Depressive, anxiety, and psychotic disorders
Depressive disorders
About 10% of adults in America experience depression each year. Almost twice as many women as men are affected by the disorder. Depression interferes with daily activities and causes pain and suffering not only to those who have the disorder, but also to those who care about them. Although multiple medications and psychosocial therapies are available to treat and manage depression, most individuals do not seek treatment. Depressive disorders affect the way a person thinks, feels, eats, and sleeps. People with depression cannot “snap out of it” and, without treatment, may experience symptoms that persist for weeks, months, or years.
Depressive disorders include major depressive disorder and dysthymic disorder. Individuals with major depression show a combination of symptoms that interfere with their ability to work, study, sleep, eat, and enjoy activities they once considered pleasurable. Dysthymic disorder is a less severe type of depression in which patients experience long-term, chronic symptoms that are not incapacitating but that affect their level of performance and daily emotions. Many people with dysthymia also experience major depression at some time in their lives. Bipolar disorder, also called manic-depression, involves depressive episodes as well, but it’s classified as a separate mood disorder rather than a subtype of depressive disorder - individuals with bipolar disorder cycle through a wide range of moods from extreme highs (mania) to extreme lows (depression). When in the depression cycle, they may show any or all of the symptoms of a depressive disorder. When cycling through mania, they may make decisions or act in a way that can be both embarrassing and dangerous. Manic individuals are extremely energetic and rarely sleep. If left untreated, the disorder can progress to a psychotic state.
Patients must understand that antidepressant medications take a minimum of 3 to 4 weeks for the full therapeutic effects of the drug to occur. Once they start to feel better, many individuals are tempted to stop taking the medication. It is important to continue treatment for a minimum of 4 to 9 months to prevent a recurrence of the depression. The patient should never stop taking antidepressant medication suddenly or without the direction of a physician. Individuals with bipolar disorders or chronic major depression may need maintenance therapy indefinitely.
Treatment for depression typically begins with a selective serotonin reuptake inhibitor (SSRI), which blocks the reuptake of serotonin only, because these medications have limited side effects. SSRIs include fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), and citalopram (Celexa). Other medications include duloxetine (Cymbalta) and venlafaxine, which are serotonin-norepinephrine reuptake inhibitors (SNRIs) that block reuptake of both serotonin and norepinephrine, and bupropion (Wellbutrin), which acts on norepinephrine and dopamine instead. If the patient’s symptoms are not relieved, the physician may order an older group of drugs called tricyclic antidepressants (TCAs), such as imipramine (Tofranil), which inhibit the reabsorption of serotonin and norepinephrine.
Recently, concern has arisen about the association of suicidal thoughts with antidepressant medications in children and adults in the first few weeks of treatment and also when dosages are altered. The U.S. Food and Drug Administration (FDA) has warned physicians to monitor patients closely when starting antidepressant therapy and to provide patient and family education on the importance of reporting to the physician any changes in symptoms.
Symptoms of depression
According to the National Institute of Mental Health (NIMH), the severity of depressive symptoms varies among individuals and also with each episode.
- Persistent sad, anxious, or “empty” feeling
- Feelings of hopelessness and pessimism
- Feelings of guilt, worthlessness, and helplessness
- Loss of interest or pleasure in hobbies and activities that once were enjoyed, including sex
- Decreased energy and complaints of fatigue
- Difficulty concentrating, remembering, and making decisions
- Insomnia, early morning awakening, or oversleeping
- Either anorexia and weight loss or overeating and weight gain
- Thoughts of death or suicide, with possible suicide attempts
- Restlessness, irritability
- Persistent physical complaints that do not respond to treatment (e.g., headaches, gastrointestinal disturbances, or chronic pain)
Anxiety disorders
Anxiety disorders affect approximately 19 million American adults. The primary symptoms are an overwhelming, irrational feeling of anxiety and fear. Anxiety disorders include panic disorder, obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), and phobias. Individuals with panic disorder report feelings of terror that strike unexpectedly and are accompanied by nausea, chest pain, palpitations, diaphoresis, weakness, vertigo, syncope, and a fear of impending doom or loss of control. People with OCD experience anxious thoughts or images (obsessions) that they cannot control, so they resort to performing specific rituals (compulsions) to try to prevent or dispel the obsession. For example, an individual may be obsessed with germs or dirt, so he or she repeatedly washes her hands; or an individual may have to repeatedly check to make sure a door is locked because of fear that it will be left open. Performing the ritual does not bring pleasure, only temporary relief of the anxiety caused by the obsession, which will grow if the compulsion is not performed.
PTSD can occur after a patient is a part of or witnesses some terrifying, horrendous, or violent physical or emotional event, such as assault, battery, rape, war, natural disasters, acts of terrorism, and serious accidents during which many people are killed or injured. The person who survives the ordeal often has flashbacks; feelings of panic, fear, or guilt; constant replaying of the event in his or her mind; or deep feelings of emotional numbness.
As a result, the person is constantly on guard for a possible threat; has an exaggerated reaction when startled; and is frequently irritable, has difficulty concentrating, and experiences sleep problems. Severe depression and inability to function normally in daily activities may also be present.
A phobia is an intense, irrational fear of something that poses little or no actual danger. It may include such things as fear of heights, escalators, tunnels, and water. Although the individual may realize that the fear is unreasonable, just the thought of facing the feared object or situation causes a panic attack or severe anxiety. The two types of treatment for anxiety disorders are antianxiety medication, such as alprazolam (Xanax) or buspirone, and specific types of psychotherapy.
Schizophrenia
Schizophrenia is a chronic, severe, disabling brain disorder with symptoms that include hallucinations and delusions; difficulty speaking and expressing emotions; and cognitive deficits, such as problems with concentration and memory loss. Schizophrenia cannot be cured, but psychotic episodes can be reduced significantly by long-term, consistent pharmaceutical treatment. However, relapses are not unusual, because most individuals with schizophrenia stop taking their antipsychotic medication periodically because they feel better, they do not believe they need the medication, or they do not think that taking it regularly is important. In addition, the earliest antipsychotic medications, such as chlorpromazine (Thorazine) and haloperidol (Haldol), caused disturbing side effects, including rigidity, persistent muscle spasms, tremors, and restlessness. These first-generation side effects are known as extrapyramidal symptoms (EPS). Newer drugs, which have limited side effects, include risperidone (Risperdal), olanzapine (Zyprexa), and aripiprazole (Abilify).
Suicide facts from the National Institute of Mental Health
Depression, bipolar disorder, and schizophrenia all carry an elevated risk of suicide, so suicide awareness is essential when caring for patients with any of these conditions.
- More than 90% of individuals who commit suicide have a diagnosable mental disorder, typically depression, or are substance abusers.
- Although women attempt suicide two to three times more often than men, four times as many men are successful.
- Risk factors vary with age, gender, and ethnic group. They include serious depressive disorders; reduced levels of serotonin (a neurotransmitter); a prior suicide attempt; family violence, including physical or sexual abuse; and exposure to the suicidal behavior of others, including family members and peers.