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.

Normally, specific parts of the brain are tuned into each another at certain frequencies, say the researchers. This rhythmic activity produces brain waves and allows information to be processed in order for us to react.

The team used the analogy of an orchestra to explain how this works. They say that brain activity can be compared to the performance of an orchestra in which string, brass, woodwind and percussion sections are joined together in rhythms dictated by the conductor. In a similar way, specific structures in the brain tune in to one another at certain frequencies. Their rhythmic activity creates brain waves, and the tuning of these brain waves normally allows information to be processed that guides our behavior. But cannabis causes disturbances in systems involved in concentration and memory, the team found.

The primary psychoactive ingredient of cannabis, known as THC, activates cannabinoid receptors, which are found in many brain areas. In the research, the team measured the electrical activity from hundreds of neurons in rats when given a drug similar to THC which also stimulates cannabinoid receptors.

This showed that the effects on individual brain regions were subtle, but brain waves across the hippocampus and prefrontal cortex were completely disrupted. These two brain areas are vital for memory and decision-making, so the rats were no longer able to accurately navigate a maze. Both areas are also involved in schizophrenia.

Findings are published in the Journal of Neuroscience. The authors write that these results show a possible mechanism behind the cognitive impairment caused by cannabis that was described by Dr Frederick T. Melges and his team back in 1970. Dr. Melges called the effect “temporal disintegration,” and described it as “difficulty in retaining, coordinating and serially indexing those memories, perceptions and expectations that are relevant to the goal one is pursuing.”

More recent studies suggest that THC given intravenously to healthy volunteers can induce several psychotic symptoms of schizophrenia, so the authors believe that THC studies be used to model broader aspects of the disease, not just cognitive dysfunction.

Dr. Jones commented, “Marijuana abuse is common among sufferers of schizophrenia and recent studies have shown that the psychoactive ingredient of marijuana can induce some symptoms of schizophrenia in healthy volunteers. These findings are therefore important for our understanding of psychiatric diseases, which may arise as a consequence of ‘disorchestrated brains’ and could be treated by re-tuning brain activity.”

Co-author Michal Kucewicz added, “These results are an important step forward in our understanding of how rhythmic activity in the brain underlies thought processes in health and disease.”

The researchers conclude, “These tools will continue to shed light on the neural mechanisms of working memory and decision making in health and disease.”

A 2012 review of current knowledge shows that the endocannabinoid system in the brain has a major role in schizophrenia. “Data reported so far clearly indicate the presence of a dysregulation in the endocannabinoid system in animal models of psychosis as well as in schizophrenic patients,” the review says.

Its authors, led by Professor Daniela Parolaro of the University of Insubria, Italy, add that animal models suggest that adolescence is “a highly vulnerable age for the consequences of cannabis exposure on different domains (such as cognition and social behavior) that are altered in psychotic disorders.”

They suggest that drugs which target the cannabinoid system are “a new therapeutic possibility for psychotic disorders.” However, they warn that drug studies so far have not had straightforward results, with different types of drug showing different effects.

But despite all these limitations, cannabidiol, a compound found in cannabis that activates cannabinoid receptors, has shown fairly consistent antipsychotic properties in animal tests. Recent studies indicate that cannabidiol may be as effective as antipsychotics in treating schizophrenia.

The benefit of cannabidiol appears similar to that gained from atypical antipsychotic drugs, and so far it is considered a safe and well-tolerated compound. Future studies will need to compare its antipsychotic effects against standard drugs for schizophrenic patients.

References

Kucewicz, M. T. et al. Dysfunctional Prefrontal Cortical Network Activity and Interactions following Cannabinoid Receptor Activation. Journal of Neuroscience, published online October 25, 2011.

Zamberletti, E., Rubino, T. and Parolaro, D. The endocannabinoid system and schizophrenia: integration of evidence. Current Pharmaceutical Design, published online June 7, 2012.

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.

Nonadherence has critical consequences, including worsening of symptoms and hospitalization. “Rates of relapse for those [patients] taking vs. not taking medications are about 44 percent and 20 percent respectively,” Velligan said.

What Predicts Nonadherence

When it comes to adhering to treatment, people with schizophrenia aren’t all that different from individuals with other chronic conditions, including diabetes and high blood pressure, Velligan said. Not taking medication seems to be a problem for conditions that require long-term treatment.

The major difference, however, is that individuals with schizophrenia can have poor insight into their illness, which makes them more likely to skip treatment. In fact, poor insight may be the biggest predictor of nonadherence. “Individuals don’t think they are ill, or don’t understand that when acute symptoms subside medication is still necessary,” Velligan said.

The very nature of schizophrenia can complicate adherence. For instance, consistency is key for following treatment. But people with schizophrenia have a hard time sticking to routines. “There is no regular pattern of behavior that can make adherence easy,” Velligan said.

They also struggle with cognitive impairments. Patients may intend to take their medication but simply forget. “In these cases sometimes as many as half the doses are missed, making the medication less effective,” Velligan said.

But the negative consequences of stopping medication aren’t obvious to patients. If a patient misses a pill, there are no immediate repercussions, she said. “Symptoms may not get worse for days, weeks or even months [which makes it] very difficult for the person to make the connection between poor adherence and rehospitalization,” she said.

Some patients skip doses or stop taking medication because of side effects. For instance, weight gain and movement side effects are especially bothersome to patients, Velligan said.

Also, patients with substance abuse problems are less likely to adhere to treatment, she said.

The service system itself can make adherence difficult. “Sometimes patients are given appointments with an outpatient doctor after hospital discharge that will occur after their prescription from the hospital will run out,” Velligan said.

Strategies That Improve Treatment Adherence

Cognitive-behavioral therapy (CBT) is effective in enhancing treatment adherence. CBT doesn’t challenge a patient’s resistance to medication; instead it explores why the person doesn’t want to take medication and helps them reevaluate their negative beliefs toward medication.

Also, CBT helps patients identify their recovery goals, and links them to treatment adherence, according to Velligan. For instance, many people with schizophrenia take their medication because of relationships, whether it’s a relationship with their spouse or family member. For these individuals, one goal may address relationship quality.

CBT incorporates motivational interviewing techniques and helps patients see a clear link between poor adherence and relapse. (This full-text article provides more information on CBT for schizophrenia.)

Visual reminders, such as signs, checklists and pill containers, facilitate adherence. Velligan and her colleagues have even used electronic pill containers to prompt patients and provide a slew of important information: “to tell patients when to take medication, remind the person of the dose and reason for medication, tell the person if they are taking the wrong medication or taking it at the wrong time, and download adherence data to a secure server so that a caregiver or caseworker can keep track of adherence are becoming more widely available.”

Another option is injectable medication. Several studies have shown that long-term injectable antipsychotics increase adherence and decrease relapse risk. (Learn more here and here.) “If a person does not show up for an injection, the treatment team knows there is an issue and can intervene in a timely way,” Velligan said. Other research has suggested that it’s also important to discuss the benefits of adherence with patients receiving injectable medication.

