Natural Treatment to Overcome Depression

Destroy Depression

Destroy Depression is written by James Gordon, a former sufferer of depression from the United Kingdom who was unhappy with the treatment he was being given by medical personnell to fight his illness. Apparently, he stopped All of his medication one day and began to search for answers on how to cure himself of depression in a 100% natural way. He spent every waking hour researching all he could on the subject, making notes and changing things along the way until he had totally cured his depression. Three years later, he put all of his findings into an eBook and the Destroy Depression System was born. The Destroy Depression System is a comprehensive system that will guide you to overcome your depression and to prevent it from injuring you mentally and physically. Read more...

Destroy Depression Overview


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Special Aspects in the Treatment of Depressive Episodes in Mamc Depressive Disorder

Several special aspects that differentiate treatment of depressive episodes during manic-depressive disorder should be noted. First, lithium appears to be an effective antidepressant in depressive episodes during manic-depressive disorder (see Tables 4.5 and 4.9), whereas the evidence is equivocal for its efficacy in unipolar depression (Fieve, Platman, & I'lutchik, 1968 Goodwin et al, 1972). Second, it should be kept in mind that all somatic antidepressant treatments are potentially pro-manic, with the probable exception of lithium. These two facts indicate that lithium should be the first-line treatment for unmedicated persons with manic-depressive disorder in the depressed phase. Third, although there are few data indicating that depression during manic-depressive disorder responds preferentially to any particular drug, there is evidence as noted above that persons with manic-depressive disorder who have hypersomnolent, anergic depressive episodes may respond to monoamine...

Somatic Treatments For Major Depression Electroconvulsive Therapy ECT

There is no widespread agreement on the underlying mechanism of action of ECT. Electrophysiological studies (Ishihara and Sasa, 1999) have shown that ECT increases the sensitivity of 5-HT3 receptors in the hippocampus, resulting in an increased release of glutamate and GABA. However, tryptophan depletion failed to reverse the improvement in mood seen in depressed patients after ECT (Cassidy et al., 1997) and does not support a primarily 5-HT-dependent mechanism. ECT has been shown to decrease the sensitivity of the noradrenergic and DA autoreceptors in the locus coeruleus and substantia nigra, resulting in an increased release of NE and DA (Ishihara and Sasa, 1999). Support for a noradrenergic mechanism also arises from a study showing a normalization of platelet alpha-2 receptors after a course of ECT (Werstiuk et al., 1996). However, the fact that ECT has efficacy in patients that fail treatment with medications argues against ECT having a similar mechanism of action (Persad, 1990)....

The Efficacy Effectiveness Gap in Manic Depressive Disorder

As reviewed in chapter 4, there are numerous medications of proven efficacy in the treatment of various phases of manic-depressive disorder. These data, particularly for lithium, strongly support the concept that manic-depressive disorder is in large degree a medication-responsive illness. However, data from real-world clinical practice indicate that high rates of been particularly interested in the potentially remediable contributors to the efficacy-effectiveness gap as it relates to manic-depressive disorder (e.g., Bauer, Williford, et al, 2001b).

Major Depression Definition

The DSM-III diagnosis of major depression requires a persistent period of dyspho-ric mood or loss of interest or pleasure and at least two weeks of four other symptoms, which may include significant weight loss or gain, appetite disturbance, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue or loss of energy, feelings of worthlessness, inappropriate guilt, impaired concentration, recurrent suicidal ideas or a suicide attempt (APA, 1980). The DSM-III-R criteria are similar, but specify a two-week period of at least five symptoms, one of which must be depressed mood or loss of interest or pleasure (APA, 1987).

Subtypes of Major Depression

Several studies of the ECA data have found evidence supportive of the validity of major depression with psychotic features and major depression with atypical features as subtypes. Johnson et al. (1991) found that 14 of major depressions were accompanied by psychotic features and that these cases, when compared with nonpsychotic depression, had a more severe course, as reflected in increased risk of relapse, persistence over one year, suicide attempts, hospitalization, comorbid-ity, and financial dependency. These findings, based on a community sample, are consistent with reports from clinical samples and provide epidemiologic support for the validity and clinical significance of psychotic depression. Horwath et al. (1992b), also reporting on ECA data, found that major depression with atypical features (defined as overeating and oversleeping) when compared to major depression without atypical features was associated with a younger age of onset, more psychomotor slowing, and more...

Session 6 treatments foe manicdepressive disorder

This session is designed to conclude Phase 1 with a completed Personal Care Plan. It provides group members with the basis for a collaborative practice model with their provider to complement the individual's self-management skills developed in Sessions 1-5. The role of pharmacological, electroconvulsive (ECT), and biological rhythm therapies is described. Emphasis is also placed on the essential role of adjunctive psychosocial treatments, including self-help programs, individual, group, and family psychotherapy, and psy-choeducation to stabilize manic-depressive disorder.

Prevalence of Depressive Disorders

Recent community longitudinal studies have provided the opportunity to examine the prevalence and outcomes associated with depressive disorders in older adults. The Established Populations for Epidemiologic Studies of the Elderly (EPESE) in the United States is one such study. The EPESE program was a set of longitudinal studies sponsored by the National Institute on Aging to identify risk factors associated with mortality, morbidity and health services utilization in individuals 65 or older (Cornoni-Huntley et al., 1986). EPESE surveys were conducted in four sites and depression was measured using the Center for Epidemiologic Studies Depression scale (CES-D) (Radloff, 1977). The prevalence of significant depressive symptomatology was 9.0 in the North Carolina sample (Blazer et al., 1991) and 15.1 in the New Haven sample (Cornoni-Huntley et al., 1986). In controlled analyses of the North Carolina data, depression was not associated with age. Specifically, the oldest old suffered fewer...

Outcomes Associated with Depressive Disorders

It is not just more symptomatic depression that puts elders at risk for disability and physical decline. Depressive symptoms and minor depression have also been linked to decline in physical functioning. In a longitudinal study of community dwelling elders, the likelihood of becoming disabled increased with each additional symptom of depression. In addition, as the number of depressive symptoms increased, the likelihood of recovering from a physical disability decreased. These effects were not accounted for by age, gender, level of educational attainment, body mass index, or chronic health conditions (Cronin-Stubbs et al., 2000). Similarly, in a four-year follow-up of 1286 persons 71 years of age or older, increasing levels of depressive symptoms predicted decline in physical performance, after adjustment for level of functioning at baseline, health status, and sociodemo-graphic status. Even among those at the high end of the physical functioning spectrum, depressed mood predicted...

Management and Treatment of Major Depression and Anxiety Disorders

The key objective in treating depressive and anxiety disorders is remission of all symptoms. Studies in the treatment of major depression have consistently shown that lack of remission is associated with higher relapse rates, more severe subsequent depressions, shorter duration between episodes, continued impairment in work settings and social relationships, increased all-cause mortality, and increased risk of suicide (Judd et al., 2000). Initiation of treatment should include education about the expected temporal course of improvement importance of regular eating, activity, social interaction, and sleep medication selection follow-up schedule and safety management if symptoms worsen or suicidal ideation is evident (Box 47-7). Box 47-7 Initiation of Treatment for Major Depression and Anxiety Disorders

Other Considerations Antidepressants and Suicidal Ideation

In 2004 the FDA added a black-box warning to all antide-pressants indicating that the use of antidepressants in children, adolescents, and young adults under 25 years of age increased the risk of suicidal thinking and behavior. The warning on antidepressants was based on an analysis of 372 clinical trials involving 11 antidepressant medications, noting an increase in the number of patients who experienced an increase in suicidal ideation and behavior, although no increase in actual suicides was observed. Further analysis of the FDA data revealed a strong age-dependent relationship, such that the greatest risk was in patients younger than 25. In clinical terms, four additional patients in 1000, age 18 to 24 years, would be expected to experience suicidal ideation or behavior as a result of taking antidepressants, and an additional 14 patients in 1000, under age 18, would be expected to experience worsening. Patients older than 30 showed a reduction in suicidal ideation as a result of...

Example of Cultural Immunity to Clinical Depression

The Kaluli of New Guinea have been studied for decades by medical anthropologists, yet not a single case of clinical depression has ever been documented among any of these people.6 When you outline the actual symptoms to them, they have no idea what you are trying to describe. To them, it sounds like an exotic affliction that falls well beyond the limits of their culture and their own personal experience. Additionally, it is not even accurate to surmise that these people experience the depression but simply express it differently or do not express it at all. There is no evidence of that either.

Tricyclic Antidepressants

Tricyclic antidepressants inhibit the reuptake of norepinephrine into the presynaptic nerve terminals. Most of these drugs also have anticholinergic effects. Tricyclic antidepressants may produce tachycardia and arrhythmias even in therapeutic doses and the hypertensive response to directly acting sympathomimetic amines is increased dramatically. Although it has been recommended that tricyclic antidepressants are discontinued 2 weeks before anaesthesia, this may not be possible in many psychiatric patients.

