Overcoming Depression

Depression is a it is a mood disorder that frequently coexists with schizophrenia and which also needs treatment. Feelings of depression and hopelessness are also common with caregivers of the mentally ill. If you or someone you know with schizophrenia is feeling particularly depressed its important to see the doctor about the condition. Also, we recommend you talk to others about your feelings in the schizophrenia.com discussion areas. Overviews on Depression

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Personal Experiences with Depression

Ways to help yourself when you are feeling suicidal. If you're thinking about suicide "Start by considering this statement: "Suicide is not chosen; it happens when pain exceeds resources for coping with pain." - resources about suicide and its prevention. Ways to Maintain Recovery from Depression What Family and Friends Can Do to Help Someone Who is Depressed Strong Relationship Between Schizophrenia and Depression Common Treatments for Depression

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Depression

Recommended Books for People who are Depressed

Overcoming Depression, 3rd edition by Demitri Papolos, Publisher: Quill; 3rd edition (February 1997), ISBN: 0060927828 The Essential Guide to Psychiatric Drugs : Includes The Most Recent Information On: Antidepressants, Tranquilizers and Antianxiety Drugs, Antipsychotics, Drugs annd Pregnancy, Drugs and the Elderly, Drugs and AIDS, Side-effects and Withdrawal Symptoms, and Much, Much More by Jack M., M.D. Gorman, Publisher: St. Martin's Press; (December 1998), ISBN: 0312954581 Consumer's Guide to Psychiatric Drugs, by John D. Preston, John H. O'Neal, Mary C. Talaga, Publisher: New Harbinger Pubns; (2000) ASIN: 157224111X

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1. 2.

The symptom of depression in schizophrenia and its management

Ciaran Mulholland and Stephen Cooper

+Author

Affiliations 1. Ciaran Mulholland is a consultant psychiatrist at Holywel Hospital, Antrim, Northern Ireland. Stephen Cooper is a Senior Lecturer and Head of the Department of Mental Health, The Queen's University of Belfast, Northern Ireland (Whitla Medical Building, 97 Lisburn Road, Belfast BT9 7BL; tel: 01232 3357910; fax: 01232 324543; e-mail: s.cooper@qub.ac.uk). They have research interests in the epidemiology, causes and neurochemical basis of depression in schizophrenia. Depression is a frequently occurring symptom in schizophrenia. While today it is often underrecognised and under-treated, historically such symptoms were the focus of much attention. Affective symptoms were used by Kraepelin as an important criterion with which to separate dementia praecox from manicdepressive illness. Kraepelin also recognised the importance of depression as a symptom in schizophrenia and identified several depressive subtypes of the illness. Mayer-Gross emphasised the despair that often occurs as a psychological reaction to acute psychotic episodes and Bleuler considered depression to be one of the core symptoms of schizophrenia. Depressive symptoms in schizophrenia are important not only because they contribute significantly to the suffering caused by the illness, whether positive psychotic symptoms are active or quiescent, but also because they exacerbate deficits in psychosocial functioning and commonly precede attempted and completed suicide. It is important to define and clinically assess such symptoms accurately as there is now increasing evidence that they can be treated successfully. Next Section

Differential diagnosis of depression in schizophrenia

There are a number of important differential diagnoses of depressive symptoms in schizophrenia. We can assume that depression and schizophrenia are not simply two independent illnesses occurring together by chance, on the basis of the epidemiology of each illness. Differential diagnoses to consider include schizoaffective disorder, organic conditions and the negative symptoms of schizophrenia. It has been argued by some that depression may in some way be caused by antipsychotic medication and this issue will be discussed in detail. Depression may also be an understandable psychological reaction to schizophrenia. When all of these possibilities have been excluded, there is evidence that depression is perhaps most often an integral part of the schizophrenic process itself. Schizoaffective disorder Differentiating schizophrenia with clinically significant depressive symptoms from schizoaffective disorder is not always easy. Clearly, the exact dividing line between the two conditions is a conceptual one. Operationalised criteria such as ICD10 (World Health Orgnization, 1992) allow us to make such a differentiation on a day-to-day basis (see Boxes 1 and 2) and will dictate treatment options to an extent. The nature and treatment of schizoaffective disorder falls outside the remit of this review.
Box 1. ICD10 diagnostic guidelines for post-schizophrenic depression

The patient has met general criteria for schizophrenia within past 12 months Some schizophrenic symptoms are still present, but no longer dominate the clinical picture (symptoms may be positive or negative, though the latter are more common) The depressive symptoms are prominent and distressing, fulfilling at least the criteria for a depressive episode, and have been present for at least two weeks (they are rarely sufficiently severe or extensive to meet criteria for a severe depressive episode)
Box 2. ICD10 diagnostic guidelines for schizoaffective disorder depressed type

Both definite schizophrenic and definite affective symptoms are prominent simultaneously, or within a few days of each other, within the same episode of illness As a consequence of this, the episode of illness does not meet criteria for either schizophrenia or for a depressive or manic episode There must be prominent depression accompanied by at least two characteristic depressive symptoms or associated behavioural abnormalities as for a depressive episode At least one and preferably two typically schizophrenic symptoms, as specified for schizophrenia, must be present

Adjustment reactions Schizophrenia carries a heavy psychological burden and it is not surprising that disappointment reactions to life's vicissitudes occur commonly. Acute reactions, lasting less than two weeks, are self-limiting and require supportive treatment or manipulation of the environment only. Often, a clear precipitating cause can be identified. There are some patients who can be characterised as suffering from a demoralisation syndrome or a chronic disappointment reaction. Differentiating such a syndrome from depression is not always easy. It is characterised by hopelessness and helplessness, with a lack of confidence and feelings of incompetence. The appropriate treatment is supportive or rehabilitative rather than pharmacological. Clearly, a reactive process cannot explain the majority of cases of depression in schizophrenia. If such a process, dependent to an extent on the return of insight, is at work, then depressive symptoms should become more common as acute psychotic symptoms respond to treatment. The opposite appears to be the case, however, with depressive symptoms more often resolving as positive symptoms resolve. Organic factors Depression-like syndromes can occur secondary to a range of medical conditions (Table 1). Neoplasms, anaemias, infections, neurological disorders and endocrine disorders can induce psychological symptoms directly in the person with schizophrenia, or depressive symptoms may occur as a reaction to illness. A myocardial infarction, for example, may present as agitation and emotional distress in someone with schizophrenia as there can be an altered pain threshold and inability to describe symptoms adequately. The medication used to treat medical disorders may also cause depressive symptoms as a side-effect. Antihypertensives, corticosteroids, anticonvulsants and L-dopa, among others, may give rise to problems. The medical history of any patient presenting with depressive symptoms should thus be carefully scrutinised. In addition, the entire range of medication that they receive, not just their psychotropic medication, and any recent changes in medication, should be considered as possible aetiological factors.