How Loved Ones Can Help with Adherence

When someone with schizophrenia stops taking medication or skips other treatments, it can be frustrating and difficult for loved ones. You may naturally feel powerless. However, you have more influence than you realize, Velligan said. Here are several ways you can help.

• Make your support contingent on adherence. It’s common for loved ones to support the person financially and provide them with a place to live, Velligan said.
• Help them find effective treatment. Get your loved one involved in therapy and working with an experienced psychiatrist, Velligan said.
• Set up reminders for medication. Use pill containers, checklists and signs to make remembering to take medication much easier, she said.
• Try injectable medication. “With an injection, the person does not have to face the decision every day about taking medication, and remind themselves every day that they have an illness,” Velligan said.

Further Reading

Velligan, D.I., Weiden, P.J., Sajatovic, M., Scott, J., Carpenter D., Ross, R., Docherty, J.P. (2009). The expert consensus guideline series: Adherence problems in patients with serious and persistent mental illness. The Journal of Clinical Psychiatry, 70, 1-46.

For decades, the dominant hypothesis of depression has been that low levels of monoamines in the brain cause this debilitating disorder.

In the ‘80s, the selective serotonin reuptake inhibitor (SSRI) fluoxetine (brand name: Prozac) heralded a new era of safer drugs which also target the monoamine system. Since then, various SSRIs and serotonin-norepinephrine reuptake inhibitors (or SNRIs) have been developed as new antidepressants. While these drugs aren’t more effective than older antidepressants, they are less toxic.

But SSRIs and SNRIs don’t work for everyone, so MAOIs and TCAs still are prescribed.

Two out of three patients with depression do not fully recover on an antidepressant medication according to findings from STAR*D, the largest clinical trial study of treatments for major depressive disorder, funded by the National Institute of Mental Health. (One-third of patients do have a remission of their depression symptoms.)

These results “are important because previously it was unclear just how effective (or ineffective) antidepressant medications are in patients seeking treatment in real-world settings,” said James Murrough, M.D., board-certified psychiatrist and a research fellow at the Mount Sinai School of Medicine Mood and Anxiety Disorders Program.

As Murrough explained, depression treatment can be thought of in thirds: “for one third of patients, symptoms remit; another third don’t have as good of an outcome, experiencing residual symptoms and waxing and waning course or chronic course and are at risk for relapse whether they’re on or off medication; and then a third don’t get much benefit at all.”

He added that around “10 to 20 percent have persistent clinically significant symptoms that aren’t decreased by current treatment — these are the patients that we are the most worried about.”

So there’s a real need to find treatments that work for these patients. Since the 1950s and 1980s breakthroughs, researchers haven’t discovered drugs that target chemical systems in the brain other than the monoamine system.

“We haven’t been able to find any new systems, because we don’t understand the underlying biology of depression,” Murrough said.

But researchers are studying other mechanisms of depression and various drugs have recently been approved to treat depression. Below, you’ll learn about these drugs along with several chemical systems research is exploring.

Recently Approved Drugs for Depression

Recently approved drugs for depression are generally “me-too” drugs. A “me-too drug is a drug whose mechanism of action (what it does at the molecular level in the brain) is not meaningfully different than its predecessor,” Dr. Murrough said.

Prime examples of me-too drugs are desvenlafaxine (Pristiq), an SNRI, and escitalopram (Lexapro), an SSRI, he said. Pristiq is simply Effexor’s main metabolite. Lexapro is essentially a close relative derivative of citalopram (Celexa). Interestingly, sales still skyrocketed when Lexapro came out.

As Murrough said, there is value in some me-too drugs. Generally, all drugs within the classes SSRIs and SNRIs are me-too drugs. But the side effect profiles for each drug have slight differences, which can help patients.

For instance, Prozac tends to be more activating, so a doctor may prescribe it for patients with low energy, Murrough said. In contrast, paroxetine (Paxil) makes people more tired, so it’s prescribed to patients who have trouble sleeping, he said.

The drug Oleptro was approved this year for depression. It doesn’t target new mechanisms, and it isn’t even a me-too drug, Murrough said. It’s a reformulation of trazodone, an atypical antidepressant that’s been used as a sleeping aid by psychiatrists and other doctors. Because it’s so sedating, its earlier form would just put patients to sleep. “It is unclear if the new formulation will offer any benefit for patients over the original,” Murrough said.

These recently approved medicines “characterize the state of drugs in psychiatry,” Murrough said, and speak to “what’s wrong with antidepressant drug development today.” Novel treatments just aren’t on the market.

Augmentation of Depression Drugs

Recently, the biggest development in depression treatment has been the use of augmenting agents, said David Marks, M.D., assistant professor at the Department of Psychiatry & Behavioral Sciences at the Duke University Medical Center.

Specifically, some research has found that adding atypical antipsychotic drugs, like aripiprazole (Abilify) and quetiapine (Seroquel), to an antidepressant can boost its effectiveness.

Atypical antipsychotics are used to treat schizophrenia and bipolar disorder. “Abilify has three strong studies that show how well it works in patients that have partially responded to antidepressants,” Marks said. According to Murrough, augmentation has become a common strategy in depression treatment.

The Glutamate System and Depression

Researchers have looked at the role of the glutamate system in depression. Glutamate is abundant in the brain and is one of the most common neurotransmitters. It’s involved in memory, learning and cognition.

Some research has implicated the dysfunction of the glutamate system in medical conditions, such as Huntington’s chorea and epilepsy, and psychological disorders, such as schizophrenia and anxiety disorders.

Recent research suggests that drugs targeting a specific type of glutamate receptor in the brain — called the NMDA receptor — may have antidepressant effects.

Studies have explored ketamine, an NMDA antagonist, in treating treatment-resistant depression and acute suicidal ideation. Ketamine has a long history in analgesia and anesthesiology.

Currently, when a person is at imminent risk for attempting suicide or has attempted suicide, they’re admitted to a psychiatric hospital and closely monitored. But, as Murrough explained, medically, there’s nothing doctors can do to help with suicidal ideation or intense depressed mood. Antidepressants typically four to six weeks to work.

Ketamine appears to have fast antidepressant effects — within hours or a day. Thus, it may help protect patients from suicidal thinking or acute dysphoria when they’re in the hospital. Unfortunately, its effects only last seven to 10 days.

This research is “highly experimental, and probably less than 100 patients in the country have participated in controlled depression studies of ketamine,” Murrough said. The patients in these studies typically have treatment-resistant depression: They haven’t responded to several antidepressants and have moderate to severe symptoms of depression.

They’re admitted to the hospital and receive ketamine intravenously from an anesthesiologist, while their vital signs are closely monitored.

