Depression In High School Students

Depression In High School Students

Course Study Description

CCEUS11 - Depression In High School Students: What Is To Be Done?  [10 contact hours] - [$50.00 -  NO OTHER COURSE FEES APPLY]  Many adolescents today are continually hindered by the twin plagues of depression and anxiety. Clear definitions of these two disorders are reviewed.  Both these conditions interrupt what should be otherwise a happy period in the lives of teens. The debilitating aspects and characteristics of each is outlined and strategies, both individual and group, are offered in this course for the school counselor. Treatment strategies are discussed from a variety of perspectives.

Course Directions

Click on the Course Directions page to read course procedures.   

Course Outcomes

As a result of the work in this course, the counselor/student will:

Text [Required Reading To Be Prepared For The Exam]

  When Nothing Matters Anymore: A Survival Guide For Depressed Teens by Bev Cobain, Elizabeth Verdick and Jeff Tolbert  ISBN # 1575420368 at $12.25, The Adolescent Depression Workbook by Mary Ellen Copeland and Stuart Copans  ISBN # 0963136623 at $20.00.

Study Guide Questions

1. How can you describe depression to a young person?

2. How can you give a teen clues to what depression is like and when they might be experiencing it?

3. What is a feelings journal and how can it be used?

4. How can you recognize major depression?

5. Describe Dysthymia, its symptoms and characteristics.

6. What is SAD?

7. What is a Bipolar Disorder?  What are its characteristics?

8. What are the causes of depression?

9. What is hopelessness?

10. What happens when drug and alcohol abuse are introduced into a depressed teen's life?

11. Distinguish between abuse and addiction.

12. What is a Dual Diagnosis?

13. What role does nutrition play in fighting depression?

14. How are depression and suicide related?

15. What are the main characteristics of teens at risk for suicide?

16. What is usually the treatment course for depression?

17. What medications are employed and what are their effects?

18. What role does psychotherapy play in alleviating depression?

19. Can herbal remedies be helpful in treating depression?

20. What is ECT?

21. What are some strategies that a young person could use to stay well and resist depression in the future?

22. What are some major things that could help a young person feel better right away?

23. Outline what you believe to be the major steps in suicide prevention.

24. What role could peer counseling play in alleviating depression?

25. How are self-esteem and depression related?

26. How can a young person use cognitive techniques to change negative thoughts?

27. What strategies can one use to monitor their moods in order to combat depression?

28. What could stand in the way of depression recovery?

29. What are some resources that might be employed to help young people with depression?

30. What role do parents play in alleviating depression in young people?

Vocabulary

Supplementary Readings [Required Reading To Be Prepared For The Exam]

Adolescent Depression

The suicide rate for adolescents has increased more than 200% over the last decade. Recent studies have shown that greater than 20% of adolescents in the general population have emotional problems and one-third of adolescents attending psychiatric clinics suffer from depression. The majority of teenage depressions can be managed successfully by the primary care physician with the support of the family, says Maurice Blackman MB, FRCPC.

Depression has been considered to be the major psychiatric disease of the 20th century, affecting approximately eight million people in North America. Adults with psychiatric illness are 20 times more likely to die from accidents or suicide than adults without psychiatric disorder.Major depression, including bipolar affective disorder, often appears for the first time during the teenage years, and early recognition of these conditions will have profound effects on later morbidity and mortality.

Is depression in adolescents a significant problem?

The suicide rate for adolescents has increased more than 200% over the last decade. Adolescent suicide is now responsible for more deaths in youths aged 15 to 19 than cardiovascular disease or cancer. Recent studies have shown that greater than 20% of adolescents in the general population have emotional problems and one-third of adolescents attending psychiatric clinics suffer from depression.Despite this, depression in this age group is greatly underdiagnosed, leading to serious difficulties in school, work and personal adjustment which often continue into adulthood.

Why is depression in this age group often missed?