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Table 1. Main differential diagnoses of depressive symptoms in schizophrenia Substance misuse is also a common cause of depressive symptoms, either as a direct effect of the substance concerned or as a withdrawal phenomenon. Alcohol is undoubtedly the most common substance causing problems. Arguably, cannabis can cause depressive symptoms with long-term use, and nicotine and caffeine may cause dysphoria upon withdrawal. Cocaine, less commonly used and more often associated with manic symptoms, can cause depression upon withdrawal. The same applies to other psychostimulants (Table 1). Differentiating depressive from negative symptoms The negative features of schizophrenia have many clinical similarities to the syndrome of depression. Lack of energy, anhedonia and social withdrawal may cause particular problems when attempting to differentiate between the two syndromes. Observed sadness is an unreliable indicator of depression in schizophrenia. Prominent subjectively low mood, suggesting depression, and prominent blunting of affect, suggesting negative symptoms, are the two features which are most helpful in differentiating the two syndromes (Siris, 1994). An emphasis on the patient's view of him- or herself may thus be a useful approach in detecting important aspects of depressive symptomatology in schizophrenia. Other symptoms that help to establish the diagnosis of depression include some of the main psychological features that occur in primary depressive illness, such as hopelessness, helplessness, worthlessness, guilt, anxiety and suicidal thinking. In schizophrenia, the biological features of the depressive syndrome, such as insomnia and retardation, are not always present and if they are present, they can be more difficult to disentangle from negative symptoms and can be an intrinsic part of the illness separate from any superimposed depressive syndrome. The role of antipsychotic medication The role of antipsychotic medication in the aetiology of depressive symptoms in schizophrenia is somewhat controversial. There have been three principal proposed roles (Table 2).

Table 2.

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Antipsychotic medication and depressive symptoms in schizophrenia Thirty years ago, it was proposed that antipsychotics acted directly causing pharmacogenic depression (De Alarcon & Carney, 1969). There is a possible theoretical explanation for this as antipsychotics act primarily on dopaminergic pathways and dopamine plays a major role in reward and pleasure mechanisms. An alternative hypothesis proposed that akinesia, an extrapyramidal side-effect of antipsychotic medication, and not necessarily accompanied by other symptoms, such as tremor, can mimic depression. This phenomenon has been termed akinetic depression (Van Putten & May, 1978). Patients behave as if their starter motor is broken and display anergia and akinesia, sometimes with accompanying low mood. Van Putten & May considered this to be a new symptom of extrapyramidal disorder, not part of Parkinsonian syndrome. Whether it can be reliably differentiated from Parkinsonian syndrome and is in fact a separate clinical entity remains open to question. Although some observations have supported these hypotheses, the weight of evidence has been against, suggesting that antipsychotics are responsible for relatively few cases of depression in schizophrenia. Depression can occur in antipsychotic-free patients with schizophrenia (Johnson, 1981a), the prevalence of significant depression falls when antipsychotic treatment is commenced (Hirsch et al, 1989) and when antipsychotics are discontinued there is an increase in the percentage of patients requiring antidepressants (Hirsch et al, 1973). Several studies have shown no difference between depressed and non-depressed patients with schizophrenia in the dosage of antipsychotic medication received. Johnson (1981b) estimated that akinetic depression accounts for 1015% of depressive-type symptoms. It is difficult to know how accurate this claim is, but akinetic depression should always be considered as a possibility and anticholinergics as a treatment option. Depressive symptoms are as common in patients on anticholinergics as in those who are not, and anticholinergics are not an effective treatment for depressive symptoms (Johnson, 1981a). More recently, attention has focused on the concept of antipsychotic-induced dysphoria. One study in normal volunteers (King et al, 1995) demonstrated that dysphoria often occurs in the absence of motor restlessness and can thus be under-diagnosed. It is possible that some patients with schizophrenia presenting with depressive symptoms may in fact be troubled by antipsychotic-induced dysphoria, without the associated motor aspects of akathisia that make the diagnosis more obvious. If present, dysphoria/akathisia is not a trivial side-effect and has even been associated with suicide (Drake & Ehrlich, 1985). Depression as a core symptom of schizophrenia Although the above factors must always be considered, it is probably the case that the majority of patients with schizophrenia who also complain of significant depressive symptoms have these symptoms as an aspect of the illness process itself. Table 3 summarises the situations in which this occurs and the main approaches to management for these.

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Table 3. Depressive symptoms and the time-course of schizophrenia

MCQ answers

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Depression as a prodromal syndrome Depressive symptoms are common in the prodromal period prior to acute psychotic episodes. Herz & Melville (1980) found that the symptoms most frequently mentioned by patients and their families were:symptoms of dysphoria that non-psychotic individuals experience under stress, such as eating less, having trouble concentrating, having trouble sleeping, depression and seeing friends less.Indeed, depression, as described above, was described by 60% of patients and more than 75% of their relatives. Johnson et al's (1983) findings were less dramatic, with 20% of their cohort experiencing more prominent affective symptoms prior to relapse. The emergence of affective symptoms may represent a psychological reaction to impending relapse, may reflect an underlying biological process mediating both these symptoms and positive psychotic symptoms, or may be an epiphenomenon. In any event, newly emerging affective symptoms are a useful early warning sign of impending relapse. Depressive symptoms during acute episodes Depressive symptoms are most frequently associated with the acute phase of the illness. Such symptoms are most prevalent before medication is commenced (Knights & Hirsch, 1981) and occur in more than half of first-episode or drug-free patients (Johnson, 1981a). The prevalence of depressive symptoms falls dramatically during the course of an admission for an acute relapse,