Ketamine is a drug of abuse, known by such street names as “Special K.” It induces trance-like or hallucination states. It also produces mild to moderate cognitive side effects, like other anesthetics. People report feeling “out of it,” intoxicated and disconnected in general.

These side effects actually “introduce a potential bias to the study design” because participants know they’re getting the treatment (when saline is given in the placebo condition), Murrough said.

To eliminate this bias, Murrough and his team are conducting the first-ever study to compare ketamine to a different anesthetic — the benzodiazepine midazolam (Versed) — which has similar transient effects as ketamine, he said. The study is currently recruiting participants.

Murrough cautioned that ketamine isn’t meant to be a treatment administrated at your doctor’s office. In a recent article in the journal Nature Medicine, he said ketamine treatment may be “akin to electroconvulsive shock treatment.”

Studying ketamine may reveal mechanisms underlying depression and help to find drugs that can be prescribed as antidepressants to a wider patient population.

Pharmaceutical companies have started exploring other NMDA receptor antagonists for treatment-resistant depression. For instance, in July 2010, the pharmaceutical company Evotec Neurosciences began testing a compound in a Phase II study, which evaluates the safety and efficacy of a drug.

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.

In contrast to the earlier drugs, atypicals usually work on serotonin receptors in addition to dopamine receptors. Drugs in this group include olanzapine (Zyprexa), clozapine (Clozaril), risperidone (Risperdal), quetiapine (Seroquel), ziprasidone (Geodon), aripiprazole (Abilify) and paliperidone (Invega).

The drugs are prescribed for conditions such as schizophrenia and bipolar disorders and may also be given for agitation, anxiety, psychotic episodes and obsessive behaviors. Their off-label use is increasing, and the Food and Drug Administration has now approved Abilify for use in adults who do not respond to antidepressants alone.

The most common side effects include dry mouth, blurred vision and constipation, dizziness or lightheadedness, and weight gain. Sometimes atypical antipsychotics can cause problems sleeping, extreme tiredness and weakness.

With long-term use, atypical antipsychotics can also carry a risk of tardive dyskinesia, a condition involving repetitive, involuntary movements often of the mouth, tongue, facial muscles and upper limbs. Physicians aim to prevent its development by using the lowest effective dose of antipsychotics for the shortest time.

When possible the medication should be stopped, or reduced, if tardive dyskinesia is diagnosed. But the condition may remain for months, years, or even permanently. Its symptoms may be reduced with the drug tetrabenazine (Xenazine), but this drug has been linked with its own side effects, including depression, dizziness, drowsiness, insomnia, fatigue and nervousness.

Other medications may also help tardive dyskinesia, including ondansetron (Zofran) and several anti-Parkinsonian drugs. Benzodiazepines have been tried, but a 2006 review found this treatment “did not result in any clear changes” so routine clinical use is not recommended. Changing to a newer form of atypical antipsychotic might be beneficial.

Associate Professor Thomas Schwartz from the Department of Psychiatry at the State University of New York says that the lower-potency atypical antipsychotics, Seroquel, Abilify and Geodon, “are probably associated with the smallest risk for tardive dyskinesia.”

Another possible side effect of atypical antipsychotics is Parkinsonism, a neurological condition involving tremors, hypokinesia (decreased bodily movement), rigidity, and unsteadiness. The risk is lower on Abilify than Geodon, due to their mechanisms of action.

These drugs are also linked with a common neurological movement disorder called dystonia. It involves involuntary and uncontrollable muscle spasms which can force affected parts of the body into abnormal, sometimes painful, movements or postures. Dystonia can be generalized throughout the body, or occur in one place such as the neck muscles, the muscles around the eyes, the face, jaw or tongue, or the vocal cords.

There is currently no cure for dystonia, but there are several popular treatments depending on the type of dystonia and age of onset. As dystonia is a complex and personal condition, the effectiveness of treatment options can vary widely between patients.

One common treatment is regular injections of botulinum toxin, usually repeated every three months. Some oral drugs are also available, including anticholinergic drugs such as trihexyphenidyl which helps control muscle spasms and the tremor by blocking the effect of a chemical messenger in the brain called acetylcholine.

Benzodiazepines are frequently used in the treatment of dystonia. They work by boosting levels of a chemical which inhibits nerve signals in the brain, so act as muscle relaxants. They may trigger sleepiness and sedation if the medication is stopped too rapidly. The GABA agonist baclofen is another muscle relaxant which may ease the muscular spasms and cramps of dystonia, but may cause lethargy, upset stomach, dizziness and dry mouth.

Akathisia, another possible side effect of atypical antipsychotics, is often described as an “inner restlessness” that makes it difficult to sit still or remain motionless. Unfortunately it is often misunderstood and misdiagnosed, sometimes leading to patients reducing or stopping their medication without advice from the physician.

It may be reduced by decreasing the dose or by changing drugs, but this should always take place under medical supervision. Treatment may include beta-blockers such as propranolol or metoprolol, or benzodiazepines such as clonazepam.

A 2010 review concluded that, “Effective and well-tolerated treatment is a major unmet need in akathisia.” But author Michael Poyurovsky, of the Tirat Carmel Mental Health Center in Israel, added, “Accumulating evidence indicates that agents with marked serotonin-2A receptor antagonism may represent a new class of potential anti-akathisia treatment.” These drugs include cyproheptadine, ketanserin, mirtazapine, nefazodone, pizotifen and trazodone, although none are yet specifically indicated for akathisia.

Rarely, atypical antipsychotics may trigger diabetes. The cause seems to involve an increase in insulin resistance and changes to insulin secretion. Metabolic syndrome can also be produced by the drugs. The FDA requires all manufacturers of atypical antipsychotics to include a warning about the risks of diabetes and hyperglycemia (high blood pressure).

The risk appears to be highest with Zyprexa and Clozaril. Geodon and Abilify are thought to have the smallest risk. Experts from the Texas Tech University Health Sciences Center in Dallas, say that “periodic monitoring of glucose should be considered” for all patients on atypical antipsychotics.

References

Bhoopathi, P. S. S. and Soares-Weiser, K. Benzodiazepines for neuroleptic-induced tardive dyskinesia. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD000205

Schwartz, T. and Raza, S. Aripiprazole (Abilify) and Tardive Dyskinesia. Pharmacy and Therapeutics, Vol. 33, January 2008, pp. 32-34.

http://en.wikipedia.org/wiki/Atypical_antipsychotic

www.dystonia.org.uk

Poyurovsky M. Acute antipsychotic-induced akathisia revisited. The British Journal of Psychiatry, Vol. 196, February 2010, pp. 89-91.

Mathys, M., Blaszczyk, A. and Busti, A. Incidence of abnormal metabolic parameters and weight gain induced by atypical antipsychotics in elderly patients with dementia. The Consultant Pharmacist, Vol. 24, March 2009, pp. 201-9.