Adolescence is a time of emotional turmoil, mood lability, gloomy introspection, great drama and heightened sensitivity. It is a time of rebellion and behavioral experimentation. The physician's challenge is to identify depressive symptomatology which may be superimposed on the backdrop of a more transient, but expected, developmental storm.

Diagnosis, therefore, must rely not only on a formal clinical interview but on information provided by collaterals, including parents, teachers and community advisors. The patient's premorbid personality must be taken into account, as well as any obvious or subtle stress or trauma that may have preceded the clinical state. The therapeutic alliance is very important since the adolescent will not usually readily share his/her feelings with an adult stranger unless trust and rapport are established.

Confidentiality must be assured, but not to the point that the parents - who are often essential allies in treatment - are wholly excluded. Diagnosis may require more than one interview and is not a process that can be rushed. Inquire directly about possible suicidal ideation.

What are the common symptoms of adolescent depression?

Depression presents in adolescents with essentially the same symptoms as in adults; however, some clinical shrewdness may be required to translate the teenagers' symptoms into adult terms. Pervasive sadness may be exemplified by wearing black clothes, writing poetry with morbid themes or a preoccupation with music that has nihilistic themes. Sleep disturbance may manifest as all-night television watching, difficulty in getting up for school, or sleeping during the day. Lack of motivation and lowered energy level is reflected by missed classes. A drop in grade averages can be equated with loss of concentration and slowed thinking. Boredom may be a synonym for feeling depressed. Loss of appetite may become anorexia or bulimia. Adolescent depression may also present primarily as a behavior or conduct disorder, substance or alcohol abuse or as family turmoil and rebellion with no obvious symptoms reminiscent of depression.

Formal psychologic testing may be helpful in complicated presentations that do not lend themselves easily to diagnosis. In the most difficult cases, a trial of treatment may be required to differentiate clinical depression from extreme developmental turmoil or conduct disorders.

How can suicide risk be determined?

It is not uncommon for young people to be preoccupied with issues of mortality and to contemplate the effect their death would have on close family and friends. Thankfully, these ideas are usually not acted upon. Suicidal acts are generally associated with a significant acute crisis in the teenager's life and may also involve concomitant depression. It is important to stress that the crisis may be insignificant to the adults around, but very significant to the teenager. The loss of a boyfriend or girlfriend, a drop in school marks or a negative admonition by a significant adult, especially a parent or teacher, may be precipitant to a suicidal act. Suicidal ideation and acts are more common among children who have already experienced significant stress in their lives.

Significant stressors include divorce, parent or family discord, physical or sexual abuse and alcohol or substance abuse. A suicide in a relative or close friend may also be an important identifier of those at the greatest risk. The teenager who exhibits obvious personality change, including social withdrawal, or who gives away treasured possessions may also be seriously contemplating ending his/her life.

Many more teenagers attempt suicide than actually succeed, and the methods used may be naive. There is a tendency to treat perceived minor attempts as attention seeking, histrionic and of no importance. This is a mistake, as a teenager who has attempted suicide and has not received any relief from his or her impossible situation may well be a successful repeater. All suicidal behaviors reflect a cry for help and must be taken seriously.

How can the physician best manage the patient?

The management of the depressed teenager begins at the first interview with the creation of a therapeutic alliance. It is important that the interview be conducted in a relaxed manner, preferably in a room other than a formal examination room. The teenager may have to be brought back the next day or on a number of successive days to adequately address problems. The physician must inspire confidence and trust, and be aware of his or her own biases. Teenagers can be oppositional and negative when depressed. They may have very fragile self-esteem and project their feelings onto the physician. It is important to understand this behavior as part of the depression and treat it accordingly.

Interviews should be conducted with and without the parent(s) present. The rules of confidentiality must be discussed with a clear understanding of which issues will be withheld (e.g., suicide intention). The teenager is an active participant in the treatment process and the physician must identify the problem to the patient and parent, offer hope and reassurance, outline treatment options and arrive at a mutually agreed-upon treatment plan. A family assessment should be undertaken to evaluate what support may be available from family members and what resources are available in crisis.