Special Issues in Prophylaxis of Manic Depressive Disorder

I in prophylaxis of manic-depressive disFirst, when is lifetime, or at least long-term, prophylaxis warranted After one manic episode One hypomanic episode One depressive episode with a strong family history of manic-depressive disorder There is insufficient empirical evidence with which to make strong recommendations, although a creative study by Zarin and Pass Second, can lithium ever be discontinued Again, there are no solid to base this decision. However, if lithium discontinuation is , there is evidence that rapid discontinuation (in less than 2 weeks) is more likely to result in relapse than slow taper (2 to 4 weeks), with relapse rates higher in persons with type I compared to type 11 disorder (Faedda, Tondo, Baldessami, Suppes, & Tohen, 1993 Suppes, Baldessarni, Faedda, Tondo, & Tohen, 1993). In those with type I disorder, relapse rate-respectively, 96 and 73 , whereas in those with type II disorder, rates were 91 and 33 (Faedda et al., 1993). There is some theoretical...

When are antidepressants useful for patients with spine problems

Antidepressants have several potential uses in patients with chronic spinal problems, including the treatment of back pain, neuropathic pain, sleep disturbance, and depression. Only the antidepressants with primarily nonadrenergic activity are useful for pain. The data regarding efficacy of antidepressants for axial pain are equivocal. At best, isolated studies show about 30 reduction in pain in one third of patients. In addition, recent data suggest these drugs are not very effective for radicular pain caused by ongoing neural compression. However, they may be quite effective for neuropathic extremity pain. The sedating antidepressants can be effective for sleep but have not been compared with standard hypnotics. They may have more side effects and greater risk. Most antidepressants can be effective for depression in the patient with chronic spinal pain, but it may take two or three trials before finding the best drug.

Side Effects of Antidepressants

The pharmacological properties that underlie the side effects of antidepressants have been better characterized than the properties responsible for the therapeutic effects. While newer antidepressants have provided little additional therapeutic efficacy compared to older drugs, they are unequivocally safer and much better tolerated. In general, side effects can be divided into those that occur early in the course of treatment and those that emerge gradually over continuous use. Frequently Occurring Initial Side Effects (first 1 to 4 weeks). The majority of initial side effects of antidepressant and antimanic drugs relate in a dose-dependent way to muscarinic cholinergic, histamine H1 and H2, and a1-adrenergic antagonist properties. Some initial side effects are also caused by increasing levels of 5-HT or NE (see Bolden-Watson and Richelson, 1993, for reviews). Most early side effects diminish in intensity over time, although cardiovascular side effects may not. Side effects due to...


Antidepressant drugs have been categorized in a variety of ways. The traditional classification scheme has been the distinction between monoamine oxidase inhibitors (MAOIs), tricyclic antidepressants (TCAs), and selective serotonin reuptake inhibitors (SSRIs). This system used pharmacological effects (what the drug actually does) for one group and chemical structure (the drug's molecular type) for the others. As we've learned more about the effects of antidepressant drugs that are essential for their beneficial effects, their classification of antidepressants has shifted to a focus on pharmacological properties.

Depressive Disorders

DSM-IV-TR outlines numerous affective disorders and provides reliable diagnostic criteria. A depressive disorder can be the final common pathway for a variety of insults, including the loss of function following a physical injury, the loss of sleep due to pain, the narcissistic injury of being fired, and the fear following harassment. For some individuals, the resultant symptoms may be consistent with an adjustment reaction with depressive features. For others, the accident or event may result in a major depressive disorder. When confronted with a depressed plaintiff, the psychiatrist should take care to make an accurate diagnosis and pay special attention to causation (see discussion in earlier section, Causation), given that there are innumerable life stres-sors including litigation itself that can cause, precipitate, or exacerbate a depressive disorder. Record reviews revealed that while in college Ms. D took an overdose of pills, resulting in a psychiatric hospitalization. She...

Depressive symptoms

Depression is probably the most common psychological disturbance in chronic pain. Various studies show that 30-80 of patients at a pain clinic have some depressive symptoms, and up to 20 meet the criteria for a major depressive disorder (Sullivan et al 1992, Banks & Kerns 1996). Although pain clinic patients are not representative, most patients with chronic back pain probably have some lesser degree of depression (von Korff et al 1993, Croft et al 1995, Ohayon & Schatzbrg 2003). However, we need to be clear what we mean by depression. In ordinary speech, we use the word depression for anything from a minor emotional reaction such as feeling fed-up to a crippling psychiatric illness or even suicide. It is important to distinguish depressed mood from actual depressive illness. Patients with chronic pain often have depressed mood and describe depressive symptoms, but this is seldom severe enough to meet the criteria for a depressive illness. It is important to identify those...

Establishing an Optimal Healing Environment

Therefore, if the drug only accounts for 9 of this effect, which factor accounts for the majority of the healing influence Maybe researchers are not giving enough credit to the clinician and the nonspecific variables that surround the prescribing of the pill. Maybe it is simply the act of listening to people who are suffering and giving them a sense of understanding that there is something they can do to overcome the suffering. Maybe it is the interaction between two people before the medicine is prescribed that has the greatest healing effect. Psychiatrists gifted at developing a trusting relationship were found to have better effects with placebo in treating depression than their colleagues less talented at developing relationships who used active drug (McKay et al., 2006). Acupuncture delivered with a greater ritual produces better effects than the same points treated with less ritual (Kaptchuk et al., 2008 Kelley et al., 2009). Maybe it is the cost. Drugs that cost more...

TABLE 12 Criteria for

Depressive episodes in manic-depressive disorder are indistinguishable from those in major depressive disorder. About half of persons with manic- depressive disorder experience depressive episodes characterized by decreased sleep and appetite, and about half experience more atypical symptoms of increased sleep and appetite. Recall that the differential diagnosis between major depressive and manic-depressive disorders is made not by cross-sectional symptom analysis but by longitudinal course. The diagnostic decision tree for manic-depressive disorder is outlined in Figure 1.1.

Ultrapositivistic Psychopharmacology Era 1970present

With the recognition that one of the main targets of these agents were recently characterized dopamine systems of the brain (Arvid Carlsson, 2001, Nobel Prize in 2000), and the discovery of the various receptor molecules for dopamine transmitters, the specificity and potency of antipsychotics were honed by creative pharmacologists such as Paul Janssen in Belgium (discoverer of haloperidol, or Haldol, and also risperidone, or Risperdal). This led to our current array of atypical antipsychotics (Chapter 10), which can also alleviate some of the negative symptoms of schizophrenia (the anhedonic flattening of affect, the social isolation, and cognitive impairments often characterized as formal thought disorders). These newer drugs also have the advantage of few troublesome long-term side effects such as motor dyskinesias that consistently emerged after long-term treatment with the earlier, more potent anti-dopaminergic antipsychotics. Within a few years of the discovery of chlorpromazine,...

In Bauer Cnts Christophk Whybrow 1993 From

Studies, a proportion of individuals with mania actually exhibit substantial dysphoric symptoms (reviewed in Bauer et al., 1991). Furthermore, quality of life in mania is worse, rather than better, than in euthymia (Vojta, Kinosian, Glick, Altshuler, & Bauer, 2001 see also chapter 2). Hence, as noted in the Introduction, our decision to return to the more informative and accurate term manic-depressive disorder. Mixed episodes, defined as the simultaneous occurrence of full-blown manic and depressive episodes (see Table 1.4), are the most prominent example of dysphoria during mania. Although it has been suggested that dysphoric mania may comprise a separate subtype of mania, the addition of this

Psychotic Syndromes

In patients with chronic mild or moderately severe anxiety, benzodiazepines, used sparingly for a few weeks to several months, can be helpful. When chronic treatment is necessary, buspirone, tricyclic antidepressants, and MAO inhibitors may be utilized in selected patients, particularly those with concomitant depression. Beta-blockers may also be useful in certain cases. Referral to a neuropsychologist or psychotherapist for training in self-reliance and relaxation techniques including biofeedback, meditation, and self-hypnosis should also be considered. The treatment of obsessive compulsive disorders should involve both pharmacological and psychological measures. Medications can significantly reduce the symptoms in over 50 percent of patients. Clomipramine is generally considered the drug of first choice, but other drugs with serotonergic properties such as fluoxetine, paroxetine, and clonazepam can be used.

Anxiety and Depression

If anxiety is severe enough to require drug therapy, a ben-zodiazepine such as lorazepam (Ativan), 0.5 to 1 mg two or three times a day, may be effective. Antidepressants such as nortriptyline (Pamelor), desipramine (Norpramin), and doxepin in low doses (25-75 mg at bedtime) have analgesic properties and can help with insomnia and agitation. Selective serotonin reuptake inhibitors (SSRIs) and sero-tonin-norepinephrine reuptake inhibitors (SNRIs) may also be effective. Mirtazapine may provide the advantage of improved sleep and appetite. Psychostimulants such as methylphenidate (Ritalin), 2.5 to 10 mg orally at 9 am and 12 noon, take effect quickly and can relieve depression and pain in some terminally ill patients, especially when prognosis is limited (Block, 2000). Grief and depression may appear similarly. The key to their differentiation is whether the patient is able to function. For example, a grieving patient will still function by taking the children to school or going to work...