and occurs in approximately 25% of patients during the six months following discharge. The close association between depressive symptoms and acute episodes adds weight to the hypotheses that such symptoms are a core feature of schizophrenia and suggests that depressive symptoms and more typically schizophrenic symptoms may share common pathophysiological processes. Depressive symptoms in chronic schizophrenia Lower rates of depressive symptoms are seen in the chronic phase of the illness with a range of 425% and an estimated mean of 15% (Leff, 1990). Most of the reported studies on chronic patients do not define the clinical stability or otherwise of the patients involved. In one study (Pogue-Geile, 1989), only patients who were clinically stable (not hospitalised in the previous six months, no medication changes in previous six weeks and judged by their clinician to be stable) and who were living in the community were assessed, and 9% were found to be currently depressed. Persistent positive symptoms in the chronic phase of the illness may lead to distress, demoralisation and depression. Post-psychotic depression The occurrence of depressive symptoms during the chronic phase of schizophrenia has been given close attention in recent years. The terms post-psychotic depression, post-schizophrenic depression and secondary depression have been used to describe this phenomenon. Unfortunately, as Siris (1990) has argued, the term post-psychotic depression has been used to describe three similar, but clinically distinct, groups of patients. In one group, depressive symptoms are clearly present during an acute psychotic episode and resolve as the positive psychotic symptoms resolve, although sometimes more slowly. These depressive symptoms only become apparent as the positive symptoms resolve, and the term revealed depression is sometimes applied. The second definition overlaps somewhat with the first but describes patients who develop depressive symptoms as their positive psychotic symptoms resolve. The third group of patients are those in whom significant depressive symptoms appear after the acute episode has resolved. The multiplicity of terms and the different ways in which they have been used has not added to the clarity of the literature. The studies in this area have varied widely in methodology, including their definitions of significant depression. The concept of post-schizophrenic (or post-psychotic) depression has now been incorporated into the ICD10 (World Health Organization, 1992) classification system (and in the appendix of DSMIV; American Psychiatric Association, 1994). ICD10 offers an operationalised definition of post-schizophrenic depression (Box 1) and attempts to avoid confusion by specifically stating that it is immaterial to the diagnosis whether depressive symptoms have been revealed or are a new development, and it is similarly immaterial whether depression is an intrinsic part of schizophrenia or a psychological reaction to it. Previous SectionNext Section

Importance of depressive symptoms

Bleuler considered prominent affective symptoms to be a good prognostic sign in schizophrenia. This notion persisted for many decades despite the lack of good evidence to support it, and evidence to the contrary is now accumulating. Depression is an associated risk factor for death by suicide in schizophrenia. Given that 10% of patients with schizophrenia end their own lives, this is of obvious importance. Patients who kill themselves are more likely to have a history of depressive episodes and to have exhibited depressive symptoms at their last contact. Suicide in schizophrenia appears to be correlated more with hopelessness and the psychological aspects of depression than with vegetative features (Drake & Cotton, 1986). Depression is also associated with attempted suicide (Prasad, 1986). Cheadle et al (1978) suggested that neurotic symptoms, many of them depressive in nature, are the principal symptoms causing distress to patients with chronic schizophrenia in the community. Johnson (1981a) found that over a two-year follow-up period the total morbidity from depression was more than twice the duration of morbidity from acute schizophrenic symptoms and that the risk of an episode of depression was over three times the risk of an acute schizophrenic relapse. Follow-up studies have shown that depression can be the main indication for 40% of admissions (Falloon et al, 1978) and that patients who manifest postpsychotic depression are more likely to experience a psychotic relapse. Glazer et al (1981) demonstated a link between depressive symptoms and poor performance in social roles, including difficulties in relationships with others. There also appears to be a correlation between post-psychotic depression and poor premorbid social adjustment and with insidious onset of the first psychotic episode. Cause of depression in schizophrenia The cause of depression, as a core symptom in schizophrenia, is not known. Interestingly, early parental loss is more common among patients with post-psychotic depression (Roy et al, 1983), as is a family history of affective disorder (Subotnik et al, 1997). Depressive symptoms are equally common in male and female patients (Addington et al, 1996). Recent work has shown an