How should depression in adolescents be treated?

There are two main avenues to treatment: psychotherapy and medication. Often, both may be required. The majority of mild depressions in teenagers respond to supportive psychotherapy with active listening, advice and encouragement. Issues of alcohol and substance abuse may have to be addressed by referral to relevant agencies. Formal family therapy may be required to deal with specific problems or issues. Comorbidity is not unusual in teenagers, and possible pathology, including anxiety, obsessive-compulsive disorder, learning disability or attention deficit hyperactive disorder, should be searched for and treated, if present.

When should medication be used?

For the more serious and persistent depressions, particularly those with vegetative symptoms or suicidal ideation, medication is essential and may be life-saving. Traditional antidepressant drugs generally are poorly tolerated by teenagers because of the common side effects, including sedation and anticholinergic action. This leads to poor compliance. The advent of selective serotonin reuptake inhibitors (SSRIs) has largely put these worries to rest. SSRIs are well tolerated by teenagers because of their fairly rapid action and low tendency to cause side effects. Low toxicity also makes them particularly helpful in an impulsive patient population. It is important that an adequate time period be given to allow the medication to work (four to six weeks) and that adequate doses are used.

There are sufficient choices of SSRIs so that a suitable medication can be found for most symptom clusters. Most teenagers can tolerate adult dosages, and lack of response may reflect a problem with dosage rather than the choice of medication. Some attempt to explain the action of the medication should be given to the patient and family, as should an explanation of possible side effects. Anxiolytic and sleep medication may also be required.

When should the patient be referred to a psychiatrist specializing in adolescents?

Referral should be considered under a number of circumstances. If the physician cannot engage in conversation with the teenager because of the patient's resistance or the physician's own insecurity about dealing with this age group, then referral is suggested. This is particularly important if the depression is judged to be severe or if there have been some suicidal concerns. Referral should also be considered if the patient's condition does not improve in the expected time or if there is any deterioration or worsening of the depression despite adequate treatment. It should be stressed that the majority of teenage depressions can be managed successfully by the primary care physician with the support of the family.

It’s not unusual for young people to experience "the blues" or feel "down in the dumps" occasionally. Adolescence is always an unsettling time, with the many physical, emotional, psychological and social changes that accompany this stage of life.

Unrealistic academic, social, or family expectations can create a strong sense of rejection and can lead to deep disappointment. When things go wrong at school or at home, teens often overreact. Many young people feel that life is not fair or that things "never go their way." They feel "stressed out" and confused. To make matters worse, teens are bombarded by conflicting messages from parents, friends and society. Today’s teens see more of what life has to offer — both good and bad — on television, at school, in magazines and on the Internet. They are also forced to learn about the threat of AIDS, even if they are not sexually active or using drugs.

Teens need adult guidance more than ever to understand all the emotional and physical changes they are experiencing. When teens’ moods disrupt their ability to function on a day-to-day basis, it may indicate a serious emotional or mental disorder that needs attention — adolescent depression. Parents or caregivers must take action.

Anger in Our Teens and in Ourselves

by Linda Lebelle

Katie is a 9th-grader and has been feeling that nothing is worth it anymore.  As hard as she tries, she just doesn't seem to fit in.  The day before she had tried out for the school play, but when she got on stage, she froze up and just stopped in the middle of her audition.  Now, everyone in the school must know about it and Katie is sure they're laughing at her. She'll never let them know how bad she feels.  She knows what they're thinking and they're right--she isn't good enough and she'll never fit in.  Katie hates them all.  

 

 

Chris punched his fist into the bedroom wall.  But it wasn't enough.  He picked up his soda can and threw it into the hall.  The brown sugary liquid dripped down the walls and onto the carpeting.  "You can't make me!" he screamed.  "I'm not going anywhere with you!  I'll do what I want!"  Chris ran down the stairs and out the front door.  His father ran after him, yelling at him to get back in the house, but he had already gotten into his car and sped away.  Chris was so mad at his father.  He had better things to do than go visit family.  He and his friends had plans, and his father wasn't going to run his life.  He knew he'd feel better when he smoked some weed.