Neuroimaging of Sadness

Motivated by its relevance for understanding clinical depression. Considerable variability in the findings can be explained by the use of widely different induction methods (externally driven or internally driven, Reiman et al., 1997) and the cognitive demands associated with the generation of the emotional state (Liotti et al., 2000a Phan et al., 2002). sadness in the healthy subjects and during the chronic dysphoria of untreated depressed patients, while dorsolateral prefrontal cortex (DLPFC BA9 46), predominantly in the right hemisphere, was deactivated in both (Mayberg et al., 1999). In addition, the activities of the two areas were inversely related. Healthy subjects induced to be anxious in the same manner showed no changes in these brain areas (Liotti et al., 2000a), confirming the specificity of those effects for feelings of sadness. The existence of reciprocal connections between the subgenual anterior cingulate and DLPFC in animals provides a mechanism whereby emotional and...

Is the Disorder Familial

Mendlewicz et al. (1975) examined the accuracy of the family history method in the context of a family study of mood disorders. The probands were 140 patients with either bipolar disorder or major depressive disorder. When the probands were used as informants for the family history method, the rates of mood disorders in the family were underestimated. The family history method was most accurate when the informant was the child or spouse of the person being diagnosed. Other studies have shown that the accuracy of family history assessments varies by diagnosis. Thompson et al. (1982) found that sensitivities for major depression and alcoholism were much higher than for generalized anxiety, drug abuse, phobic disorder, and depressive personality. Moreover, diagnoses based on spouse or offspring reports were more sensitive than those based on parent or sibling reports. In Andreasen et al.'s (1986) study the sensitivities and specificities of the family history method were consistent with...

Reciprocity Of Human Corticolimbic Activity

The studies reviewed above delineate potential mechanisms of limbic-cortical interactions that may be crucial to understand how the human brain accomplishes the business of normal and abnormal emotion regulation. Emotional arousal accompanying the experience of intense subjective feelings in healthy subjects (Liotti et al., 2000a Damasio et al., 2000) or active episodes of major depression (Mayberg et al., 1999) as well the emotional arousal in the presence of basic drives such as air hunger, thirst, or pain (Liotti et al., 2001) give rise to activation of subcortical, paleocerebel-lum, and limbic structures, as well as paralimbic cortex, and the concomitant, inverse sign, namely deactivation of neocortical regions known to subserve cognitive functions (Liotti and Mayberg, 2001). Conversely, cognitive processing and recovery from an acute episode of depression are accompanied by increased activation in neocortical networks subserving attentional processing, such as the DLPFC, inferior...

What are the Relative Contributions of Genes and Environment

Figure 1 gives an example of how twin data can shed light on the etiology of psychiatric illnesses. The figure presents results from six different twin studies of broadly defined mood disorders, or ''manic-depressive disorder'' (Tsuang and Faraone, 1990). Each bar on the graph represents a single study. The cross-hatched part of each bar indicates what percentage of the disorder could be attributed to genetic factors. The black part of the bar indicates what percentage could be attributed to common or shared environmental factors. The white part of the bar indicates the proportion of variance due to unique environmental factors or events experienced by one twin but not the other. This pattern of results attributes approximately 60 of the variance in mood disorders to genetic factors it attributes 30-40 of the variance to common environmental factors. Unique

Long Term Adaptation to

Currently, information is limited regarding the types of adjustment and psychiatric problems that are experienced by chronically ill children, but available research suggests that these children primarily have internalizing syndromes (R.J. Thompson et al. 1990). In a population of children with cystic fibrosis, 37 of those who received psychiatric diagnoses were diagnosed with an anxiety disorder, 23 with oppositional defiant disorder, 14 with enuresis, 12 with conduct disorder, and 2 with a depressive disorder (R.J. Thompson et al. 1990). The issue of whether these indicators of psychosocial functioning change over time is complicated. Although there is reason to suspect that changes in illness severity and illness status over time might influence adjustment, research suggests that psychiatric problems, when they are present in chronically ill children, persist over time. One study found that nearly two-thirds of children with chronic physical illnesses who had been classified as...

Burden of Disease

Depressive disorders are common, chronic, and costly. Depression is the fourth leading contributor to the global burden of disease and a leading cause of disability. In the primary care setting, the point prevalence of major depression ranges from 5 to 9 for adults, and up to 50 of depressed patients are not recognized (Pignone et al., 2002a). The estimated prevalence of major depressive disorder is 2.0 in children younger than 13 years and 5.6 in adolescents age 13 to 18 (Williams et al., 2009). Risk factors for depression include female gender, family or personal history of depression, substance abuse, and chronic disease.

Accuracy of Screening

Several screening instruments are available and have a sensitivity of 80 to 90 and specificity of 70 to 85 (Pignone et al., 2002a). Instruments include the Beck Depression Inventory, the Zung Self-Assessment Depression Scale, and the General Health Questionnaire. Most instruments are easy to use and take less than 5 minutes to administer, although most depressed patients can be identified simply by asking about depressed mood and anhedonia (loss of pleasurable feelings). The Patient Health Questionnaire for Adolescents and the Beck Depression Inventory-Primary Care have demonstrated good sensitivity and specificity in primary care settings in adolescents (Williams et al., 2009). A review of these tools can be found in the article at http afp 2002 0915 p1001.html.

Effectiveness of Early Detection and Intervention

There are effective treatments for patients with depressive illnesses detected through screening. Antidepressant medications include selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs). Psychosocial and psy-chotherapeutic interventions are also effective treatments for major depression. Clinicians who screen for depression should have systems in place to ensure that positive screening results are followed by accurate diagnosis, proper treatment, and adequate follow-up. All positive screening tests should be followed by full diagnostic interviews using standard diagnostic criteria to determine the presence or absence of major depression, dysthymia, or other psychological problems. The potential harms of screening include false-positive screening results, the inconvenience of further workup, and the potential adverse effects of labeling an individual depressed.

Spectra of Mood Disorders

Traditionally, there are two broad classes of mood disorders major depression and bipolar disorder, estimated by some studies to affect roughly 5-10 and 1 of the population, respectively. Even here, though, there are further spectra, which range into milder variants. The underlying risk for mood disorders displays a strong genetic influence, as shown by the results of adoption and twin studies. However, there is also a large (but poorly understood) environmental component. Bipolar risk or liability involves a more marked genetic component than does risk for unipolar depression. The strong tendency for bipolar mood disorders to run in families is illustrated by one study of over 500 relatives of bipolar disordered (manic-depressive) individuals, in which over 23 of the relatives had a major mood disorder. Even though these relatives were chosen because they had a family member with bipolar disorder, over half of all the mood disorders in these relatives were unipolar depression rather...

Bipolar Unipolar Disorder Distinctions

At this time, research is more plentiful on creativity in families with bipolar compared to unipolar disorders. It is worth repeating that pure unipolar depression is an even more common outcome in individuals with a bipolar family history than are bipolar mood swings, and that such depression may also predict for creativity. One preliminary study suggests, for example, that creativity may be higher in depressed patients with bipolar disorder in their family than in depressed patients without this family history. Perhaps there are subtle and subclinical factors operating - even ones that are adaptive and positive - beyond the more debilitating symptoms. This issue needs careful study. Clinicians can be so intent on sniffing out psychiatric illness and dysfunction that they fail to notice when something is going right, such as unusual creativity.

Evolutionary Significance

In October 1996, an invitational conference in New York, on Manic-Depressive Illness Evolutionary and Ethical Issues, was convened by Kay Jamison of Johns Hopkins and Robert Cook-Deegan of the National Academy of Sciences. Participants came from around the world to discuss the genetic and environmental factors, social costs, and adaptive value of bipolar disorder. The participants, who included distinguished scientists and clinicians, urged caution, in this burgeoning era of genetic engineering, against any precipitous efforts to remove from the population gene(s) that increase liability for bipolar disorder, given that this liability is complex, not fully understood, and may have creative advantages for individuals and society.

Reliability Theory And Binary Judgments

The reliability theory just reviewed does not make strong assumptions about the kind of measurement embodied in X, and indeed many of the results hold for binary variables such as ones that might represent specific psychiatric diagnoses (e.g., X 1 when the respondent is thought to have current major depression, X 0 otherwise). Kraemer (1979) has shown explicitly how the results work with binary judgments. From her mathematical analysis of the problem it can be seen that the systematic component of X that I have called T E( X) will end up as a proportion falling between the extremes of 0 and 1. It represents the expected proportion of diagnosticians who would give the diagnosis to the respondent being evaluated. If T is close to 1, then most diagnosticians would say that the respondent is a case, and if T is close to 0, then most would say that the respondent is not a case. Note that while X itself is binary, T is quantitative in the range (0,1).

Oneway Anova Analyses

AX 1 and X2 represent test-retest diagnoses of major depression (X 1, present X 0, not present), and Z1 and Z2 represent ratings of adaptive functioning. aX 1 and X2 represent test-retest diagnoses of major depression (X 1, present X 0, not present), and Z1 and Z2 represent ratings of adaptive functioning.