association between depressive symptoms and attentional impairment, suggesting frontal lobe dysfunction (Kohler et al, 1998a) and increased bilateral temporal lobe volumes and decreased laterality (Kohler et al, 1998b). These findings among others suggest that the neurobiology of depressive symptoms in schizophrenia may have similarities with that of depressive illness itself. Further work is required to clarify the issue. Treatment issues The assessment and treatment of depressive symptoms in schizophrenia remains clinically challenging. Recent advances in psychopharmacology and other treatment approaches elevate the importance of establishing the diagnosis at an early stage. The therapeutic goal is significantly to reduce the excess morbidity and mortality associated with depressive symptoms. The first steps are to exclude cases of schizoaffective disorder and to treat them appropiately, to treat any medical conditions that are present,and to consider the possibility of substance misuse as a contributing factor. Any evidence that antipsychotic medication is producing akinesia should lead to a reduction in dosage and/or the introduction of anticholinergic medication. Akathisia, with its concomitant feeling of dysphoria, should always be considered in patients describing subjective mood disturbance. The akathisia/dysphoria syndrome, if present, requires active management. Use of an anticholinergic drug is generally effective. Other options include -adrenoceptor antagonists (e.g. propranolol), a benzodiazapine or a change in antipsychotic drug. If the above factors have been addressed and the clinician is sure that negative symptoms are not being mistaken for depressive symptoms, then the treatment options are largely dictated by the stage of the illness. An expectant approach, with increased psychosocial support, may be the way foward if emerging depressive symptoms are thought to herald an acute relapse. Clearly, antipsychotic medication should be introduced or increased if there is serious concern that an acute episode is developing. Indeed, follow-up studies indicate that early intervention at the first signs of relapse improves outcome (Johnstone et al, 1984). During acute episodes, depressive symptoms should not be treated separately from other symptoms and are likely to resolve as the episode resolves. In the majority of cases increased antipsychotic medication, increased psychosocial support and, if necessary, hospitalisation, will successfully treat depression as well as positive symptoms. There is accumulating evidence that the new atypical antipsychotics are more efficacious in treating the depression associated with an acute episode. Olanzapine, for example, was superior to haloperidol in this regard in a recent study (Tollefson et al, 1997). Other atypicals, such as risperidone, ziprasidone and zotepine, may also have a mood-elevating effect. The atypicals may prove to be useful for the depression that emerges during the chronic phase of the illness. Clozapine has been shown to reduce hopelessness, depression and suicidality in people with chronic schizophrenia (Meltzer & Okalyi, 1995). There is a good case for the prescription of an antidepressant when the patient has persistent depressive symptoms and is not in a phase of acute illness. There have been 11 published double-blind, placebo-controlled trials of tricyclic antidepressants. The results of these demonstrated improvement v.placebo in five, and no improvement in six. Unfortunately, these studies vary in patient selection criteria, particularly in relation to the patient's phase of illness, but the better-conducted trials tend to support a treatment effect (Plasky, 1991). A caveat with the tricyclics, however, is that occasionally there can be a worsening of the positive psychotic symptoms. Clinical trials of selective serotonin reuptake inhibitors (SSRIs) have overall been in favour of an effect on depressive symptoms in schizophrenia. Some of the studies have focused more on negative symptoms and have not included patients with severe depressive symptoms. However, in general, patients seem to do better on an SSRI than with placebo. A recent study designed specifically to compare an SSRI with placebo in patients with schizophrenia with moderate or severe depression also found clear benefit (Mulholland et al, 1997). Given the relative safety of SSRIs compared with the tricyclics, they would seem to be the antidepressants of choice. However, it is necessary to bear in mind possible pharmacokinetic interactions with antipsychotics because of the enzyme inhibitory effects of some of the SSRIs on the CYP450 system. Electroconvulsive therapy (ECT) was in earlier years often advocated for patients with schizophrenia experiencing prominent affective symptoms. This practice appears to stem from clinical observations made in the 1940s (when ECT was the only effective treatment) that patients with schizophrenia who improved with ECT often had strong affective components. However, some of these statements emanated from the USA, where many patients diagnosed as having schizophrenia would, in Europe, have received a diagnosis of affective psychosis. Chart review studies of patients given ECT in 1950, 1970 and 1985 did not find consistent evidence that patients with affective symptoms did better with ECT than others. Modern, placebo-

controlled clinical trials in the 1980s did not find significant improvement in depressive symptoms in patients with schizophrenia given ECT, but did so in patients with psychotic symptoms (Cooper et al, 1995). Rehabilitation, social support and work opportunities are likely to lessen the demoralisation seen in schizophrenia. Cognitive therapy has been shown to be effective (Kingdon et al, 1994), although its role in the treatment of depressive symptoms in particular has not been studied. Given its usefulness in treating depressive illness, this is worth exploring. In summary, depressive symptoms in schizophrenia are common, are a significant cause of morbidity and mortality and can be adequately differentiated from other symptoms and medication effects. Such symptoms are amenable to treatment and should be actively sought out in all patients. Previous SectionNext Section

Multiple choice questions

1. Depression in schizophrenia: 1. 2. 3. 4. 5. 1. is most often seen during periods of remission is associated with an increased risk of attempted suicide may be an early sign of impending relapse is an insignificant cause of morbidity is a good prognostic sign.

In the differential diagnoses of depression in schizophrenia: 1. 2. alcohol misuse must be excluded confusion with negative symptoms sometimes occurs medical conditions are not important more consideration should be given to subjective depression the possibility of impending relapse should be considered.

3. 4.

5.

1.

Symptoms which help to differentiate negative from depressive symptoms include: 1. 2. 3. 4. 5. 1. hopelessness suicidal thinking subjective low mood retardation anxiety.

Antipsychotic medication: 1. frequently causes a

pharmacog enic depression 2. may cause dysphoria without associated motor movements should be decreased if depressive symptoms appear in a previously stable patient akinetic depression may account for up to 25% of cases of depressive symptoms in schizohreni a will often treat depressive as well positive symptoms present during acute episodes.

3.

4.

5.

1.

Treatments likely to be useful in the treatment of depression in schizophrenia include: 1. tric ycli c ant ide pre ssa nts aty pic al ant ips ych otic s inc rea sed psy

2.

3.

cho soc ial sup por t 4. sel ecti ve ser oto nin reu pta ke inhi bit ors hos pit alis ati on.

5.

ANTIPSYCHOTIC MEDICATIONS

A person who is psychotic is out of touch with reality. People with psychosis may hear "voices" or have strange and illogical ideas (for example, thinking that others can hear their thoughts, or are trying to harm them, or that they are the President of the United States or some other famous person). They may get excited or angry for no apparent reason, or spend a lot of time by themselves, or in bed, sleeping during the day and staying awake at night. The person may neglect appearance, not bathing or changing clothes, and may be hard to talk to--barely talking or saying things that make no sense. They often are initially unaware that their condition is an illness. These kinds of behaviors are symptoms of a psychotic illness such as schizophrenia. Antipsychotic medications act against these symptoms. These medications cannot "cure" the illness, but they can take away many of the symptoms or make them milder. In some cases, they can shorten the course of an episode of the illness as well. There are a number of antipsychotic (neuroleptic) medications available. These medications affect neurotransmitters that allow communication between nerve cells. One such neurotransmitter, dopamine, is thought to be relevant to schizophrenia symptoms. All these medications have been shown to be effective for schizophrenia. The main differences are in the potency--that is, the dosage (amount) prescribed to produce therapeutic effects-and the side effects. Some people might think that the higher the dose of medication prescribed, the more serious the illness; but this is not always true.