 

What do these young people have in common?  

 

They're battling with anger. They are not getting what they want and things are not the way they think they should be.  They are feeling intense displeasure or antagonism toward someone or something that comes with the realization that things are not always in their control.  

 

Anger is a feeling; not a behavior.

 

Anger takes many forms--from indignation and resentment to rage and fury--and it is the expressions of the forms of anger--the behavior--that we see.  Katie represses her anger and withdraws.  Chris is defiant and destroys property.  They will continue their behavior, or it may escalate, until they decide to look within themselves to the roots of their anger.

 

Anger can be harmful or healthy.

 

Anger is a frightening emotion.  Its negative expressions can include physical and verbal violence, prejudice, malicious gossip, antisocial behavior, sarcasm, addictions, withdrawal, and psychosomatic disorders.  This can devastate lives--destroying relationships, harming others, disrupting work, clouding effective thinking, affecting physical health, and ruining futures. 

 

But, there is a positive aspect--it can show us that a problem exists, as anger is usually a secondary emotion brought on by fear.  It can motivate us to resolve those things that are not working in our lives and help us face our issues and deal with the underlying reasons for the anger, specifically:

Depression

Anxiety

Grief

Alcohol Abuse

Substance Abuse

Trauma

 

Being a parent of an angry teen brings up the anger in ourselves. 

 

Teenagers face a lot of emotional issues during this period of development.  They're faced with questions of identity, separation, relationships, and purpose.  The relationship between teens and their parents is also changing as teens become more and more independent.  

 

This can bring about frustration and confusion that leads to anger and a pattern of reactive behavior for both parents and teens. Unless we work to change our own behavior, we cannot help teens change theirs. We need to respond rather than react to each other and to situations. The intention is not to deny the anger, but to control that emotion and express it in a proactive way. 

 

The first step to identifying and managing anger is to look within ourselves.  

 

Parents and teens can ask these questions of themselves to bring about self-awareness:

 

Where does this anger come from?

 

What situations bring out this feeling of anger?

 

Do my thoughts begin with absolutes such as "must," "should," "never?"

 

Are my expectations unreasonable?

 

What unresolved conflict am I facing?   

 

Am I reacting to hurt, loss, or fear? 

 

Am I aware of anger's physical signals (e.g., clenching fists, shortness of breath, sweating)?

 

How do I choose to express my anger?  

 

To whom or what is my anger directed?  

 

Am I using anger as a way to isolate myself, or as a way to intimidate others? 

 

Am I communicating effectively?

 

Am I focusing on what has been done to me rather than what I can do?  

 

How am I accountable for what I'm feeling?  

 

How am I accountable for how my anger shows up? 

 

Do my emotions control me, or do I control my emotions?

 

What can we do for our teen and for ourselves?

 

Listen to your teen and focus on feelings.  Try to understand the situation from your child's perspective.  Blaming and accusing only builds up more walls and ends all communication.  Tell how you feel, stick to facts, and deal with the present moment.  Practice relaxation and meditation.  Show that you care and show your love.  Work towards a solution where everyone wins.  Remember that anger is the feeling and behavior is the choice.

When I suggest to a new patient that they consider antidepressant medication, I get a picture of all the misconceptions people have about what these medications do. First of all, they are not happy pills; they don't artificially induce a feeling of bliss or unrealistic well-being. No medication can do that, except for alcohol and some illegal drugs, and their effects don't last. Nor do antidepressants insulate you from life, make you not care about important things, or insensitive to pain or loss. Tranquilizers can do that, for a while, but antidepressants can't. Also, antidepressants aren't addictive, nor does their effect diminish so that you will have to increase your dosage later on. What antidepressants do is somehow prevent us from sliding down the chute into the blackest depths of depression when something bad happens. We still can feel hurt, pain, worry, but we feel these like normal people do, without depression.