Functional Outcome Social and Occupational Outcome

Substantial levels of functional impairment are also characteristic of manic-depressive disorder, even when major disease-specific indices have improved. The book-length study of manic-depressive disorder in the pre-lithium era by Winokur and colleagues (Winokur et al., 1969) documented their sample's functional impairment in detail. For example, 79 of those employed prior to their index episode lost their jobs during that episode. Among those with incomplete remission during follow-up, 73 had long-term decrements in occupational status. Even more striking, 25 of those with complete remissions or only infrequent episodes developed similar occupational decrements. In an early study, 60 had less than satisfactory social recovery (Hastings, 1958). In a study of persons with manic-depressive disorder treated at the NIMH, only 41 had returned to their jobs at 3 years follow-up, and 15 were totally unemployed. Forty-five percent had normal family and social function, 21 evidenced complete...

Neurotransmitters in disease

Anxiety probably involves many neurotransmitters including GABA, 5-HT, norepinephrine and dopamine. There are strong indications that central monoamine metabolism is disturbed in endogenous depression, and that the disturbance is causal. Tricyclic antidepressants inhibit the presynaptic uptake of 5-HT and norepinephrine (Fig. 12.10). All antidepressants facilitate synaptic activity of amines however, tricyclic antidepressants also block cholinergic receptors. The anticholinesterase physostigmine can relieve manic symptoms. Tricyclic antidepressants inhibit presynaptic uptake of 5-hydroxytrvptaminc and norepinephrine. MAO, monoamine oxidase. Tricyclic antidepressants inhibit presynaptic uptake of 5-hydroxytrvptaminc and norepinephrine. MAO, monoamine oxidase.

Examples of Criterion Validity

Although the CES-D, like the BDI in the above example, yields a numerical score, its proposed use as a screening instrument for depression was for the purpose of identifying not the degree of depression, but the presence of a particular clinical syndrome, namely, DSM-III-R major depression. The criterion was therefore a categorical (i.e., qualitative) rating rather than a numerical (i.e., quantitative) rating, making it inappropriate to use correlational procedures. Instead, to evaluate the validity of the instrument for case identification, the authors employed statistical methods that have been expressly developed for qualitative data, including sensitivity, specificity, and receiver operating characteristic (ROC) analysis. Sensitivity and specificity are both calculated using data that have been summarized in a 2 x 2 table of frequencies (see Table 1 for definitions and computational formulas). In the example at hand, a 2 x 2 table was used to cross-classify the numbers of screened...

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Is exceeded only by that for schizophrenia Olfson, Leon, & Weissman, 1992). If one can extrapolate to persons with manic-depressive disorder from the data for tal illness costs (McGuire, 1991) of individuals with manic-depressive disorder alwell. Over 90 of caregivers in one study reported moderate or greater distress, and caregiver beliefs and perceptions were a significant predictor of burden (Perlick et al., 1999). Wyatt and Hentner (1995) estimated that the annual societal costs of manic-depressive disorder alone exceeded 45 billion in 1990, exceeded only

What psychological factors are important in the management of chronic pain

Several psychological systems are potentially at work in the patient with chronic spinal pain. These include the traditional Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) categories, cognitive-behavioral factors, and character traits. In one functional restoration program, 59 of patients with chronic back pain had active psychopathology, which included major depression in 45 , substance abuse disorder in 19 , and anxiety disorder in 17 . Although there were psychological illnesses present before the spinal pain began, most of the disorders developed after the spinal injury. Cognitive-behavioral factors commonly observed include fear, fear-avoidant behavior, and poor coping abilities.

Predictors Of Functional Outcome And Illness Costs

Depressive disorder, there is relatively little information regarding predictors Pathological Basis of Manic-Depressive Disorder Similarly, in trying to understand the source of symptoms at a particular time in a particular person with manic-depressive disorder which we all do

Depression and Physical Symptom Perception

Observations based on adult studies suggest that patients with depressive symptoms have more medically unexplained symptoms, even when controlling for the severity of their physical illnesses, and have a heightened awareness of and tendency to focus on the physical illness symptoms as well as other organic symptoms (Katon 2003 Walker and Howard 1996). Researchers have demonstrated that for adults with physical symptoms who report psychological distress, the number of self-reported psychological symptoms highly correlates with the number of their physical symptoms (Pennebaker et al. 1982). Although fewer studies have focused on pediatric than adult populations, similar associations have been described for children and adolescents (Apley 1967 Campo et al. 2002). In a cross-sectional study, Konijnenberg et al. (2006) examined psychiatric morbidity in children with medically unexplained chronic pain and pediatricians' abilities to identify psychological factors that might contribute to...

Depression and Functional Impairment

Similar to adult studies, studies of pediatric patients have found that depression has been associated with increased functional disability (Kashikar-Zuck et al. 2001, 2002 Katon 2003 Smith et al. 2003). Co-occurring depression and physical illnesses have been associated with disruptions of functioning at home, at school, and in recreational activities. In a study examining depression among youngsters with chronic pain, Kashikar-Zuck et al. (2001) found depression to be strongly associated with functional disability but not with pain severity. Adult studies have shown an association between the improvement of depressive symptoms and improvements on measures of functional impairment (Ormel et al. 1993).

The Freefloating Individualistic Structure Of Identity

But the picture is not so bright when one considers the relationship between individualism and mental health. Of the reviews that have been carried out on this topic, most have concluded that individualism is associated with specific social and psychological ills, including clinical depression, suicide, crime, divorce, child abuse, stress, and anxiety-related disorders. Although collectivist cultural structures have certain potential drawbacks, research shows that they are more conducive to mental health.

Genetic and Congenital Hypotheses

Basis of manic-depressive disorder, particularly biological tools. This research, including both mo (Table 3.2). Overall, rates of manic-depressive disorder in interestingly, rates or unipolar depression in about two-fold elevated over those in the j rate of depression in the general population (5 to 20 ), this twofold increase is a rate of about 20 . Important for this in turn means that the probability that a manic-depressive proband have a child with unipolar depression is greater than the probability that he or she will have a child with manic-depressive disorder (5 to 15 vs.

Evolutionary Perspectives

A large evolutionary literature focuses on stratification systems and mental health, especially within primate societies (e.g. Gilbert, 1992 McGuire & Troisi, 1998 Stevens & Price, 2000). Primates share with humans social hierarchies with high and low status positions and situations of chronic social subordination. In both species, positions in these hierarchies are associated with similar psychological responses. Under most circumstances, dependent monkeys have far more depression-like behaviors than dominant ones as indicated by higher levels of stress hormones and lower levels of blood serotonin (Saplosky, 1989 McGuire & Troisi, 1998). Chronic social subordination is also associated with high stress hormones associated with depressive symptoms (Shively, 1998). Finally, when rank in status hierarchies changes, these physiological profiles change as well the loss of rank in primate social hierarchies triggers the production of the neuro-chemical correlates of depression...

Integrative Role For Brain Cytokines

Implications for Biological Psychiatry. Traditionally, psychological stress and major depression have both been associated with impaired immune function and increased susceptibility to disease. In recent years, however, it has been recognized that exposure to psychological stressors and major depressive episodes are also associated with signs of immune activation for an excellent review see Connor and Leonard (1998) . One particularly interesting facet of this immune activation is that circulating levels of proinflammatory cytokines are elevated during times of stress and in clinically depressed populations. Since proinflammatory cytokines normally produce the behavioral and physiological adjustments that occur during sickness, it has been suggested that their release may mitigate some consequences of exposure to psychological stressors and major depressive episodes (Maier and Watkins, 1998). For instance, psychological stressors, depression, and sickness due to infection all produce...

Primary Mood Disorders

Physically ill pediatric patients must meet the full DSM-IV-TR criteria for primary depressive episode for this diagnosis to be made however, no standardized approach currently exists for diagnosing depression among individuals who are physically ill. Clinicians are challenged to determine whether the classic signs and symptoms of clinical depression, such as dysphoria, anhedonia, fatigue, pain, psycho-motor retardation, anorexia, weight loss, cognitive impairment, and insomnia, represent demoralization, the physical illness itself, the effects of medical treatments, and or prolonged separations from family and friends. The presence of feelings of worth-lessness, inappropriate guilt, diminished ability to think, or suicidal thoughts is generally more consistent with the diagnosis of a primary depressive episode (Goldston et al. 1994). Youngsters at risk for a primary depression are those who have had a previous depressive episode, histories of parental depression, adverse family...

Surveys of Populations

Subsequent analyses of these data have projected estimates of services use to the adult U.S. population for a one-year period by combining data from the first ECA interview with the follow-up interview conducted approximately one-year later. These new estimates suggested that the one-year prevalence of DSM-III disorders covered by the Diagnostic Interview Schedule (DIS) was 28.1 , or about 44.7 million people aged 18 years or over. About 1 of the population had an inpatient stay for mental health reasons and about 10.7 had an outpatient visit in this same one-year period. For outpatient visits, about 5.6 of the population was seen in the mental health specialty sector and about 6.4 in the general medical sector, with some individuals being seen in both. About 64 of individuals with an active diagnosis of schizophrenia received any mental health service in a one-year period, and about 54 of those with major depression did (Regier et al., 1993).

