over “Criterion A,” the trigger for post-traumatic stress disorder. It has significant clinical and legal implications.

Criterion A defines those stresses that may be considered a potentially traumatic event:

• The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others.
• The person’s response involved intense fear, helplessness, or horror.

A major aspect of the controversy is over whether the definition is too broad or too narrow. Too broad of a definition would dilute it and could lead clinicians to misidentify normal reaction to stressful events. Too narrow a definition leaves out those deserving eligible care. Revisions to criterion A are proposed the upcoming edition of the primary “Manual of Mental Disorders.”

Currently, a diagnosis of acute stress disorder requires criterion A, plus clinically significant functional impairment as well as at least three of five dissociative symptoms.

In a later chapter, proposed changes to the acute stress disorder diagnosis and future directions for research into early predictors of post-traumatic stress disorder are discussed.

Chapter 4, “Classification of Posttraumatic Stress Disorder,” reviews the current criteria of PTSD. It examines the symptoms and their overlap with symptoms for other disorders.

The authors observe, “Although many traumas do involve the acute experience of intense fear, helplessness, or horror, events evoking primary emotions of anger or shame can also generate PTSD.”

Later the handbook addresses modifications to the definition of PTSD and proposed changes for the DSM-5 manual. Authors of this chapter note, “The precise factor structure of PTSD has been addressed by many research teams over the past 15 years. The structure of the construct as described in the DSM-IV is that PTSD consists of three symptom clusters: Re-experiencing, Avoidance/ numbing, and Hyper-arousal. Utilizing confirmatory factor analysis strategies, studies tested whether the three symptom clusters of DSM-IV provide the best model for the latent structure of PTSD. In short, the overwhelming majority of studies support a four-factor model.” and, “Among these four-factor models, re-experiencing, avoidance, and hyper-arousal have emerged as distinct clusters in all of these studies.” Rationale for the addition of new symptoms is examined and future research is suggested.

Chapter 7, which is called “Epidemiology of Posttraumatic Stress Disorder in Adults,” summarizes information on the prevalence of PTSD in U.S. veterans of the Vietnam War as well as the soldiers returning home more recently from deployment in Iraq and Afghanistan. It gives an overview of PTSD research, risk factors, and the risk for other post trauma disorders. Some of the concluding results are:

• There is a direct relationship between the intensity of conflict and risk of PTSD.
• At least 80 percent of residents in the United States qualify for the diagnosis of PTSD.
• Only a small proportion of those exposed to traumatic events actually develop PTSD.
• Exposure to a violent assault is more likely to result in PTSD than other types of traumatic events.
• Women are at higher risk for PTSD than men.

The chapter reaches the conclusion, “The most important impact of the extensive epidemiological literature of PTSD has been a sharp shift away from the original model in DSM-III that PTSD was a normal response to an abnormal stressor. The idea that traumatic events would cause PTSD in most victims, regardless of preexisting vulnerabilities, has been refuted. PTSD is seen as a pathological response by a minority of persons.”

Another section examines populations of people with psychiatric, behavioral, cognitive, or physical disabilities who have a higher than normal likelihood to be exposed to psychological trauma.  “Individuals with severe psychiatric disorders, substance abuse disorders, developmental disabilities, and persons who are incarcerated are more likely to experience trauma throughout their lives, especially interpersonal victimization, and are more likely to develop posttraumatic stress disorder (PTSD),”according to the book.

“Contributions from Theory,” the fourth section of the extensive handbook, looks at the current research in genetics and genomics of PTSD, related biological issues, learning models and family models of PTSD.

The next section of the book covers assessment. The most widely used assessment tools for PTSD are described, including structured interviews, self-reports, and psychophysiological methods. Key PTSD issues are discussed, including identifying an index traumatic event, the linking of symptoms, detecting malingering and reporting false or exaggerated symptoms. Psychophysiological measurements vary, but often include recordings of heart rate, skin conductance, musculature contraction/relaxation and electrocortical measures such as EEG. While psychophysiological procedures provide more evidence for PTSD, these tests have limitations. Roughly 40 percent of people with PTSD show little or no physiologic reactivity. The authors conclude that an approach using one or more of each type of measurement is the best way to go.

Overall, The Oxford Handbook of Traumatic Stress Disorders is an invaluable, comprehensive guide for clinical psychologists, psychiatrists and social workers who care for those with traumatic stress disorders.

J. Gayle Beck and Denise M. Sloan have prepared an extremely detailed gem that I highly recommend for graduate students, scholars and practitioners in psychology and related fields.

The Oxford Handbook of Traumatic Stress Disorders
Edited by J. Gayle Beck, Denise M. Sloan
Oxford University Press, Inc., February, 2012
Hardcover, 576 pages
$150

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.

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.