These medications also can help us sleep better, give us more energy, and greater ability to concentrate. They seem to help us change our perspective or sense of proportion, so that we can appreciate better the good side of life and not be overwhelmed by the negative.

The way antidepressants work is interesting. There are two chemicals that have to do with the transmission of impulses between nerve cells in the brain and seem to be associated with depression. It seems as if depressed people burn up these chemicals more quickly than other people. Antidepressants help to maintain these chemicals at more stable levels in the brain.

Antidepressant medication is an important aid that should be considered by anyone who feels they are suffering from depression. But because their use requires close observation and more training than most physicians have, I don't recommend you ask your general practitioner to give you a trial run. Instead, see a psychiatrist who is experienced in the administration of these potent and helpful medicines.

If you, or someone you love, might be suffering from depression, get help right away. Treatment is effective and affordable. Talk to your health care provider or call your local mental health clinic before a bad situation becomes worse.

ADHD and Depression

A study recently published in the Journal of Affective Disorders (January 1998, 113-122) examined the course of depression in 76 children with ADHD in order to learn more about the relationship between ADHD and depression. The authors were especially interested in whether depression in children with ADHD represents an actual clinical depression, or whether it may be better understood as a kind of "demoralization" that can result from the day to day struggles that children with ADHD often have.

Lets begin by reviewing what mental health professionals mean when they talk about depression. The important point to emphasize is that the clinical diagnosis of depression requires the presence of a collection of different symptoms - just because one is feeling down or depressed does not necessarily mean that the diagnosis of major depression would be appropriate.

According to DSM-IV, the publication of the American Psychiatric Association that lists the official diagnostic criteria for all psychiatric disorders, the symptoms of major depression are as follows:

In addition, it must be determined that the symptoms cause clinically significant distress or impairment, are not due to the direct physiological effects of a medication or general medical condition, and are not better accounted for by bereavement (i.e.,  loss of a loved one).

As you can see, the important point is that true clinical depression is indicated by a collection of symptoms that persist for a sustained   time period, and is clearly more involved that feeling "sad" or "blue" by itself.

Let me also say a few words about depression in children. Research has shown that the core symptoms for depression in children and adolescents are the same as for adults. Certain symptoms appear to be more prominent at different ages, however. As already noted above, in children and teens the predominant mood may be extreme irritability rather than "depressed". In addition, somatic complaints and social withdrawal are especially common in children, and hypersomina (i.e., sleeping too much) and psychomotor retardation (i.e., being extremely slow moving are less common).

What, then, would a "typical" depressed child look like?  Although there of course would be wide variations from child to child, such a child might seem to be extremely irritable, and this would represent a distinct change from their typical state. They might stop participating or getting excited about things they used to enjoy and display a distinct change in eating patterns. You would notice them as being less energetic, they might complain about being unable to sleep well, and they might start referring to themselves in critical and disparaging ways. It is also quite common for school grades to suffer as their concentration is impaired, as does their energy to devoted to any task. As noted above, this pattern of behavior would persist for at least several weeks, and would appear as a real change in how the child typically is.

With this brief overview of depression behind us, lets get back to the study. The authors of this study started with 76 boys who had been diagnosed with both major depression and ADHD and followed them over a 4 year period. Because depression can be such a debilitating condition they were interested in learning what factors predicted persistent major depression, and how the course of depression and ADHD were intertwined.

The results of the study indicated that the strongest predictor of persistent major depression was interpersonal difficulties (i.e.,  being unable to get along well with peers). In contrast, school difficulty and severity of ADHD symptoms were not associated with persistent major depression. In addition, the marked diminishment of ADHD symptoms did not necessarily predict a corresponding remission of depressive symptoms. In other words, the course of ADHD symptoms and the course of depressive symptoms in this sample of children appeared to be relatively distinct.