Restorative Effects of Sleep

As mentioned above, sleep problems are common in psychiatric disorders. Again, the most prominent example is the tendency of depressed individuals to sustain sleep poorly and to wake in the middle of the night, partly because their pituitary adrenal stress waking alarm system become active much earlier than normal (Kryger et al., 2000). Other features include an excessively rapid entry into the REM phase after sleep onset. Since sleep recruits endogenous antistress mechanisms and depression impairs quality sleep, the sleep problems of depression may tend to perpetuate ongoing problems. Although there is likely some truth to that hypothesis, such a problem would have to reside within the disruption of SWS rather than REM. A remarkable finding is that REM sleep deprivation is a fairly effective short-term antidepressant, and practically all of the pharmacological antidepressants are excellent REM sleep inhibitors (Kryger et al., 2000). One could construct a provisional explanation by...

Sleep Problems and Remedies from Ambien to Zolpidem

As flurazepam, as well as a large number of BZs as well as sedating antidepressants that are still commonly used for sleep problems (Table 4.1). Also, there is vigorous research activity to develop slow-release forms of the fast-acting agents, as well as natural ingredients such as melatonin, to help sustain sleep through the night. Of course, chronic use of BZs is not advised because of strong withdrawal reactions when tolerance has developed to these agents (see Chapter 16). The one highly effective over-the-counter agent is the natural hormone melatonin, whose efficacy has long been known (Arendt, 1995) but which has not been promoted by the pharmaceutical or medical community since it has not been approved by government regulatory boards. Obviously, there is little incentive for conduct of necessary efficacy trials for agents that cannot be patented. Accordingly, the search continues to identify melatonin congeners that can be patented. Even though there is now a large number of...

Psychotherapeutic Interventions

Onstrated a lower rate of major depression at the end of treatment than nondirective supportive therapy. Cognitive-behavioral therapy resulted in higher rates of remission (64.7 ) than systemic behavior family therapy (37.9 ) or nondirective supportive therapy (39.4 ), although systemic behavior family therapy and nondirective supportive therapy appeared to demonstrate some efficacy (Brent et al. 1997). In a randomized, controlled trial comparing psychody-namic psychotherapy and family therapy in 72 patients ages 9-15 years, Trowell et al. (2007) reported the resolution of depression in both treatment conditions, with 74.3 of the psychodynamic psychotherapy participants reporting no further clinical depression compared with 75.7 of the participants in family therapy.

The playing out of a genetically derived script impervious to the impact of

Have approached manic-depressive disorder from docrine, neuroanatomic, and neurophysiology vantage points, in addition to the genetic and psychosocial orientations outlined above. the catecholamine hypothesis, articulated with regard to depression by Prange (1964) and by Schildkraut (1965). Deficiency of norepinephrine or its effects was postulated to cause depression. A series of studies by Bunney and coworkers (Bunney, Goodwin, & Murphy, 1972 Bunney, Goodwin, Murphy, House, & Gordon,' 1972 Bunney, Murphy, Goodwin, & Borge, 1972) explicitly extended these observations to manic-depressive disorder, proposing that changes in catecholamine function were responsible for the switch to mania. Dopamine, which has been a prominent focus of schizophrenia research but relatively neglected in affective disorders until recently, has received attention specifically in the study of mania. Dopamine may underlie several of the prominent features of mania, including psychosis (Goodwin &...

Diagnostic Suggestions

Depressed Mood 311 Depressive Disorder NOS 296.xx Bipolar I Disorder 296.89 Bipolar II Disorder 300.4 Dysthymic Disorder 301.13 Cyclothymic Disorder 296.2x Major Depressive Disorder, Single Episode 296.3x Major Depressive Disorder, Recurrent 295.70 Schizoaffective Disorder

Neurotransmitter Correlates

Only one study has focused on the effects of an acetylcholinergic challenge in personality-disordered patients. The investigators reported that injections of physostig-mine, which increases brain acetylcholine by inhibiting the enzyme acetylcholines-terase, increased self-reported depressive symptoms in borderline patients but not in healthy volunteers (Steinberg et al., 1997). In the only investigation of a neuropeptide in personality-disordered patients, Coccaro et al. (1998) found a significant positive correlation between CSF measures of vasopressin and life history of aggression and aggression against other people in particular. Notably, this association could not be accounted for by covarying out associations of serotonergic measures with life history of aggression (Coccaro et al., 1998)

The Nature of Mental Health and Distress

These limitations notwithstanding, a distinction that mental health researchers have made between positive and negative mental health may be helpful in thinking about mental health and distress from the vantage point of critical theories. A number of mental health researchers have emphasized the point that mental health is not merely the absence of mental illness (Keyes, 2002a Ryff & Singer, 1998). About one half of the adult population in the United States will not experience serious mental illness throughout life, while about 90 of the population will not experience major depression in any particular year. But this does not mean that the people who remain free of mental illness are mentally healthy. Keyes distinguishes between flourishing and languishing. Flourishing indicates a state in which an individual feels positive emotion toward life and is functioning well psychologically and socially (Keyes, 2002b, p. 294). Languishing, by contrast, is a state in which an individual is...

Maintaining Wellness Tip No 4 Relying on Social Supports

Candace, a 49-year-old woman with bipolar II disorder, suffered from an ongoing depression that was not alleviated by antidepressants or mood stabilizers. After becoming frustrated with the myriad of medications she had tried, she consulted a psychotherapist, who observed that she was quite socially isolated She had broken up with her boyfriend two months earlier, she had few new friends or even acquaintances, and she had become disconnected from her parents and her two sisters. Her therapist encouraged her to try some new social activities, which she strongly resisted doing. Her weekends were largely spent alone in her apartment, where my thoughts eat me alive, Social support feeling emotional connections with people with whom one regularly interacts is an important protective factor against depression. Sheri Johnson and her colleagues found that after an episode of depression, people with bipolar disorder who had good social support systems recovered more quickly and had less severe...

Maternal responsiveness

Mother-infant interactions were observed subsequent to the acute depressive episode, when children were 6 months old. Maternal responsiveness was rated by a trained research assistant (RA) using a measure adapted by Milgrom and Burn (1988) from rating scales by Censullo, Lester, and Hoffman (1985) and by Brazelton, Koslowski, and Main (1974).

Assessing Unmet Needs for Psychopharmacologic Treatment

Ing subpopulations in whom unmet needs are greatest and modifiable reasons for such undertreatment. Primary care patients with major depression have received considerable attention, in part because primary care settings are the most likely place for patients with this common and impairing condition to present. Earlier studies consistently found underuse of antidepressants and other treatments among such patients (Keller et al., 1982). Such findings have led to large-scale campaigns to increase awareness in the general public as well as educational programs to increase recognition of mental illnesses among primary care providers (Hirschfeld et al., 1997). However, recent data from the second half of the 1990s suggests that despite these efforts and the introduction of newer, more tolerable agents, psychiatric medications continue to be underused by patients with depression and other highly prevalent psychiatric disorders (Wang et al., 2000b). Another group in whom it has been...

Interventions to Optimize Psychiatric Medication

In addition to identifying patterns, predictors, and outcomes of psychiatric medication use, psychopharmacoepidemiology has also increasingly used such information to develop, target, and then evaluate interventions to optimize the way psychiatric medications are used. Some interventions have focused on improving the psy-chotropic prescribing of clinicians, including one-on-one educational approaches such as ''academic-detailing.'' In this approach, modeled on the promotional activities of drug companies, educational outreach workers such as pharmacists are deployed by a non-commercial organization, often a medical school, to visit physicians in order to teach them how to prescribe more appropriately. Field trials in nursing homes have shown these interventions to be highly effective in improving not only the quality of psychotropic prescribing but patient outcomes as well (Avorn et al., 1992). Recent interventions have also focused on patients, through patient education and care...

Neurotransmitter Imaging of the Serotoninergic System

The serotoninergic system is thought to be critically involved in a large number, if not the majority, of psychiatric illnesses. The most important and well studied of these is major depressive disorder (MDD). However, the serotonin system is also considered important in schizophrenia, anxiety and phobias, obsessive-compulsive disorder, eating disorders, sleep, and numerous other psychiatric conditions. Serotonin and Depression. Several studies have found evidence for an increased availability of serotonin 5-HT2A receptors in the brains of unmedicated depressed patients and suicide victims (Cheetham et al., 1988 D'Haenen et al., 1992 Stanley and Mann, 1983). The extent to which these findings exist in depressed persons without recent suicide attempts remains controversial. A 18F setoperone PET study assessed the 5-HT2 receptor binding potential in 14 depressed and 19 healthy subjects (Meyer et al., 1999b). Interestingly, the 5-HT2 binding potential was not increased in untreated...