The first antipsychotic medications were introduced in the 1950s. Antipsychotic medications have helped many patients with psychosis lead a more normal and fulfilling life by alleviating such symptoms as hallucinations, both visual and auditory, and paranoid thoughts. However, the early antipsychotic medications often have unpleasant side effects, such as muscle stiffness, tremor, and abnormal movements, leading researchers to continue their search for better drugs. The 1990s saw the development of several new drugs for schizophrenia, called "atypical antipsychotics." Because they have fewer side effects than the older drugs, today they are often used as a first-line treatment. The first atypical antipsychotic, clozapine (Clozaril), was introduced in the United States in 1990. In clinical trials, this medication was found to be more effective than conventional or "typical" antipsychotic medications in individuals with treatment-resistant schizophrenia (schizophrenia that has not responded to other drugs), and the risk of tardive dyskinesia (a movement disorder) was lower. However, because of the potential side effect of a serious blood disorder--agranulocytosis (loss of the white blood cells that fight infection)-patients who are on clozapine must have a blood test every 1 or 2 weeks. The inconvenience and cost of blood tests and the medication itself have made maintenance on clozapine difficult for many people. Clozapine, however, continues to be the drug of choice for treatment-resistant schizophrenia patients. Several other atypical antipsychotics have been developed since clozapine was introduced. The first was risperidone (Risperdal), followed by olanzapine (Zyprexa), quetiapine (Seroquel), and ziprasidone (Geodon). Each has a unique side effect profile, but in general, these medications are better tolerated than the earlier drugs. All these medications have their place in the treatment of schizophrenia, and doctors will choose among them. They will consider the person's symptoms, age, weight, and personal and family medication history. Dosages and side effects. Some drugs are very potent and the doctor may prescribe a low dose. Other drugs are not as potent and a higher dose may be prescribed. Unlike some prescription drugs, which must be taken several times during the day, some antipsychotic medications can be taken just once a day. In order to reduce daytime side effects such as sleepiness, some medications can be taken at bedtime. Some antipsychotic medications are available in "depot" forms that can be injected once or twice a month. Most side effects of antipsychotic medications are mild. Many common ones lessen or disappear after the first few weeks of treatment. These include drowsiness, rapid heartbeat, and dizziness when changing position. Some people gain weight while taking medications and need to pay extra attention to diet and exercise to control their weight. Other side effects may include a decrease in sexual ability or interest, problems with

menstrual periods, sunburn, or skin rashes. If a side effect occurs, the doctor should be told. He or she may prescribe a different medication, change the dosage or schedule, or prescribe an additional medication to control the side effects. Just as people vary in their responses to antipsychotic medications, they also vary in how quickly they improve. Some symptoms may diminish in days; others take weeks or months. Many people see substantial improvement by the sixth week of treatment. If there is no improvement, the doctor may try a different type of medication. The doctor cannot tell beforehand which medication will work for a person. Sometimes a person must try several medications before finding one that works. If a person is feeling better or even completely well, the medication should not be stopped without talking to the doctor. It may be necessary to stay on the medication to continue feeling well. If, after consultation with the doctor, the decision is made to discontinue the medication, it is important to continue to see the doctor while tapering off medication. Many people with bipolar disorder, for instance, require antipsychotic medication only for a limited time during a manic episode until moodstabilizing medication takes effect. On the other hand, some people may need to take antipsychotic medication for an extended period of time. These people usually have chronic (long-term, continuous) schizophrenic disorders, or have a history of repeated schizophrenic episodes, and are likely to become ill again. Also, in some cases a person who has experienced one or two severe episodes may need medication indefinitely. In these cases, medication may be continued in as low a dosage as possible to maintain control of symptoms. This approach, called maintenance treatment, prevents relapse in many people and removes or reduces symptoms for others. Multiple medications. Antipsychotic medications can produce unwanted effects when taken with other medications. Therefore, the doctor should be told about all medicines being taken, including over-the-counter medications and vitamin, mineral, and herbal supplements, and the extent of alcohol use. Some antipsychotic medications interfere with antihypertensive medications (taken for high blood pressure), anticonvulsants (taken for epilepsy), and medications used for Parkinson's disease. Other antipsychotics add to the effect of alcohol and other central nervous system depressants such as antihistamines, antidepressants, barbiturates, some sleeping and pain medications, and narcotics. Other effects. Long-term treatment of schizophrenia with one of the older, or "conventional," antipsychotics may cause a person to develop tardive dyskinesia (TD). Tardive dyskinesia is a condition characterized by involuntary movements, most often around the mouth. It may range from mild to severe. In some people, it cannot be reversed, while others recover partially or completely. Tardive dyskinesia is sometimes seen in people with schizophrenia who have never been treated with an

antipsychotic medication; this is called "spontaneous dyskinesia." However, it is most often seen after long-term treatment with older antipsychotic medications. The risk has been reduced with the newer "atypical" medications. There is a higher incidence in women, and the risk rises with age. The possible risks of long-term treatment with an antipsychotic medication must be weighed against the benefits in each case. The risk for TD is 5 percent per year with older medications; it is less with the newer medications.
1

ANTIMANIC MEDICATIONS

Bipolar disorder is characterized by cycling mood changes: severe highs (mania) and lows (depression). Episodes may be predominantly manic or depressive, with normal mood between episodes. Mood swings may follow each other very closely, within days (rapid cycling), or may be separated by months to years. The "highs" and "lows" may vary in intensity and severity and can co-exist in "mixed" episodes. When people are in a manic "high," they may be overactive, overly talkative, have a great deal of energy, and have much less need for sleep than normal. They may switch quickly from one topic to another, as if they cannot get their thoughts out fast enough. Their attention span is often short, and they can be easily distracted. Sometimes people who are "high" are irritable or angry and have false or inflated ideas about their position or importance in the world. They may be very elated, and full of grand schemes that might range from business deals to romantic sprees. Often, they show poor judgment in these ventures. Mania, untreated, may worsen to a psychotic state. In a depressive cycle the person may have a "low" mood with difficulty concentrating; lack of energy, with slowed thinking and movements; changes in eating and sleeping patterns (usually increases of both in bipolar depression); feelings of hopelessness, helplessness, sadness, worthlessness, guilt; and, sometimes, thoughts of suicide. Lithium. The medication used most often to treat bipolar disorder is lithium. Lithium evens out mood swings in both directions--from mania to depression, and depression to mania--so it is used not just for manic attacks or flare-ups of the illness but also as an ongoing maintenance treatment for bipolar disorder. Although lithium will reduce severe manic symptoms in about 5 to 14 days, it may be weeks to several months before the condition is fully controlled. Antipsychotic medications are sometimes used in the first several days of treatment to control manic symptoms until the lithium begins to take effect. Antidepressants may also be added to lithium during the depressive phase of bipolar disorder. If given in the absence of lithium or another mood stabilizer, antidepressants may provoke a switch into mania in people with bipolar disorder. A person may have one episode of bipolar disorder and never have another, or be free of illness for several years. But for those who have