The results of this study suggest that in children with ADHD who are depressed, the depression is not simply the result of demoralization that can result from the day to day struggles that having ADHD can cause. Instead, although such struggles may be an important risk factor that makes the development of depression in children with ADHD more likely, depression in children with ADHD is a distinct disorder and not merely "demoralization."

Depression in children can be effectively treated with psychological intervention. In fact, the evidence to support the efficacy of psychological interventions for depression in children and adolescents is more compelling than the evidence supporting the use of medication.

The important point that can be taken from this study, I think, is that parents need to be sensitive to recognizing the symptoms of depression in their child, and not to simply assume that it is just another facet of their child's ADHD. In addition, if a child with ADHD does develop depression as well, treatments that target the depressive symptoms specifically need to be implemented. As this study shows, one should not assume that just addressing the difficulties caused by the ADHD symptoms will also alleviate a child's depression.

WHAT IS BIPOLAR DISORDER?

Why is bipolar disorder called an illness?

Everyone has ups and downs in mood--happiness, sadness, and anger are normal emotions and an essential part of everyday life. In contrast, bipolar disorder is a medical condition in which people have mood swings out of proportion, or totally unrelated, to things going on in their lives. These swings affect thoughts, feelings, physical health, behavior, and functioning. Bipolar disorder is not your fault, nor is it the result of a "weak" or unstable personality. It is a treatable medical disorder for which there are specific medications that help most people.

When does bipolar disorder begin?

Bipolar disorder usually begins in adolescence or early adulthood, although it can sometimes start in early childhood or as late as the 40s or 50s. When someone over 50 has a manic episode for the first time, the cause is more likely to be a problem imitating bipolar disorder (e.g., neurological illness or the effects of drugs, alcohol, or some prescription medications).

Why is it important to diagnose and treat bipolar disorder as early as possible?

On average, people with bipolar disorder see 3-4 doctors and spend over 8 years seeking treatment before they receive a correct diagnosis. Earlier diagnosis, proper treatment, and finding the right medications can help people avoid the following:

Is bipolar disorder inherited?

Bipolar disorder tends to run in families. Researchers have identified a number of genes that may be linked to the disorder, suggesting that several different biochemical problems may occur in bipolar disorder (just as there are different kinds of arthritis). However, if you have bipolar disorder and your spouse does not, there is only a 1 in 7 chance that your child will develop it. The chance may be greater if you have a number of relatives with bipolar disorder or depression.

What causes bipolar disorder?

There is no single, proven cause of bipolar disorder, but research strongly suggests that it is often an inherited problem related to a lack of stability in the transmission of nerve impulses in the brain. This biochemical problem makes people with bipolar disorder more vulnerable to emotional and physical stresses. If there is an upsetting life experience, substance use, lack of sleep, or other excessive stimulation, the normal brain mechanisms for restoring calm functioning don't always work properly.

This theory of an inborn vulnerability interacting with an environmental trigger is similar to theories proposed for many other medical conditions. In heart disease, for example, a person might inherit a tendency to have high cholesterol or high blood pressure, which cause gradual damage to the heart's supply of oxygen. During stress, such as physical exertion or emotional tension, the person might suddenly develop chest pain or have a heart attack if the oxygen supply becomes too low. As with heart disease and other medical conditions, treatment for bipolar disorder focuses on taking the right medications and making life-style changes to reduce the risk of mood episodes.

What are the symptoms of bipolar disorder?

Over the course of bipolar disorder, four different kinds of mood episodes can occur:

1. Mania (manic episode). Mania often begins with a pleasurable sense of heightened energy, creativity, and social ease-feelings that can quickly escalate out of control into a full-blown manic episode. People with mania typically lack insight, deny anything is wrong, and angrily blame anyone who points out a problem. In a manic episode, the following symptoms are present for at least 1 week, to the point where the person has trouble functioning in a normal way:

Plus at least four (and often almost all) of the following:

In very severe cases, there may be psychotic symptoms such as hallucinations (hearing or seeing things that aren't there) or delusions (firmly believing things that aren't true)

2. Hypomania (hypomanic episode). Hypomania is a milder form of mania with similar but less severe symptoms and less impairment. In hypomanic episodes, the individual may have an elevated mood, feel better than usual, and be more productive. These episodes often feel good and the quest for hypomania may even cause people to stop their medication. However, all too often there is a severe price to pay for hypomania-either escalation to mania or a crash to depression.