Imaging of Other Neurotransmitter Systems

Agren H, Reibring L, Hartvig P, et al. (1991). Low brain uptake of L- 11C 5-hydroxytryptophan in major depression a positron emission tomography study on patients and healthy Volunteers. Acta Psychiatr Scand 83 449-455. Hartvig P, Agren H, Reibring L, et al. (1991). Positron emission tomography of 11C 5-hydroxy-tryptophan utilization in the brains of healthy volunteers and a patient with major depression. Acta Radiol Suppl 376 159-160. Malison RT, Price LH, Berman R, et al. (1998). Reduced brain serotonin transporter availability in major depression as measured by 123I -2 beta-carbomethoxy-3 beta-(4-iodophenyl)tropane and single photon emission computed tomography see comments . Biol Psychiatry 44 1090-1098. Mann JJ, Malone KM, Diehl DJ, Perel J, Cooper TB, Mintun MA (1996). Demonstration in vivo of reduced serotonin responsivity in the brain of untreated depressed patients. Am J Psychiatry 153 174-182. Willeit M, Praschak-Rieder N, Neumeister A, et al. (2000). 123I -beta-CIT SPECT...

Social Class Beyond Property The Link Between Exploitation and Mental Health

To follow that tradition more closely, indicators of class exploitation should take into account that 1) the material welfare of a class causally depends on the material deprivation of another 2) this causal relation in 1) involves the asymmetrical exclusion of the exploited class from access to certain productive resources (e.g., property rights) and 3) the causal mechanism that translates the exclusion in 2) into differential welfare involves the appropriation of the fruits of labour of the exploited class by those who control the access to productive resources (i.e., the exploiter class) (Wright, 1996). Thus, we can observe that most Neo-Marxian measures of social class measure 1) and 2) in the form of property relations, but do not capture the appropriation of labour effort. In a recent study (Muntaner, Li, Xue, O'Campo, Chung, & Eaton, 2004b Muntaner, Li, Xue, Thompson, O'Campo, Chung, & Eaton, 2006) we found an association between class exploitation and...

Psychological Symptoms

Vivid dreams or nightmares may herald psychosis. Other potential causes of psychosis, dementia, or depression, such as infections, metabolic changes, electrolyte disturbances, or toxic exposures should be ruled out. Confusion may be alleviated by the presence of a night light or correction of vision and hearing deficits. PD therapy should be adjusted to decrease off periods when depression and anxiety may be more likely to occur. Low-efficacy PD medications should be gradually decreased and stopped in patients with psychosis. Patients should be encouraged to participate in tasks that improve cognition, such as puzzles or reading. Some patients and their families may benefit from professional counseling. Some antidepressants may be used for anxiety, panic, or depression. Low-dose quetiapine (12.5-200 mg) at bedtime can improve psychosis. Dementia symptoms may improve with an acetylcholinesterase inhibitor or memantine. Consider electroconvulsive therapy in depressed patients who fail...

Conclusion The Sociology of Mental Health Can And Should be More Structural

C., McGonagle, K. A., & Swartz, M. S. (1994). The prevalence and distribution of major depression in a national community sample The National Comorbidity Survey. American Journal of Psychiatry,151, 979-86. Muntaner, C., Li, Y., Xue, X., O'Campo, P., Chung, H. J., & Eaton, W. W. (2006). County level socioeconomic position, work organization and depression disorder A repeated measures cross-classified multilevel analysis of low-income nursing home workers. Health and Place, 12, 688-700. Roberts, R. E., & Lee, E. S. (1993). Occupation and the prevalence of major depression, alcohol, and drug abuse in the United States. Environmental Research, 61, 266-278. Stansfeld, S. A., Head, J., Fuhrer, R., Wardle, J., & Cattell, V. (2003). Social inequalities in depressive symptoms and physical functioning in the Whitehall II study Exploring a common cause explanation. Journal of Epidemiology and Community Health, 57, 361-367.

Issues in Usage Lithium and Commonly Used Anticonvulsants

Prior to the 1970s, manic-depressive disorder was managed with treatment targeted only toward resolution of individual episodes antidepressants and to have efficacy in acute depression or in prophylaxis. Nonetheless, neuroleptics are widely used in manic-depressive disorder, with up to two thirds of individuals with the disorder receiving chronic treatment (Keck et al 1996), at least some of which is likely warranted for <

Individual Psychotherapy

Psychotherapy may have a role in the treatment of children with conversion disorder. Hiller et al. (2003) found that cognitive-behavioral therapy (CBT) reduced depressive symptoms, somatization, hypochondriasis, and inadequate cognitions about body and health in patients with somatoform disorder. The paucity of pediatric studies in the area is readily apparent.

Motor Performance Deficits

Motor and psychomotor deficits in depression involve a range of behaviors including changes in motility, mental activity, and speech (Caligiuri and Ellwanger, 2000 Lemke et al., 1999). Depressed patients often perceive these signs as motor slowness, difficulty translating thought to action, and lack of interest or fatigue. These motor signs appear to be well correlated with both the severity of depression and treatment outcome. Spontaneous motor activity is significantly lower when patients are depressed compared to the euthymic, or nondepressed, state with a progressive increase in activity levels as other clinical features improve.

Issues in Using Self Report Data

Evaluees in forensic evaluations typically have a reason or motivation to distort their history or presentation to the forensic evaluator, based on their interest in the outcome of the litigation. Accused sexual offenders commonly deny, minimize, or distort previous sexual offenses in a self-serving manner, consciously or unconsciously, and denial is a significant clinical issue in their assessment and management (Lanyon 2001). Head injury claimants in litigation retrospectively inflate their pre-injury scholastic functioning to a greater degree than nonlitigating control subjects (Greiffenstein et al. 2002). Beyond these distortions, memory for past events is generally reconstructive and often inaccurate it is not complete and accurate like a videotape (Haber and Haber 2000 Hyman and Loftus 1998). An evaluee's memory for relevant events such as the presenting crime may be distorted as a result of intoxication, emotional arousal, psychosis, mood disturbance, or personality disorder...

Functional Abnormalities

Positron emission tomography (PET) and single-photon emission tomography (SPECT) studies of both primary depression (unipolar, bipolar) and depression associated with specific neurological conditions (focal lesions, degenerative diseases, epilepsy, multiple sclerosis) identify many common regional abnormalities (reviewed in Mayberg, 1994 Ketter et al., 1996). For example, in depressed patients with one of three prototypical basal ganglia disorders Parkinson's disease, Huntington's disease, and left caudate stroke resting-state paralimbic hypometabolism (ventral prefrontal cortex, anterior cingulate, anterior temporal cortex) was found to differentiate depressed from nondepressed patients within each group, as well as depressed from nondepressed patients, independent of disease etiology (Mayberg, 1994). These regional findings, replicated in other neurological disorders (Bromfield et al., 1992 Hirono et al., 1998 Starkstein et al., 1990c), suggests involvement of...

Issues in Usage Benzodiazepines

Benzodiazepines (see Table 4.17) will be reviewed only briefly here, as their use is only adjunctive to the core agents in manic-depressive disorder. As outlined above, some studies have documented efficacy for clonazepam and lorazepam in the treatment of acute mania, although they are not likely to be of equal efficacy to lithium, neuroleptics, or anticonvulsants. They are in Usage Antidepressants (e.g., Sussman, 1994). Their side effect profile differs from that of the tricyclic antidepressants, and they are often well tolerated by persons with < (Rudorfer, Manji, & Potter, 1994). Importantly, toxicity in is relatively less than tricyclic antidepressants. decrease serotonin effects at selected groups of postsynaptic serotonin receptors. Trazodone is highly sedative, which can be useful in treating depressive episodes in which insomnia predominates however, this property often precludes increasing the dose sufficiently high to reach antidepressant levels. This unwanted side...

Limbic Cortical Dysregulation Model of Depression

The combination of clinical symptoms seen in depressed patients (i.e., mood, motor, cognitive, vegetative-circadian). Regions are grouped into three main compartments or levels cortical, subcortical, and limbic. The frontal-limbic (dorsal-ventral) segregation additionally identifies those brain regions where an inverse relationship is seen across the different PET paradigms. Sadness and depressive illness are both associated with decreases in cortical regions and relative increases in limbic areas. The model, in turn, proposes that illness remission occurs when there is appropriate modulation of dysfunctional limbic-cortical interactions (solid black arrows) an effect facilitated by various forms of treatment. It is further postulated that initial modulation of unique subcortical targets by specific treatments facilitates adaptive changes in particular pathways necessary for network homeostasis and resulting clinical recovery. Medial frontal, rostral cingulate, and orbital frontal...

Decision to Initiate Medication Treatment

Treatment should follow a careful assessment of symptoms and course, a review of general health status, a formal diagnosis, and in some cases physical examination and laboratory testing (Depression Guideline Panel, 1993). This can usually be accomplished in one visit, especially if medically relevant history and past psychiatric and substance abuse history are available. Once a diagnosis of major depression or bipolar disorder has been made, medication treatment is usually indicated. Medication treatment should be initiated with the understanding that the choice of agent may be significantly affected by presenting symptoms and concurrent psychiatric, medical, or substance abuse diagnoses. Concomitant supportive, educational, and or cognitive psychotherapy is usually indicated, although in severe depression or mania significant modifications in the methodology and goals of psychotherapy are usually required, and these will change over time depending on the extent and rate of clinical...