more than one manic episode, doctors usually give serious consideration to maintenance (continuing) treatment with lithium. Some people respond well to maintenance treatment and have no further episodes. Others may have moderate mood swings that lessen as treatment continues, or have less frequent or less severe episodes. Unfortunately, some people with bipolar disorder may not be helped at all by lithium. Response to treatment with lithium varies, and it cannot be determined beforehand who will or will not respond to treatment. Regular blood tests are an important part of treatment with lithium. If too little is taken, lithium will not be effective. If too much is taken, a variety of side effects may occur. The range between an effective dose and a toxic one is small. Blood lithium levels are checked at the beginning of treatment to determine the best lithium dosage. Once a person is stable and on a maintenance dosage, the lithium level should be checked every few months. How much lithium people need to take may vary over time, depending on how ill they are, their body chemistry, and their physical condition. Side effects of lithium. When people first take lithium, they may experience side effects such as drowsiness, weakness, nausea, fatigue, hand tremor, or increased thirst and urination. Some may disappear or decrease quickly, although hand tremor may persist. Weight gain may also occur. Dieting will help, but crash diets should be avoided because they may raise or lower the lithium level. Drinking low-calorie or nocalorie beverages, especially water, will help keep weight down. Kidney changes--increased urination and, in children, enuresis (bed wetting)-may develop during treatment. These changes are generally manageable and are reduced by lowering the dosage. Because lithium may cause the thyroid gland to become underactive (hypothyroidism) or sometimes enlarged (goiter), thyroid function monitoring is a part of the therapy. To restore normal thyroid function, thyroid hormone may be given along with lithium. Because of possible complications, doctors either may not recommend lithium or may prescribe it with caution when a person has thyroid, kidney, or heart disorders, epilepsy, or brain damage. Women of childbearing age should be aware that lithium increases the risk of congenital malformations in babies. Special caution should be taken during the first 3 months of pregnancy. Anything that lowers the level of sodium in the body--reduced intake of table salt, a switch to a low-salt diet, heavy sweating from an unusual amount of exercise or a very hot climate, fever, vomiting, or diarrhea-may cause a lithium buildup and lead to toxicity. It is important to be aware of conditions that lower sodium or cause dehydration and to tell the doctor if any of these conditions are present so the dose can be changed. Lithium, when combined with certain other medications, can have unwanted effects. Some diuretics--substances that remove water from

the body--increase the level of lithium and can cause toxicity. Other diuretics, like coffee and tea, can lower the level of lithium. Signs of lithium toxicity may include nausea, vomiting, drowsiness, mental dullness, slurred speech, blurred vision, confusion, dizziness, muscle twitching, irregular heartbeat, and, ultimately, seizures. A lithium overdose can be life-threatening. People who are taking lithium should tell every doctor who is treating them, including dentists, about all medications they are taking. With regular monitoring, lithium is a safe and effective drug that enables many people, who otherwise would suffer from incapacitating mood swings, to lead normal lives. Anticonvulsants. Some people with symptoms of mania who do not benefit from or would prefer to avoid lithium have been found to respond to anticonvulsant medications commonly prescribed to treat seizures. The anticonvulsant valproic acid (Depakote, divalproex sodium) is the main alternative therapy for bipolar disorder. It is as effective in nonrapid-cycling bipolar disorder as lithium and appears to be superior to lithium in rapid-cycling bipolar disorder. Although valproic acid can cause gastrointestinal side effects, the incidence is low. Other adverse effects occasionally reported are headache, double vision, dizziness, anxiety, or confusion. Because in some cases valproic acid has caused liver dysfunction, liver function tests should be performed before therapy and at frequent intervals thereafter, particularly during the first 6 months of therapy.
2

Studies conducted in Finland in patients with epilepsy have shown that valproic acid may increase testosterone levels in teenage girls and produce polycystic ovary syndrome (POS)in women who began taking the medication before age 20.3,4 POS can cause obesity, hirsutism (body hair), and amenorrhea. Therefore, young female patients should be monitored carefully by a doctor.

Other anticonvulsants used for bipolar disorder include carbamazepine (Tegretol), lamotrigine (Lamictal), gabapentin (Neurontin), and topiramate (Topamax). The evidence for anticonvulsant effectiveness is stronger for acute mania than for long-term maintenance of bipolar disorder. Some studies suggest particular efficacy of lamotrigine in bipolar depression. At present, the lack of formal FDA approval of anticonvulsants other than valproic acid for bipolar disorder may limit insurance coverage for these medications. Most people who have bipolar disorder take more than one medication. Along with the mood stabilizer--lithium and/or an anticonvulsant--they may take a medication for accompanying agitation, anxiety, insomnia, or depression. It is important to continue taking the mood stabilizer when taking an antidepressant because research has shown that treatment with an antidepressant alone increases the risk that the patient will switch to mania or hypomania, or develop rapid cycling. Sometimes, when a bipolar patient is not responsive to other medications, an atypical
5

antipsychotic medication is prescribed. Finding the best possible medication, or combination of medications, is of utmost importance to the patient and requires close monitoring by a doctor and strict adherence to the recommended treatment regimen.
ANTIDEPRESSANT MEDICATIONS