While 85 percent of Americans recognize that schizophrenia is a disorder, only 24 percent are actually familiar with it. And according to a 2008 survey by the National Alliance on Mental Illness (NAMI), 64 percent can’t recognize its symptoms or think the symptoms include a “split” or multiple personalities. (They don’t.)

Aside from ignorance, images of the aggressive, sadistic “schizophrenic” are plentiful in the media. Such stereotypes only further the stigma and quash any shred of sympathy for individuals with this illness, writes Dr. Torrey. Stigma has a slew of negative consequences. It’s been associated with reduced housing and employment opportunities, diminished quality of life, low self-esteem and more symptoms and stress (see Penn, Chamberlin & Mueser, 2003).

So it’s bad enough that people with schizophrenia are afflicted with a terrible disease. But they also have to deal with the confusion, fear and disgust of others. Whether your loved one has schizophrenia or you’d like to learn more, gaining a better understanding of it helps demystify the disease and is a huge help to those who suffer from it.

Below are some pervasive myths — followed by actual facts — regarding schizophrenia.

1. Individuals with schizophrenia all have the same symptoms.

For starters, there are different types of schizophrenia. Even individuals diagnosed with the same subtype of schizophrenia often look very different. Schizophrenia is “a huge, huge range of people and problems,” said Robert E. Drake, M.D., Ph.D, professor of psychiatry and of community and family medicine at Dartmouth Medical School.

Part of the reason that schizophrenia is so mysterious is because we’re unable to put ourselves in the shoes of someone with the disorder. It’s simply hard to imagine what having schizophrenia would be like. Everyone experiences sadness, anxiety and anger, but schizophrenia seems so out of our realm of feeling and understanding. It may help to adjust our perspective. Dr. Torrey writes:

Those of us who have not had this disease should ask ourselves, for example, how we would feel if our brain began playing tricks on us, if unseen voices shouted at us, if we lost the capacity to feel emotions, and if we lost the ability to reason logically.

2. People with schizophrenia are dangerous, unpredictable and out of control.

“When their illness is treated with medication and psychosocial interventions, individuals with schizophrenia are no more violent than the general population,” said Dawn I. Velligan, Ph.D, professor and co-director of the Division of Schizophrenia and Related Disorders at the Department of Psychiatry, UT Health Science Center at San Antonio. Also, “People with schizophrenia more often tend to be victims rather than perpetrators of violence although untreated mental illness and substance abuse often increase the risk of aggressive behavior,” said Irene S. Levine, Ph.D, psychologist and co-author of Schizophrenia for Dummies.

3. Schizophrenia is a character flaw.

Lazy, lacking in motivation, lethargic, easily confused…the list of “qualities” individuals with schizophrenia appear to have goes on and on. However, the idea that schizophrenia is a character defect “is no more realistic than suggesting that someone could prevent his epileptic seizures if he really wanted to or that someone could ‘decide’ not to have cancer if he ate the right foods. What often appears as character defects are symptoms of schizophrenia,” write Levine and co-author Jerome Levine, M.D., in Schizophrenia for Dummies.

4. Cognitive decline is a major symptom of schizophrenia.

Seemingly unmotivated individuals most likely experience cognitive difficulties with problem solving, attention, memory and processing. They may forget to take their medication. They may ramble and not make sense. They may have a tough time organizing their thoughts. Again, these are symptoms of schizophrenia, which have nothing to do with character or personality.

5. There are psychotic and non-psychotic people.

The public and clinicians alike view psychosis as categorical — you’re either psychotic or you’re not — instead of symptoms residing on a continuum, said Demian Rose, M.D., Ph.D, medical director of the University of California, San Francisco PART Program and director of the UCSF Early Psychosis Clinic. For instance, most people will agree that individuals aren’t simply depressed or happy. There are gradients of depression, from mild one-day melancholy to deep, crippling clinical depression. Similarly, schizophrenia symptoms are not fundamentally different brain processes, but lie on a continuum with normal cognitive processes, Dr. Rose said. Auditory hallucinations may seem extraordinarily different but how often have you had a song stuck in your head that you can hear pretty clearly?

6. Schizophrenia develops quickly.

“It’s quite rare to have a big drop in functioning,” Dr. Rose said. Schizophrenia tends to develop slowly. Initial signs often show during adolescence. These signs typically include school, social and work decline, difficulties managing relationships and problems with organizing information, he said. Again, symptoms lie on a continuum. In schizophrenia’s beginning stages, an individual may not hear voices. Instead, he may hear whispers, which he can’t make out. This “prodromal” period — before the onset of schizophrenia — is the perfect time to intervene and seek treatment.

7. Schizophrenia is purely genetic.

“Studies have shown that in pairs of identical twins (who share an identical genome) the prevalence of developing the illness is 48 percent,” said Sandra De Silva, Ph.D, psychosocial treatment co-director and outreach director at the Staglin Music Festival Center for the Assessment and Prevention of Prodromal States (CAPPS) at UCLA, departments of psychology and psychiatry. Because other factors are involved, it’s possible to reduce the risk of developing the illness, she added. There are various prodromal programs that focus on helping at-risk adolescents and adults.

Along with genetics, research has shown that stress and family environment can play a big role in increasing a person’s susceptibility to psychosis. “While we can’t change genetic vulnerability, we can reduce the amount of stress in someone’s life, build coping skills to improve the way we respond to stress, and create a protective low-key, calm family environment without a lot of conflict and tension in hopes of reducing the risk of illness progression,” De Sliva said.

8. Schizophrenia is untreatable.

“While schizophrenia is not curable, it is an eminently treatable and manageable chronic illness, just like diabetes or heart disease,” Levine said. The key is to get the right treatment for your needs. See Living with Schizophrenia here for details.

9. Sufferers need to be hospitalized.

Most individuals with schizophrenia “do well living in the community with outpatient treatment,” Velligan said. Again, the key is the right treatment and adhering to that treatment, especially taking medication as prescribed.

10. People with schizophrenia can’t lead productive lives.

“Many individuals can lead happy and productive lives,” Velligan said. In a 10-year study of 130 individuals with schizophrenia and substance abuse — which co-occurs in nearly 50 percent of patients — from the New Hampshire Dual Diagnosis Study, many gained control over both disorders, reducing their episodes of hospitalization and homelessness, living on their own and achieving a better quality of life (Drake, McHugo, Xie, Fox, Packard & Helmstetter, 2006). Specifically, “62.7 percent were controlling symptoms of schizophrenia; 62.5 percent were actively attaining remissions from substance abuse; 56.8 percent were in independent living situations; 41.4 percent were competitively employed; 48.9 percent had regular social contacts with non–substance abusers; and 58.3 percent expressed overall life satisfaction.”

11. Medications make sufferers zombies.

When we think of antipsychotic medication for schizophrenia, we automatically think of adjectives like lethargic, listless, uninterested and vacant. Many believe medication causes these sorts of symptoms. However, most often these symptoms are either from schizophrenia itself or because of overmedication. Zombie-like reactions are “relatively minor, compared with the number of patients who have never been given an adequate trial of available medications,” according to Dr. Torrey in Surviving Schizophrenia.