Adjunct Pharmacologic Treatments

Antidepressants may be useful for patients with depressive symptoms that are not due to negative symptomatology or emotional blunting secondary to parkinsonian-type side effects. Since suicide and depression are linked, aggressive treatment is necessary when depression is present. Selective serotonin reuptake inhibitors (SSRIs) are the preferred agents, but may inhibit the CYP450 enzymes, thus raising plasma concentrations of clozapine, olanzapine, and haloperidol. Mood stabilizers, such as lithium and the anticonvulsants, have long been used adjunctively with antipsychotics to treat the affective component of schizoaffective disorder. Lastly, much research is currently underway to develop better treatments for primary negative symptoms and cognitive impairment however, no approved treatments are yet available.

Upon completion of the chapter the reader will be able to

Explain the etiology and pathophysiology of major depressive disorder (MDD). 3. Differentiate antidepressants according to pharmacologic properties, adverse-effect profiles, pharmacokinetic profiles, drug interaction profiles, and dosing features. 4. Predict adverse-effect profiles of antidepressants based on pharmacology. 6. Educate patients and caregivers on the proper use of antidepressants.

Pharmacological Mechanisms of Antidepressant Drug Action

Most antidepressants have potent pharmacological effects that cause increased synap-tic levels of the monoamine neurotransmitters NE and or 5-HT and in some cases DA. Levels of monoamines can be increased by blocking their reuptake as well as by inhibition of their metabolism by the enzyme MAO. However, while levels of monoamines increase within hours of ingestion of the first dose of an antidepressant, the therapeutic response does not begin until 2 to 4 weeks later. This lack of temporal relationship between increased synaptic levels of monoamines and clinical response has led to a search for other effects of these medications that correlate more closely with therapeutic response. Composite results from multiple studies are presented in Figure 8.1. One of the most striking findings is that antidepressant responses can be rapidly but transiently reversed, with the response being dependent on the class of antidepressant. About 80 percent of patients who were taking an SSRI for...

Clinical Presentation And Diagnosis

The diagnosis of a major depressive episode requires the presence of a certain number of depressive symptoms (five) for a minimum specified duration (2 weeks) that cause clinically significant effects (Table 38-1). HINT In order to remember the nine diagnostic symptoms for a major depressive episode, learn the following mnemonic Depression SIG E CAPS (depression, sleep, interest, guilt, energy, concentration, appetite, psychomotor, suicide). In turn, the diagnosis of MDD is based on the presence of one or more major depressive episodes during a person's lifetime.

Discontinuation of Therapy

When the clinician and patient are ready to attempt discontinuation of therapy, whether at the end of the continuation phase or during the maintenance phase, it is best to do so via gradual taper of the antidepressant. This is done for two reasons. First, almost all antidepressants can produce withdrawal syndromes if discontinued abruptly or tapered too rapidly, especially antidepressants with shorter half-lives (e.g., venla- faxine, paroxetine, and fluvoxamine). These withdrawal syndromes can cause sleep disturbances, anxiety, fatigue, mood changes, malaise, GI disturbances, and a host of other symptoms,17 and often are confused with depressive relapse or recurrence.16 In general, a tapering schedule involving a small dosage decrement (e.g.paroxetine 5 mg) every 3 to 5 days should prevent significant withdrawal symptoms.1 Second, depressive symptoms may return on taper or discontinuation of the antidepressant. If antidepressant therapy is discontinued abruptly and depressive symptoms...

Monoamine Reuptake Inhibitors

Monoamine reuptake inhibition is the most common mechanism by which antidepres-sant drugs work. Drugs with this pharmacological action include the old TCAs, the selective 5-HT reuptake inhibitors (SSRIs), and several newer drugs such as venlafax-ine, duloxetine, and reboxetine. The older drugs in this group (such as imipramine, desipramine, and amitriptyline) tend to be relatively nonselective and frequently have many active metabolites. The newer drugs tend to be highly selective for reuptake blockade with less receptor blocking properties and because of this have fewer side effects (e.g., venlafaxine). Table 8.5 shows the relative affinity of selected antidepressants for binding to the 5-HT and NE transporters. NE Reuptake Inhibitors (NRIs). Desipramine is one of the classical NRIs, and there are extensive data available regarding its clinical efficacy profile. It is well established as effective in the acute treatment of major depressive episodes in 45 to 63 percent of outpatients...

Clinical Manifestations and Diagnosis Clinical Manifestations

Benson (1983) suggest that all forms of dementia other than Alzheimer's and Pick's disease show signs of subcortical dysfunction in addition to more obvious cortical signs. This is especially true of dementia associated with basal ganglia disease, which regularly produces the characteristic subcortical pattern of slowed thinking, attention deficit, memory impairment, and apathy. Subcortical dementia occurs in 20 to 40 percent of patients with Parkinson's disease (Marttila and Rinne 1976) and is also observed in progressive supranuclear palsy, Huntington's chorea, and Wilson's disease. Symptomatic treatment of basal ganglia disease occasionally improves the associated dementia. Antidepressants may improve cognition as well as any associated depression (Albert, Feldman, and Willis 1974). Depression is the most common treatable illness that may masquerade as Alzheimer-type senile dementia. Cognitive abilities return to baseline levels when depression is treated....

NE Receptor Antagonist

FDA approved for the treatment of depression in the summer of 1998, mirtazapine is unique among antidepressants by virtue of the fact that it does not inhibit the reuptake 5-HT, NE, or DA. Its primary mechanism of action relates to its potent antagonism of a2-adrenergic receptors and 5-HT2 receptors. It is also a potent antagonist of 5-HT3 and histamine H1 receptors, effects that influence its Mirtazapine has been shown to be more effective than placebo in both hospitalized patients and outpatients, and patients with severe depression (17-item Hamilton Depression Scale score > 25). It has comparable efficacy with amitriptyline (Bremner, 1995), doxepin (Marttila et al., 1995), and chlorimipramine (Richou et al., 1995) and has been shown to be more efficacious than trazodone (Van Moffaert et al., 1995) and fluoxetine (Wheatley et al., 1998) in severely ill depressed patients.

Diagnosis of Bipolar Disorder

Bipolar disorder can be conceptualized as a continuum or spectrum of mood disorders.9 They include four subtypes bipolar I (periods of major depressive, manic, and or mixed episodes) bipolar II (periods of major depression and hypomania) cyclothymic disorder (periods of hypomanic episodes and depressive episodes that do not meet all criteria for diagnosis of a major depressive episode), and bipolar disorder NOS. The defining feature of bipolar disorders is one or more manic or hypomanic episodes in addition to depressive episodes that are not caused by a medical condition, substance abuse, or other psychiatric disorder.1

Hypericum and Other Alternatives

In the mid-1990s there was considerable interest in the possible use of Hypericum perforatum (St. John's Wort) as a new treatment for major depression. Numerous European studies had suggested that Hypericum had equal efficacy to standard antidepressant drugs but was safer and more tolerable (Whiskey et al., 2001). Unfortunately, two well-designed large placebo-controlled U.S. studies failed to support the efficacy of Hypericum for the treatment of major depression (Shelton et al., 2001 Hypericum Depression Trial Study Group, 2002).

Transcranial Magnetic Stimulation

Activation or inhibition of the cortex has been shown to vary with the frequency of the magnetic pulses. A 20-Hz stimulation at the motor threshold (MT) over the left prefrontal cortex of depressed patients was shown to increase the perfusion of the prefrontal cortex (L > R) as well as the cingulate gyrus and left amygdala. A 1-Hz stimulation was only associated with decreases in rCBF (Speer, 2000). The intensity of the magnetic stimulation has also been shown to affect the pattern of activation. Repetitive TMS at 120 percent MT over the left prefrontal cortex produced greater local and contralateral activation than stimulation at 80 percent MT (Nahas, 2001). A negative correlation between the severity of negative symptoms in major depression and rCBF to the left dorsal-lateral prefrontal cortex has been reported (Galynker et al., 1998). Both converging lines of evidence support a hypofunction in the left prefrontal cortex in major depression that may be modified by rTMS and...

Nonpharmacologic Therapy

Antidepressants, benzodiazepines, buspirone, hydroxyzine, pregabalin, and the second-generation antipsychotics (SGAs), olanzapine and risperidone, have controlled clinical trial data supporting their use in GAD. Antidepressants have replaced benzodiazepines as the drugs of choice for chronic GAD owing to a tolerable side-effect profile, no risk for dependency, and efficacy in common comorbid conditions including depression, panic, obsessive-compulsive disorder (OCD), and SAD. Benzodiazepines remain the most effective and commonly used treatment for short-term management of anxiety where immediate relief of symptoms is desired. They are also recommended for intermittent or adjunctive use during GAD exacerbation or for sleep disturb- Antidepressants Antidepressants (Table 40 3) are consideredfirst-line agents in the management of chronic GAD. These agents reduce the psychic symptoms (e.g., worry and apprehension) of anxiety with a modest effect on autonomic or somatic symptoms (e.g.,...