Major depression, the kind of depression that will most likely benefit from treatment with medications, is more than just "the blues." It is a condition that lasts 2 weeks or more, and interferes with a person's ability to carry on daily tasks and enjoy activities that previously brought pleasure. Depression is associated with abnormal functioning of the brain. An interaction between genetic tendency and life history appears to determine a person's chance of becoming depressed. Episodes of depression may be triggered by stress, difficult life events, side effects of medications, or medication/substance withdrawal, or even viral infections that can affect the brain. Depressed people will seem sad, or "down," or may be unable to enjoy their normal activities. They may have no appetite and lose weight (although some people eat more and gain weight when depressed). They may sleep too much or too little, have difficulty going to sleep, sleep restlessly, or awaken very early in the morning. They may speak of feeling guilty, worthless, or hopeless; they may lack energy or be jumpy and agitated. They may think about killing themselves and may even make a suicide attempt. Some depressed people have delusions (false, fixed ideas) about poverty, sickness, or sinfulness that are related to their depression. Often feelings of depression are worse at a particular time of day, for instance, every morning or every evening. Not everyone who is depressed has all these symptoms, but everyone who is depressed has at least some of them, co-existing, on most days. Depression can range in intensity from mild to severe. Depression can cooccur with other medical disorders such as cancer, heart disease, stroke, Parkinson's disease, Alzheimer's disease, and diabetes. In such cases, the depression is often overlooked and is not treated. If the depression is recognized and treated, a person's quality of life can be greatly improved. Antidepressants are used most often for serious depressions, but they can also be helpful for some milder depressions. Antidepressants are not "uppers" or stimulants, but rather take away or reduce the symptoms of depression and help depressed people feel the way they did before they became depressed. The doctor chooses an antidepressant based on the individual's symptoms. Some people notice improvement in the first couple of weeks; but usually the medication must be taken regularly for at least 6 weeks and, in some cases, as many as 8 weeks before the full therapeutic effect occurs. If there is little or no change in symptoms after 6 or 8 weeks, the doctor may prescribe a different medication or add a second medication such as lithium, to augment the action of the original antidepressant.

Because there is no way of knowing beforehand which medication will be effective, the doctor may have to prescribe first one and then another. To give a medication time to be effective and to prevent a relapse of the depression once the patient is responding to an antidepressant, the medication should be continued for 6 to 12 months, or in some cases longer, carefully following the doctor's instructions. When a patient and the doctor feel that medication can be discontinued, withdrawal should be discussed as to how best to taper off the medication gradually. Never discontinue medication without talking to the doctor about it. For those who have had several bouts of depression, long-term treatment with medication is the most effective means of preventing more episodes. Dosage of antidepressants varies, depending on the type of drug and the person's body chemistry, age, and, sometimes, body weight. Traditionally, antidepressant dosages are started low and raised gradually over time until the desired effect is reached without the appearance of troublesome side effects. Newer antidepressants may be started at or near therapeutic doses. Early antidepressants. From the 1960s through the 1980s, tricyclic antidepressants(named for their chemical structure) were the first line of treatment for major depression. Most of these medications affected two chemical neurotransmitters, norepinephrine and serotonin. Though the tricyclics are as effective in treating depression as the newer antidepressants, their side effects are usually more unpleasant; thus, today tricyclics such as imipramine, amitriptyline, nortriptyline, and desipramine are used as a second- or third-line treatment. Other antidepressants introduced during this period were monoamine oxidase inhibitors (MAOIs). MAOIs are effective for some people with major depression who do not respond to other antidepressants. They are also effective for the treatment of panic disorder and bipolar depression. MAOIs approved for the treatment of depression are phenelzine (Nardil), tranylcypromine (Parnate), and isocarboxazid (Marplan). Because substances in certain foods, beverages, and medications can cause dangerous interactions when combined with MAOIs, people on these agents must adhere to dietary restrictions. This has deterred many clinicians and patients from using these effective medications, which are in fact quite safe when used as directed. The past decade has seen the introduction of many new antidepressants that work as well as the older ones but have fewer side effects. Some of these medications primarily affect one neurotransmitter, serotonin, and are called selective serotonin reuptake inhibitors (SSRIs). These include fluoxetine (Prozac), sertraline (Zoloft), fluvoxamine (Luvox), paroxetine (Paxil), and citalopram (Celexa). The late 1990s ushered in new medications that, like the tricyclics, affect both norepinephrine and serotonin but have fewer side effects. These new medications include venlafaxine (Effexor) and nefazadone (Serzone).

Cases of life-threatening hepatic failure have been reported in patients treated with nefazodone (Serzone). Patients should call the doctor if the following symptoms of liver dysfunction occur - yellowing of the skin or white of eyes, unusually dark urine, loss of appetite that lasts for several days, nausea, or abdominal pain.

Other newer medications chemically unrelated to the other antidepressants are the sedating mirtazepine (Remeron) and the more activating bupropion (Wellbutrin). Wellbutrin has not been associated with weight gain or sexual dysfunction but is not used for people with, or at risk for, a seizure disorder. Each antidepressant differs in its side effects and in its effectiveness in treating an individual person, but the majority of people with depression can be treated effectively by one of these antidepressants. Side effects of antidepressant medications. Antidepressants may cause mild, and often temporary, side effects (sometimes referred to as adverse effects) in some people. Typically, these are not serious. However, any reactions or side effects that are unusual, annoying, or that interfere with functioning should be reported to the doctor immediately. The most common side effects of tricyclic antidepressants, and ways to deal with them, are as follows:
Dry mouth--it is helpful to drink sips of water; chew sugarless gum; brush teeth daily. Constipation--bran cereals, prunes, fruit, and vegetables should be in the diet. Bladder problems--emptying the bladder completely may be difficult, and the urine stream may not be as strong as usual. Older men with enlarged prostate conditions may be at particular risk for this problem. The doctor should be notified if there is any pain. Sexual problems--sexual functioning may be impaired; if this is worrisome, it should be discussed with the doctor. Blurred vision--this is usually temporary and will not necessitate new glasses. Glaucoma patients should report any change in vision to the doctor. Dizziness--rising from the bed or chair slowly is helpful. Drowsiness as a daytime problem--this usually passes soon. A person who feels drowsy or sedated should not drive or operate heavy equipment. The more sedating antidepressants are generally taken at bedtime to help sleep and to minimize daytime drowsiness. Increased heart rate--pulse rate is often elevated. Older patients should have an electrocardiogram (EKG) before beginning tricyclic treatment.

The newer antidepressants, including SSRIs, have different types of side effects, as follows:
Sexual problems--fairly common, but reversible, in both men and women. The doctor should be consulted if the problem is persistent or worrisome.