12. Antipsychotic medications are worse than the illness itself.

Medication is the mainstay of schizophrenia treatment. Antipsychotic medications effectively reduce hallucinations, delusions, confusing thoughts and bizarre behaviors. These agents can have severe side effects and can be fatal, but this is rare. “Antipsychotic drugs, as a group, are one of the safest groups of drugs in common use and are the greatest advance in the treatment of schizophrenia that has occurred to date,” Dr. Torrey writes.

13. Individuals with schizophrenia can never regain normal functioning.

Unlike dementia, which worsens over time or doesn’t improve, schizophrenia seems to be a problem that’s reversible, Dr. Rose said. There’s no line that once it’s crossed signifies that there’s no hope for a person with schizophrenia, he added.

References

Drake, R.E., McHugo, G.J., Xie, H., Fox, M., Packard, J., & Helmstetter, B. (2006). Ten-Year Recovery Outcomes for Clients With Co-Occurring Schizophrenia and Substance Use Disorders>. Schizophrenia Bulletin, 32, 464-473.

Penn, D.L., Chamberlin, C., & Mueser, K.T. (2003). The effects of a documentary film about schizophrenia on psychiatric stigma. Schizophrenia Bulletin, 29, 383-391.

“Your daughter has schizophrenia,” I told the woman.

“Oh, my God, anything but that,” she replied. “Why couldn’t she have leukemia or some other disease instead?”

“But if she had leukemia she might die,” I pointed out. “Schizophrenia is a much more treatable disease.”

The woman looked sadly at me, then down at the floor. She spoke softly. “I would still prefer that my daughter had leukemia.”

“This book is a product of a thousand such conversations,” writes research psychiatrist and schizophrenia specialist E. Fuller Torrey, M.D., in Surviving Schizophrenia: A Manual for Families, Patients And Providers. Getting a diagnosis of schizophrenia can be devastating. Families and patients alike think there’s no hope. What follows may be shock, shame and confusion. But schizophrenia isn’t a death sentence or an inevitable descent into psychosis and violence, as some movies and shows would have you believe. Even though it may be terrifying, receiving a proper diagnosis is a good thing: It’s one step closer to the right treatment.

“Earlier treatment and shorter duration of untreated psychosis is associated with better treatment response, less likelihood of relapse and better clinical outcome,” said Sandra De Silva, Ph.D, psychosocial treatment co-director and outreach director at the Staglin Music Festival Center for the Assessment and Prevention of Prodromal States (CAPPS) at UCLA, departments of psychology and psychiatry.

Here’s a look at what effective treatment for schizophrenia entails, how you can manage the disorder and what to do if you notice early warning signs.

Early Diagnosis of Schizophrenia

Schizophrenia rarely occurs unexpectedly. Instead, it produces a gradual decline in functioning. There are usually early warning signs, referred to as the “prodrome,” which last one to three years, which provide the perfect place to intervene.

Early symptoms are the same as in psychotic illnesses, but “they are experienced at a milder, subthreshold level,” De Silva said. The key symptoms to look for are “suspiciousness, unusual thoughts, changes in sensory experience (hearing, seeing, feeling, tasting or smelling things that others don’t experience), disorganized communication (difficulty getting to the point, rambling, illogical reasoning) and grandiosity (unrealistic ideas of abilities or talents),” according to De Silva. Just one of these symptoms is the “greatest predictor of psychosis to date — greater than having a parent with schizophrenia,” she said. In fact, according to recent research, 35 percent of individuals who presented with one of these symptoms developed psychosis within 2.5 years. Substance use, such as alcohol and marijuana, also has been shown to boost risk.

Early Intervention for Schizophrenia

So what can you do if you think your loved one is showing these early signs? There are various prodromal clinics in the U.S. and some abroad that offer services — usually including regular evaluations and treatment — for at-risk youth and their families. At De Silva’s clinic, CAPPS, individuals from 12 to 25 years old get a diagnostic screening, assessments and case management at no charge. Early treatment aims to reduce the risk of developing schizophrenia, delay its onset (which research shows has a better prognosis), decrease severity after onset and improve outcomes in all areas, De Silva said.

Treatment of Schizophrenia

“The longer an illness is left untreated, the greater the disruption to the person’s ability to study, work, make friends and interact comfortably with others,” De Silva said. A combination of treatments is best for individuals with schizophrenia. Medication is the mainstay of treatment, “used to minimize hallucinations, help the individual think more clearly, focus on reality and sleep better,” according to Dawn Velligan, Ph.D, professor and co-director of the Division of Schizophrenia and Related Disorders at the Department of Psychiatry, UT Health Science Center at San Antonio . However, “decades of research have shown that psychosocial treatments “are also important in improving symptoms and quality of life,” she added.

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.

Schizophrenia is a chronic, debilitating disorder, characterized by an inability to distinguish between what is real and what isn’t. A person with schizophrenia experiences hallucinations and delusional thoughts and is unable to think rationally, communicate properly, make decisions or remember information. To the public, a sufferer’s behavior might seem odd or outrageous. Not surprisingly, the disorder can ruin relationships and negatively affect work, school and everyday activities.

About one-third of individuals with schizophrenia attempt suicide. Fortunately, however, schizophrenia is treatable with both medication and therapy, making it imperative to recognize the symptoms and receive the correct diagnosis. The earlier a person is accurately diagnosed, the sooner he or she can start an effective treatment plan.

What Causes Schizophrenia?

As with other psychological disorders, it’s believed that schizophrenia is a complex interplay of genetics, biology (brain chemistry and structure) and environment.

• Genetics: Schizophrenia typically runs in families, so it’s likely the disorder is inherited. If an identical twin has schizophrenia, the other twin is 50 percent more likely to have the disorder. That also points out the likelihood of other causes: If schizophrenia were purely genetic, both identical twins always would have the disorder.
• Brain chemistry and structure: Neurotransmitters—chemicals in the brain, including dopamine and glutamate, that communicate between neurons—are believed to play a role. There also is evidence to suggest that the brains of individuals with schizophrenia are different from those of healthy individuals (for details, see Keshavan, Tandon, Boutros & Nasrallah, 2008).
• Environment: Some research points to child abuse, early traumatic events, severe stress, negative life events and living in an urban environment as contributing factors. Additional causes include physical and psychological complications during pregnancy, such as viral infection, malnutrition and the mother’s stress.

What Are the Different Types of Schizophrenia?