An Evidence Based Review of Psychotherapy Studies

The results of the literature search are reviewed be Table 5.2. Studies are categorized as Class A., B, or C. In Table 5.2 . are categorized as positive (+), negative (-), or equivocal (+ -) based on results reported in each study. A result is reported as (+) if at least some para-in the group of outcome variables were positive (e.g., improvement of but not depressive symptoms improvement of some but not all mea-of substance abuse). If no statistical analyses are presented (e.g., for Class C and some Class B studies), then the author's qualitative conclusions serve as the basis for the rating. In the early days of lithium treatment, Benson (1975) reported a retrospective series of 31 individuals with manic-depressive disorder treated in his private practice with individual, group, or couples group Individuals were in almost all cases seen at least bimonthly, and several seen multiple times per week. Benson followed individuals for 3 to 41 months and defined treatment failure as...

Etiology and Epidemiology

Finally some researchers have attempted to fit anorexia nervosa within other established psychiatric categories such as affective disorders and obsessional neurosis. Many anorectics in fact display behavior patterns associated with obsessive-compulsive disorders perfectionism, excessive orderliness and cleanliness, meticulous attention to detail, and self-righteousness. This correlation has led a number of researchers to suggest that anorexia nervosa is itself a form of obsessive-compulsive behavior (Rothenberg 1986). Depressive symptoms are also commonly seen in many patients with anorexia nervosa. Various family, genetic, and endocrine studies have found a corre

The Cultural Dynamics of Western Depression

The actual statistics concerning depression in Western culture are quite sobering. Clinical depression has become the most common presenting problem for those seeking psychotherapy. This phenomenon reflects the research findings that indicate a steady and rapid increase in the frequency of depression in recent decades. Martin Seligman has summarized the existing research on the rates of occurrence of clinical depression after analyzing different lines of evidence, among them several well-controlled longitudinal studies, Seligman concludes that depression is approximately ten times as common as it was only 50 years ago. He also considered all potential factors that could distort the available statistics, but the same pattern remained, drawing him to the unmistakable conclusion that there is an epi

Psychiatric Assessment

The psychiatric assessment must include particular attention to symptoms of restricting, purging, binge eating, and exercising, as well as feelings about shape and weight. Anxiety and compulsive behavior around food and weight require investigation. The presence of depressed mood, anhedonia, insomnia, decreased energy, and flattened affect must be explored given their associations with malnutrition (Franklin et al. 1948 Keys et al. 1950). Noting the time of onset of depression symptoms relative to disordered eating symptoms is important to help differentiate a primary depressive disorder from an eating disorder.

Antipsychotic and Atypical Antipsychotic Drugs

Olanzepine, risperidone, and quetiapine are all being studied as both monotherapy and as an adjunctive therapy for treatment of acute mania. Of the three, olanzapine is the best studied, with double-blind comparator trials as well as doubleblind placebo-controlled trials showing significant efficacy (Tohen et al., 1999) in acute mania. All atypical antipsychotic drugs are being widely used in the United States for the treatment of agitation and psychosis in manic or psychotically depressed patients, in spite of the absence of controlled data. Interestingly, olanzapine and risperidone have both been reported to cause mania in some patients with schizophrenia, schizoaffective, or bipolar disorder. At this point, none of these drugs should be used for long-term monotherapy of bipolar disorder in patients who have been tried on other available agents since no long-term studies have been completed.

More Recently Developed Contexts of Care Manual Based Interventions and Controlled Clinical Trials

Neither lithium nor the plethora of more recently developed medications have proven to be the panacea for manic-depressive disorder. As the availability of treatment of proven efficacy for manic-depressive disorder has grown, so has the complexity of treatment. Further, the problems of adherence and knowledge deficit continue, and provider knowledge deficit regardAll these contribute to what has been called the efficacy-effectiveness gap for for he indfvidud with' he llness is 'administered through the Life Goals Program Phase 1. Provider education is provided through an adaptation of the VA treatment guidelines for manic-depressive disorder (reviewed in Bauer et al, 1999). Access and continuity are provided by a health nurse who implements manual-based procedures to access to care for the treated individual (described in Bauer, Williford, et al, 2001 Shea, McBride, et al, 1997). 8 On the other hand, there are several ways in which the GHC study will be complementary to the VA study....

Generalised anxiety disorder GAD

GAD in the TBI-affected patient is also frequently associated with depression (Jorge, Robinson, Starkstein et al., 1993) with comorbidity rates ranging from 33 to 65 (Stavrakaki & Vargo, 1986). For example, Jorge, Robinson, Starkstein et al. (1993) studied a mixed TBI sample, all of whom were diagnosed with GAD (n 7) and also met the criteria for major depression. Merskey and Woodforde (1961) noted that of their 27 cases of minor TBI referred for assessment in the absence of medico-legal considerations, 7 cases (25.9 ) had endogenous depression while 9 cases (33.3 ) featured a diagnosis of mixed anxiety and depression. Van Reekum, Bolago, Finlayson, Garner, and Links (1996) assessed 18 subjects (10 with severe TBI and 8 with mild or moderate TBI) an average of 4.9 years following the TBI using the SADS-L (Endicott & Spitzer, 1978). Of the sample, 11 (58 ) received a post-TBI diagnosis of major depression. Bipolar affective disorder was found in three subjects (16 ) and...

Epidemiological Diagnostic Instruments in the United States

One event that changed the attitude of American researchers toward the utility of diagnosis was the discovery of drugs that controlled hallucinations and delusions. To use the drugs appropriately, a doctor had to be able to separate schizophrenia and other psychoses from the remainder of mental disorders. To estimate how many persons would require such treatment, epidemiologists needed to distinguish psychoses from other disorders. Similarly, the later discovery of drugs for treating depression, for treating and preventing manic attacks, and for treating anxiety interested clinicians and epidemiologists in accurate diagnosis.

Collaborative Practice and Support Systems

Qualitative inspection of the studies reviewed reveals certain themes and consistencies that appear in multiple interventions. First, and by definition, psychotherapy presupposes a collaborative practice approach to managing manic-depressive disorder. This collaboration includes the individual being treated, provider, and, where possible, partner or family members. Rather These issues of sustainability are not specific to psychosocial treatments, but they have been a focus of debate around increasingly expensive medications for other psychiatric and medical disorders as well. However, the payoff for manic-depressive disorder is potentially great in terms of reduced morbidity if researchers can develop psychosocial interventions that are indeed able to be disseminated and sustained in general clinical practice. We will now turn in detail to the conceptual background and structure of the Life Goals Program, which was designed with such issues as dissemination and sustainability in mind.

Neuropsychiatric Syndromes

The relationship between psychotic bipolar disorder and schizophrenia is unclear, but certainly within schizophrenia, full-fledged manic syndromes occur and serious depressive episodes are common. These can occur either during psychotic episodes or when psychotic symptoms are either absent or stable. The lifetime risk for major depression is very high, with perhaps a third to a half of patients experiencing at least one such episode. This problem contributes to the very high risk of suicide in schizophrenia approximately 10 percent of patients may kill themselves.

Life Course Perspectives Key Principles

A variety of modeling techniques are used to examine life course patterns regression techniques in which factors measured at one point in time are used to predict outcomes observed later in time, path models that posit complex combinations of direct and indirect effects, survival or event history models that estimate time till transitions or other discrete outcomes, and growth curve models in which trajectories are the independent and or dependent variables (e.g., trajectories of social support predicting trajectories of depressive symptoms).

The Persisting Effects of Early Traumas and Adversities

A variety of childhood traumas and adversities substantially increase the risk of later mental health problems. Childhood traumas are typically defined as occurring before the age of 11, but some investigators set the boundaries a year or two earlier or later. Childhood traumas significantly related to mental health problems in middle and later adulthood include parental death, parental divorce, physical abuse, and sexual abuse. There is strong and consistent evidence that parental divorce during childhood is associated with a variety of mental health outcomes, including general distress, depressive symptoms and disorder, and anxiety symptoms and disorders (e.g., Cherlin, Chase-Lansdale, & McRae, 1998 Harris, Brown, & Bifulco, 1990 McLeod, 1991 O'Connor, Thorpe, Dunn, & Golding, 1999 Ross & Mirowsky, 1999). Evidence for parental death, however, is mixed. Some studies report that parental death at an early age is associated with increased...

Disability and Specific Mental Disorders

Although patients with even very severe mental disorders can often work in a limited capacity or in a sheltered setting, certain disorders clearly are more likely to result in work impairment. Psychotic conditions such as schizophrenia or severe bipolar disorder routinely lead to major impairment in social and occupational functioning. Similarly, certain chronic anxiety and depressive disorders that are unresponsive to treatment can be disabling, if not from all work, then perhaps for the type of work that the patient was for

Defeat Depression

Defeat Depression

Learning About How To Defeat Depression Can Have Amazing Benefits For Your Life And Success! Discover ways to cope with depression and melancholic tendencies! Depression and anxiety particularly have become so prevalent that it’s exceedingly common for individuals to be taking medication for one or even both of these mood disorders.

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