3. Depression (major depressive episode). In a full-blown "major" depressive episode, the following symptoms are present for at least 2 weeks and make it difficult for you to function:

Plus at least four of the following:

Severe depressions may also include hallucinations or delusions.

4. Mixed Episode. Perhaps the most disabling episodes are those that involve symptoms of both mania and depression occurring at the same time or alternating frequently during the day. You are excitable or agitated as in mania but also feel irritable and depressed, instead of feeling on top of the world.

What are the different patterns of bipolar disorder?

People vary in the types of episodes they usually have and how often they become ill. Some people have equal numbers of manic and depressive episodes; others have mostly one type or the other. The average person with bipolar disorder has four episodes during the first 10 years of the illness. Men are more likely to start with a manic episode, women with a depressive episode. While a number of years can elapse between the first two or three episodes of mania or depression, without treatment most people eventually have more frequent episodes. Sometimes these follow a seasonal pattern (for example, getting hypomanic in the summer and depressed in the winter). A small number of people cycle frequently or even continuously through the year.

Episodes can last days, months, or sometimes even years. On average, without treatment, manic or hypomanic episodes last a few months, while depressions often last well over 6 months. Some individuals recover completely between episodes and may go many years without any symptoms, while others continue to have low-grade but troubling depression or mild swings up and down.

Special terms are used to describe common patterns:

HOW IS BIPOLAR DISORDER TREATED?

Stages of Treatment

Components of Treatment

Electroconvulsive therapy

Although electroconvulsive therapy (ECT) has had a lot of negative publicity, it can be a life-saver and is often the safest and most effective treatment for psychotic depression. ECT may also be needed if you are severely ill and cannot wait for medicines to work, if you have had several unsuccessful trials of antidepressant medications, or if you have medical conditions or pregnancy that make drug therapy less safe. Remember ECT is much safer and more comfortable than it has been portrayed in Hollywood movies and can be remarkably effective. Like all treatments, ECT has potential side effects. Although there is usually short-term memory disturbance, most ECT patients feel that the benefits far outweigh the prospect of suffering from long-term severe, unremitting depression.

About hospitalization

Treatment in the hospital is sometimes needed but is usually brief (1-2 weeks). Hospitalization can be essential to prevent self-destructive, impulsive, or aggressive behavior that the person will later regret. Manic patients often lack insight that they are ill and require hospitalization. Research has shown that after recovery, most manic patients are grateful for the help they received, even if it was given against their will at the time. During depression, hospitalization may be needed if a person becomes very suicidal. Hospitalization is also used for individuals who have medical complications that make it harder to monitor medication and for people who cannot stop using drugs or alcohol. Remember, early recognition and treatment of manic and depressive episodes can lower the chances of hospitalization.

Medication for lifetime prevention

Successful management of bipolar disorder requires a great deal from patients and families. There will almost certainly be many times when you will be sorely tempted to stop your medication because 1) you feel fine, 2) you miss the highs, or 3) you are bothered by side effects. If you stop your medication, you probably won't have an acute episode immediately in the next days or weeks, but eventually you will probably have a relapse. Don't forget the kindling model, which suggests that each episode worsens your chances of having a smooth long-term course.

Sometimes the diagnosis is uncertain after a single episode and it is possible to taper the medication after about a year. However, if you have had only one episode of mania but have a very strong family history (suggesting you may have inherited the disorder), or if the episode was so severe that it almost ruined your life, you should strongly consider taking medication for several years if not for life. If you have had two or more manic or depressive episodes, experts strongly recommend taking preventive medication indefinitely.