• Paranoid schizophrenia is characterized by auditory hallucinations and delusions about persecution or conspiracy. However, unlike those who have other subtypes of the disease, these individuals show relatively normal cognitive functioning.
• Disorganized schizophrenia is a disruption of thought processes, so much so that daily activities (e.g., showering, brushing teeth) are impaired. Sufferers frequently exhibit inappropriate or erratic emotions. For instance, they might laugh at a sad occasion. Also, their speech becomes disorganized and nonsensical.
• Catatonic schizophrenia involves a disturbance in movement. Some might stop moving (catatonic stupor) or experience radically increased movement (catatonic excitement). Also, these individuals might assume odd positions, continuously repeat what others are saying (echolalia) or imitate another person’s movement (echopraxia).
• Undifferentiated schizophrenia includes several symptoms from the above types, but the symptoms don’t exactly fit the criteria for the other kinds of schizophrenia.
• Residual schizophrenia is diagnosed when a person no longer exhibits symptoms or these symptoms aren’t as severe.

What Are the Risk Factors for Schizophrenia?

Recent research identified five risk factors for teens, which are similar in adults:

1. Schizophrenia in the family
2. Unusual thoughts
3. Paranoia or suspicion
4. Social impairment
5. Substance abuse

Symptoms of Schizophrenia

There are three types of symptoms in schizophrenia: positive, negative and cognitive.

1. Positive (symptoms that should not be present)
   • Hallucinations (something a person sees, smells, hears and feels that isn’t really there). The most common hallucination in schizophrenia is hearing voices.
   • Delusions (a false belief that isn’t true)
2. Negative (symptoms that should be present)
   • Flat (individuals show no emotion) or inappropriate affect (e.g., giggling at a funeral)
   • Avolition (little interest or drive). This can mean little interest in daily activities, such as personal hygiene.

   These symptoms often are harder to recognize, because they’re so subtle.

3. Cognitive symptoms (associated with thinking)
• Disorganized speech (the person isn’t making any sense)
• Grossly disorganized or catatonic (unresponsive) behavior
• Inability to remember things
• Poor executive functioning (a person is unable to process information and make decisions)

How Is Schizophrenia Diagnosed?

To diagnose schizophrenia, a trained mental health professional conducts a face-to-face clinical interview, asking detailed questions about family health history and the individual’s symptoms.
Though there isn’t a medical exam for schizophrenia, doctors typically order medical tests to rule out any health conditions or substance abuse that might mimic schizophrenia symptoms.

According to the DSM-IV-TR, the standard reference book mental health professionals use to help make diagnoses, medical conditions that can imitate symptoms of schizophrenia include: neurological conditions (e.g., Huntington’s disease, epilepsy, auditory nerve injury); endocrine conditions (e.g., hyper- or hypothyroidism); metabolic conditions (e.g., hypoglycemia); and renal (kidney) diseases.

What Treatments Exist for Schizophrenia?

Schizophrenia can be successfully managed with medication and psychotherapy. For the majority of schizophrenia sufferers, medication is highly effective in controlling symptoms. However, finding the right medication can take time; each medication affects each person differently. Patients typically try several medications before finding the best one for them.

It’s important to discuss the details of each medication’s risks and benefits with your doctor, take the medication as prescribed and never stop taking your medication without first talking to the doctor.

What Kinds of Medications Are Used for Schizophrenia?

• Typical antipsychotics. Available since the mid-1950s, these older antipsychotics used to be the first line of treatment, because they successfully reduced hallucinations and delusions. These include: haloperidol (Haldol), chlorpromazine (Thorazine), perphenazine (Etrafon, Trilafon) and fluphenzine (Prolixin).

  Many patients stop taking their medication because of its extrapyramidal side effects. “Extrapyramidal” actions are those that affect movement, such as muscle spasms, cramps, fidgeting and pacing.

  Taking typical antipsychotics long-term can cause tardive dyskinesia—involuntary, random movements of the body, such as facial grimacing and movements of the mouth, tongue and legs. Because of these side effects, atypical antipsychotics largely have replaced traditional antipsychotics.

• Atypical antipsychotics. Developed in the 1990s, these medications have become the standard treatment for schizophrenia. That’s because they effectively control positive symptoms and help treat negative symptoms without the same side effects as traditional antipsychotics. They include: aripiprazole (Abilify), risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel), clozapine (Clozaril), olanzapine/fluoxetine (Symbyax), and ziprasidone (Geodon).

  Though they rarely cause extrapyramidal complications, each atypical antipsychotic comes with its own side effects. For instance, though effective and much cheaper than other atypicals, clozapine can cause agranulocytosis — a condition that leaves the bone marrow unable to produce enough white blood cells to fight off infection. The newer antipsychotics don’t cause agranulocytosis, but they do cause significant weight gain and increase the risk for diabetes, which can have serious health complications.

Psychotherapy

When combined with medication, psychotherapy can be a valuable tool in managing schizophrenia. Therapy facilitates medication adherence, social skills, goal setting, support and everyday functioning. Different types of psychotherapy benefit patients in different ways.

Illness management helps patients become an expert on their disorder, so they learn more about their symptoms, the warning signs of a potential relapse, various treatment options and coping strategies. The goal is for patients to be actively involved in their treatment.

Rehabilitation gives patients the tools to be independent and navigate everyday life by teaching them social, vocational and financial skills. Patients learn how to manage money, cook and communicate better. There are many different types of rehabilitation programs.

Cognitive-behavioral therapy helps patients develop techniques to challenge their thoughts, ignore the voices in their heads and overcome apathy.

Family education provides families with the tools to help and support their loved one. Families gain a deeper understanding of schizophrenia and learn coping strategies and other skills to prevent relapses and bolster treatment adherence.

Family therapy aims to reduce familial stress by teaching relatives how to discuss problems immediately, brainstorm solutions and pick the best one. Families who participate in therapy significantly decrease the chances of their loved one relapsing.

Group therapy offers a supportive environment that fosters discussion of real-life problems and their solutions, encourages social interaction and minimizes isolation.

Hospitalization

A person with schizophrenia might require hospitalization if he or she is experiencing severe delusions or hallucinations, suicidal thoughts, problems with substance abuse or any other potentially dangerous or self-harmful issues.

What Do I Do Next?

Learning about schizophrenia is an important first step in finding help. If you would like to learn more about schizophrenia, check out Psych Central’s guide to the disorder.

If you think you have schizophrenia (or your loved one might), the next step is to seek an evaluation by a trained mental health professional. To find a therapist near you, use Psych Central’s therapist locator, ask your physician or consult a community mental health clinic for a referral.

Further Reading

National Alliance on Mental Illness (NAMI)

Tardive Dyskinesia

National Institute of Mental Health

Helpguide, Rotary Club of Santa Monica

Approximately 2.6 percent of American adults have bipolar disorder (formerly called manic depression and manic depressive disorder), according to the National Institute of Mental Health. These mood swings include “highs” (mania), when individuals feel either on top of the world or on edge, and “lows” (depression), when they feel sad and hopeless. Suicide attempts are common in bipolar disorder, especially during depressive episodes.

Bipolar disorder can be effectively treated with medication and psychotherapy. With proper treatment, individuals with bipolar can lead fulfilling, productive lives. This is why it’s so important to recognize the symptoms and see a mental health professional for an evaluation.

What Causes Bipolar Disorder?

There is no single cause for bipolar disorder. Indeed, like all psychological disorders, bipolar disorder is a complex condition with multiple contributing factors, including:

• Genetic: Bipolar disorder tends to run in families, so researchers believe there is a genetic predisposition for the disorder. Scientists also are exploring the presence of abnormalities on specific genes.
• Biological: Researchers believe that some neurotransmitters, including serotonin and dopamine, don’t function properly in individuals with bipolar disorder.
• Environmental: Outside factors, such as stress or a major life event, may trigger a genetic predisposition or potential biological reaction. For instance, if bipolar disorder was entirely genetic, both identical twins would have the disorder. But research reveals that one twin can have bipolar, while the other does not, implicating the environment as a potential contributing cause.

What Are the Different Types of Bipolar Disorder?

• Bipolar I is considered the classic type of bipolar disorder. Individuals experience both manic and depressive episodes of varying lengths.
• Bipolar II involves less severe manic episodes than bipolar I; however, their depressive episodes are the same.
• Cyclothymia is a chronic but milder form of bipolar disorder, characterized by episodes of hypomania and depression that last for at least two years.
• Mixed episodes are ones in which mania and depression occur simultaneously. Individuals might feel hopeless and depressed yet energetic and motivated to engage in risky behaviors.
• Rapid-cycling bipolar individuals experience four or more episodes of mania, depression or both within one year.

What Are the Risk Factors for Bipolar Disorder?

Risk factors include having:

• Cyclothymia (see definition above). About half of individuals with cyclothymia will experience a manic episode.
• Any other psychological disorder
• A family history of bipolar or other psychological disorders
• Alcohol and substance abuse
• Medication interactions. For instance, antidepressants may trigger mania.
• Major life changes
• Severe stress

Symptoms of Bipolar Disorder

There are four possible bipolar states:

1. Mania
2. Hypomania
3. Depression
4. A mixture of mania and depression (called a “mixed episode”).

Mood states are highly variable. Some people can experience mood changes in one week, while others can spend months or even years in one episode.

What Does Mania Look Like?

• Feelings of euphoria and elation or irritability and anger
• Impulsive, high-risk behavior, including grand shopping sprees, drug and alcohol abuse and sexual promiscuity
• Aggressive behavior
• Increased energy and rapid speech
• Fleeting, often grandiose ideas
• Decreased sleep (typically the individual doesn’t feel tired after as few as three hours of sleep)
• Decreased appetite
• Difficulty concentrating; disorganized thoughts
• Inflated self-esteem
• Delusions and hallucinations (in severe cases)

What Does Hypomania Look Like?

Hypomania is less severe than a full-blown manic episode. Hypomanic individuals can seem pleasant, friendly, energetic and productive. Though it doesn’t sound problematic, increasing hypomania can lead to risky behaviors and full mania.

What Does Depression Look Like?

• Feelings of hopelessness and sadness
• Inability to sleep or sleeping too much
• Loss of interest in formerly enjoyable activities; loss of energy (sometimes to the point of inability to get out of bed)
• Changes in appetite and weight
• Feelings of worthlessness and inappropriate guilt
• Inability to concentrate or make a decision
• Thoughts of death and suicide

What Does a Mixed Episode Look Like?

Mixed episodes involve simultaneous symptoms of mania and depression, including irritability, depressed mood, extreme energy, thoughts of suicide and changes in sleep and appetite.

A Note about Suicide

Because of the high suicide risk in those with bipolar disorder, it’s important to note the warning signs. In addition to those mentioned in the depression symptoms above, others include:

• Withdrawing from loved ones and isolating oneself
• Talking or writing about death or suicide
• Putting personal affairs in order
• Previous attempts

For more information about suicide, check out Frequently Asked Questions about Suicide.

How Is Bipolar Disorder Diagnosed?

There are no medical tests to diagnose bipolar disorder. However, a psychologist, psychiatrist or other trained mental health professional can diagnose the disorder by conducting a face-to-face clinical interview. Your clinical interview will include detailed questions about your and your family’s medical and mental health history and your symptoms.

What Treatments Exist for Bipolar Disorder?

Bipolar disorder can be effectively managed with a combination of medication and psychotherapy to help in reducing both the number of episodes and their intensity. Treatment also can help prevent future episodes if the individual is willing to work on personal issues and develop healthy habits.

What Kinds of Medication Are Used for Bipolar Disorder?

• Mood stabilizers. These medications are prescribed to help stabilize manic symptoms, prevent future episodes and reduce suicide risk. The most well-known of these is lithium, which is effective in 60 to 80 percent of manic and hypomanic episodes. Anticonvulsant (or anti-seizure) medications also have mood stabilizing effects. These include valproate (Depakote), carbamazepine (Tegretol), lamotrigine (Lamictal), gabapentin (Neurotin) and topiramate (Topamax).

  Every medication has its own set of potentially serious side effects. For instance, Lamictal can cause Stevens-Johnson syndrome, a potentially fatal skin disease, though this is rare and is entirely avoidable by careful, slow dose titration.

• Atypical antipsychotics. The newest medications, atypical antipsychotics were originally developed to treat psychosis (a symptom of schizophrenia). Like the mood stabilizers above, atypical antipsychotics help to control mood swings. These seven medications are commonly prescribed for bipolar: aripiprazole (Abilify), risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel), ziprasidone (Geodon), clozapine (Clozaril) and olanzapine/fluoxetine (Symbyax).

  Contrary to popular belief, these medications aren’t without significant side effects, including rapid weight gain, high cholesterol and risk for diabetes, which occurs most commonly with olanzapine and clozapine. In some cases, atypical antipsychotics have been associated with a life-threatening condition known as diabetic ketoacidosis (DKA).

  In June 2004, the U.S. Food and Drug Administration (FDA) requested that all companies who manufacture atypical antipsychotics include a warning about the elevated risk for hyperglycemia and diabetes (see here ).

  In addition, several organizations, including the American Diabetes Association and American Psychiatric Association, have published recommendations for doctors on how to treat patients taking these medications. For more information, read the press release at the American Diabetes Association website.

• Calcium-channel blockers. Used to treat angina and high blood pressure, these medications — including verapamil (Calan, Isoptin, Verelan) and nimodipine (Nimotop) — also have mood stabilizing effects. They have fewer side effects than other bipolar drugs but aren’t as effective.
• Combination therapy. When one medication isn’t working, a doctor might prescribe two mood stabilizers or a mood stabilizer along with an adjunctive medication to treat symptoms such as anxiety, hyperactivity, insomnia and psychosis. For example, Xanax (alprazolam), a fast-acting benzodiazepine, typically is taken for two weeks before mood-stabilizing medication starts to work. Antidepressants might be prescribed for patients who are in a depressive phase, but research suggests they aren’t effective, can trigger mania and exacerbate episodes long term.