How often does preventive medication work? What if I start to feel symptoms?

Mood stabilizers (lithium, valproate, carbamazepine) are the core of prevention. About one in three people with bipolar disorder will be completely free of symptoms by taking mood stabilizing medication for life. Most people experience a great reduction in how often they become ill or in the severity of each episode. Don't be discouraged if you occasionally feel that you might be going into a manic or depressive episode. Always report changes to your doctor immediately, because adjustments in your medicine at the first warning signs can usually restore a normal mood. Sometimes it just takes a slight increase in the blood level of your mood stabilizer, or other medicines may need to be added. Medication adjustments are usually a routine part of treatment (just as insulin doses are changed from time to time in diabetes). Never be afraid to report changes in symptoms-they usually don't require any very dramatic change in treatment and your doctor will be eager to help.

Take your medicine as directed even if you have felt better for a long time.

Sometimes people who have felt well for a number of years hope that the bipolar disorder has gone away and that they don't need medicine anymore. Unfortunately, the medications do not "cure" bipolar disorder. Stopping them even after many years of good health can lead to a disastrous relapse, sometimes within a few months. Generally, the only times you should seriously think of stopping preventive medication are if you want to become pregnant or have a serious medical problem that would make the medicines unsafe. Even these may not be absolute reasons to stop. Always talk these situations over carefully with your doctor. If you are going to stop, it is important to taper the medicines very slowly (over weeks to months).

Tell your doctor right away about any side effects you have.

Some people have different side effects than others and one person's side effect (e.g., unpleasant sleepiness) may actually help another person (e.g., someone who suffers from insomnia). The side effects you may get from medication depend on:

At least half of those who take mood stabilizers have side effects (See table below). These are especially common if high doses and a combination of medicines are needed during the acute phase of treatment. Lowering doses and decreasing the number of medicines usually helps, but some people may have severe enough side effects to require a change of medicine. Side effects tend to be worse early in the treatment, but some people who have taken lithium for 20 years or longer with good results develop problems with side effects or toxicity as they become older. Fortunately, valproate or carbamazepine are often excellent alternatives as long the switch is made gradually. Valproate appears to cause the fewest side effects during long-term treatment.

If side effects are a problem for you, there are a number of approaches your doctor may suggest:

Changing medicine is a complicated decision. 

It is dangerous to make changes in your medicine on your own!

MEDICATION

The two most important types of medication used to control the symptoms of bipolar disorder are mood stabilizers and antidepressants. Your doctor may also prescribe other medications to help with insomnia, anxiety, restlessness, or psychotic symptoms.

What are mood stabilizers?

Mood stabilizers are used to improve symptoms during acute manic, hypomanic, and mixed episodes; they may sometimes also reduce symptoms of depression. They are the mainstay of long-term preventive treatment for both mania and depression. Three mood stabilizers are widely used in the United States:

Fortunately, each of the three mood stabilizers has different chemical actions in the body. If one does not work for you, or you have persistent side effects, your doctor can suggest another, or combine two medications at doses you can manage. For all three mood stabilizers, blood tests are used to determine the correct dose and to monitor safety.

Selecting a mood stabilizer for an acute manic episode

The first line drugs for the acute phase treatment of a manic episode are lithium and valproate. In choosing between them, your doctor will take into account whether either of these medicines has worked for you in the past or whether there are particular side effects that might affect your preference. All other things being equal, the initial decision may be based on the subtype of bipolar disorder that you have: experts prefer lithium for patients with euphoric (overly happy) moods and valproate for patients with mixed features (manic episodes with a very unhappy or irritable mood) or for patients who are rapid cyclers.

Acute treatment with lithium or valproate usually helps significantly in a few weeks. However, if the first medication does not work well enough, your doctor may switch you to the other or combine them. Carbamazepine is also useful as a backup, especially for mixed episodes or rapid cycling.