Psychotherapy

Psychotherapy is a crucial component of long-term bipolar disorder management. Even when your mood swings are under control, it’s still important to stay in treatment.

Several different psychotherapeutic methods have proved to be effective in treating bipolar disorder.

• Cognitive behavioral therapy (CBT) helps individuals develop strategies to cope with their symptoms, change negative thinking and behavior, monitor their moods and predict their mood to try to prevent a relapse.
• Interpersonal and social rhythm therapy is a combination of interpersonal therapy and CBT. This newer treatment focuses on circadian rhythms to help clients establish and maintain routines and build healthier relationships.
• Psychoeducation teaches individuals about their disorder and treatment and gives them the tools to manage it and anticipate mood swings. Psychoeducation also is valuable for family members.

How Else Can I Manage Bipolar Disorder?

• Take your medication.
• See a therapist regularly.
• Learn more about bipolar disorder and its treatment
• Participate in online communities or in-person support groups
• Adopt healthy habits, including exercising, practicing stress management techniques, eating healthy, avoiding alcohol and drugs, getting seven to eight hours of sleep and avoiding any potential triggers.

What Do I Do Next?

By starting to learn about bipolar disorder, you’ve already taken a significant first step. If you’d like to learn more, check out our detailed guide here.

If you think you or a loved one has bipolar disorder, it’s important to be evaluated by a trained mental health professional. To find a therapist in your area, use a search engine such as this one, or check with your primary care physician or community mental health clinic for referrals.

Further Reading

The Numbers Count: Mental Disorders in America

National Institutes on Mental Health

University of Maryland Medical Center

National Alliance on Mental Health (NAMI)

Depression and Bipolar Support Alliance (DBSA)

Since their initial development, further research has demonstrated that atypical antipsychotics can also have helpful mood stabilizing properties. Because of this, this class of drugs is commonly prescribed for someone with bipolar disorder. Someone who takes an atypical antipsychotic will find that their moods swings will typically become less frequent and less intense.

There are seven commonly prescribed atypical antipsychotic medications for schizophrenia:

• Abilify (aripiprazole)
• Risperdal (risperidone)
• Zyprexa (olanzapine)
• Seroquel (quetiapine)
• Cloazril (clozapine)
• Symbyax (olanzapine/fluoxetine)
• Geodon (ziprasidone)

Common side effects of these medications include weight gain and drowsiness. Weight gain can be a significant issue — most people taking an atypical antipsychotic can expect to gain weight. Because weight gain is also associated with an increased risk for Type II diabetes, individuals taking an atyptical antipsychotic should be carefully monitored by their physician. Exercise and a nutritional, balanced diet are also important.

It is a common misnomer that atypical antipsychotic medications have less side effects than other drugs. Atypical antipsychotic medications have significant side effects, it’s just that their side effect profile is different than that of most other drugs used to treat mental disorders. Your doctor cannot tell you whether a specific medication is going to help you or what side effects you will experience — only through a trial and error process will you find a medication that is effective for you with minimal side effects.

Psychiatrists will typically try a course of an atypical antipsychotic for the treatment of schizophrenia before trying any other medication. Your psychiatrist may also prescribe an additional medication to help supplement the effectiveness of the atypical antipsychotic.

Always take all medications as directed and ask your doctor what to do if you miss a dose.

There are seven commonly prescribed atypical antipsychotic medications for bipolar disorder:

• Abilify (aripiprazole)
  Reviews of Abilify (aripiprazole)
• Risperdal (risperidone)
  Reviews of Risperdal
• Zyprexa (olanzapine)
  Reviews of Zyprexa
• Seroquel (quetiapine)
  Reviews of Seroquel
• Geodon (ziprasidone)
  Reviews of Geodon
• Cloazril (clozapine)
• Symbyax (olanzapine/fluoxetine)

Common side effects of these medications include weight gain and drowsiness. Weight gain can be a significant issue — most people taking an atypical antipsychotic can expect to gain weight. Because weight gain is also associated with an increased risk for Type II diabetes, individuals taking an atyptical antipsychotic should be carefully monitored by their physician. Exercise and a nutritional, balanced diet are also important.

It is a common misnomer that atypical antipsychotic medications have less side effects than other drugs. Atypical antipsychotic medications have significant side effects, it’s just that their side effect profile is different than that of most other drugs used to treat mental disorders. Your doctor cannot tell you whether a specific medication is going to help you or what side effects you will experience — only through a trial and error process will you find a medication that is effective for you with minimal side effects.

If you want to learn more about how to manage medication side effects, you’ll find this article helpful.

Psychiatrists will typically try a course of an atypical antipsychotic for the treatment of bipolar disorder before trying any other medication. Your psychiatrist may also prescribe an additional medication to help supplement the effectiveness of the atypical antipsychotic.

Always take all medications as directed and ask your doctor what to do if you miss a dose.

This is referred to as “discontinuation syndrome.” Some studies have shown that up to 80% of people discontinuing certain antidepressant medications, for instance, experience symptoms of discontinuation syndrome.

What is Discontinuation Syndrome?

Discontinuation syndrome is characterized by one or more of the following symptoms (Haddad, 2001):

• Dizziness, vertigo or ataxia (problems with muscle coordination)
• Paresthesia (tingling or pricking of your skin), numbness, electric-shock-like sensations
• Lethargy, headache, tremor, sweating or anorexia
• Insomnia, nightmares or excessive dreaming
• Nausea, vomiting or diarrhea
• Irritability, anxiety, agitation or low mood

How Do I Prevent Discontinuation Syndrome?

Discontinuation syndrome is relatively easy to minimize or prevent altogether in most people. The key to discontinuing many psychiatric medications is to do so under a doctor’s supervision in a slow and gradual process over weeks’ time. This process is called titration — gradually adjusting the dose of the medication until the desired effect is achieved, in this case, stopping it. Gradually tapering the dose of the medication over a few weeks (and sometimes, months) usually minimizes the appearance of any discontinuation syndrome symptoms.

Most people who experience this syndrome do so because they either abruptly stop taking their medication, or try to remove themselves off of it much too quickly, and in many cases, not under the guidance of their prescribing physician. One should never stop taking any medication prescribed by a doctor until one has talked to their doctor about stopping.

Sometimes people feel embarrassed or uncomfortable talking to their physician about stopping a medication because they feel like they are a failure in doing so. Doctors, however, have patients who need to stop taking their medications for a wide variety of reasons every day, and usually have no trouble helping a person discontinue the medication gradually. Perhaps the medication isn’t working for you, perhaps its causing uncomfortable side effects, perhaps you just want to try something else. Share the reason with your doctor, and work with him or her to minimize the possibility of discontinuation syndrome.

Reference: Robinson, D.S. (2006). Antidepressant Discontinuation Syndrome. Primary Psychiatry, 13(10):23-24.