Headache--this will usually go away after a short time. Nausea--may occur after a dose, but it will disappear quickly. Nervousness and insomnia (trouble falling asleep or waking often during the night)--these may occur during the first few weeks; dosage reductions or time will usually resolve them. Agitation (feeling jittery)--if this happens for the first time after the drug is taken and is more than temporary, the doctor should be notified. Any of these side effects may be amplified when an SSRI is combined with other medications that affect serotonin. In the most extreme cases, such a combination of medications (e.g., an SSRI and an MAOI) may result in a potentially serious or even fatal "serotonin syndrome," characterized by fever, confusion, muscle rigidity, and cardiac, liver, or kidney problems.

The small number of people for whom MAOIs are the best treatment need to avoid taking decongestants and consuming certain foods that contain high levels of tyramine, such as many cheeses, wines, and pickles. The interaction of tyramine with MAOIs can bring on a sharp increase in blood pressure that can lead to a stroke. The doctor should furnish a complete list of prohibited foods that the individual should carry at all times. Other forms of antidepressants require no food restrictions. MAOIs also should not be combined with other antidepressants, especially SSRIs, due to the risk of serotonin syndrome. Medications of any kind--prescribed, over-the-counter, or herbal supplements--should never be mixed without consulting the doctor; nor should medications ever be borrowed from another person. Other health professionals who may prescribe a drug-such as a dentist or other medical specialist-should be told that the person is taking a specific antidepressant and the dosage. Some drugs, although safe when taken alone, can cause severe and dangerous side effects if taken with other drugs. Alcohol (wine, beer, and hard liquor) or street drugs, may reduce the effectiveness of antidepressants and their use should be minimized or, preferably, avoided by anyone taking antidepressants. Some people who have not had a problem with alcohol use may be permitted by their doctor to use a modest amount of alcohol while taking one of the newer antidepressants. The potency of alcohol may be increased by medications since both are metabolized by the liver; one drink may feel like two. Although not common, some people have experienced withdrawal symptoms when stopping an antidepressant too abruptly. Therefore, when discontinuing an antidepressant, gradual withdrawal is generally advisable.
Questions about any antidepressant prescribed, or problems that may be related to the medication, should be discussed with the doctor and/or the pharmacist. ANTIANXIETY MEDICATIONS

Everyone experiences anxiety at one time or another--"butterflies in the stomach" before giving a speech or sweaty palms during a job interview are common symptoms. Other symptoms include irritability, uneasiness,

jumpiness, feelings of apprehension, rapid or irregular heartbeat, stomachache, nausea, faintness, and breathing problems. Anxiety is often manageable and mild, but sometimes it can present serious problems. A high level or prolonged state of anxiety can make the activities of daily life difficult or impossible. People may have generalized anxiety disorder (GAD) or more specific anxiety disorders such as panic, phobias, obsessive-compulsive disorder (OCD), or post-traumatic stress disorder (PTSD). Both antidepressants and antianxiety medications are used to treat anxiety disorders. The broad-spectrum activity of most antidepressants provides effectiveness in anxiety disorders as well as depression. The first medication specifically approved for use in the treatment of OCD was the tricyclic antidepressant clomipramine (Anafranil). The SSRIs, fluoxetine (Prozac), fluvoxamine (Luvox), paroxetine (Paxil), and sertraline (Zoloft) have now been approved for use with OCD. Paroxetine has also been approved for social anxiety disorder (social phobia), GAD, and panic disorder; and sertraline is approved for panic disorder and PTSD. Venlafaxine (Effexor) has been approved for GAD. Antianxiety medications include the benzodiazepines, which can relieve symptoms within a short time. They have relatively few side effects: drowsiness and loss of coordination are most common; fatigue and mental slowing or confusion can also occur. These effects make it dangerous for people taking benzodiazepines to drive or operate some machinery. Other side effects are rare. Benzodiazepines vary in duration of action in different people; they may be taken two or three times a day, sometimes only once a day, or just on an "as-needed" basis. Dosage is generally started at a low level and gradually raised until symptoms are diminished or removed. The dosage will vary a great deal depending on the symptoms and the individual's body chemistry. It is wise to abstain from alcohol when taking benzodiazepines, because the interaction between benzodiazepines and alcohol can lead to serious and possibly life-threatening complications. It is also important to tell the doctor about other medications being taken. People taking benzodiazepines for weeks or months may develop tolerance for and dependence on these drugs. Abuse and withdrawal reactions are also possible. For these reasons, the medications are generally prescribed for brief periods of time--days or weeks--and sometimes just for stressful situations or anxiety attacks. However, some patients may need long-term treatment. It is essential to talk with the doctor before discontinuing a benzodiazepine. A withdrawal reaction may occur if the treatment is stopped abruptly. Symptoms may include anxiety, shakiness, headache, dizziness, sleeplessness, loss of appetite, or in extreme cases, seizures. A withdrawal reaction may be mistaken for a return of the anxiety because

many of the symptoms are similar. After a person has taken benzodiazepines for an extended period, the dosage is gradually reduced before it is stopped completely. Commonly used benzodiazepines include clonazepam (Klonopin), alprazolam (Xanax), diazepam (Valium), and lorazepam (Ativan). The only medication specifically for anxiety disorders other than the benzodiazepines is buspirone (BuSpar). Unlike the benzodiazepines, buspirone must be taken consistently for at least 2 weeks to achieve an antianxiety effect and therefore cannot be used on an "as-needed" basis. Beta blockers, medications often used to treat heart conditions and high blood pressure, are sometimes used to control "performance anxiety" when the individual must face a specific stressful situation--a speech, a presentation in class, or an important meeting. Propranolol (Inderal, Inderide) is a commonly used beta blocker.
INDEX OF MEDICATIONS

To find the section of the text that describes a particular medication in the lists below, find the generic (chemical) name and look it up on the first list or find the trade (brand) name and look it up on the second list. If the name of the medication does not appear on the prescription label, ask the doctor or pharmacist for it. (Note: Some drugs are marketed under numerous trade names, not all of which can be listed in a short publication like this one. If your medication's trade name does not appear in the list--and some older medicines are no longer listed by trade names--look it up by its generic name or ask your doctor or pharmacist for more information.) Stimulant medications that are used by both children and adults with ADHD are listed in the children's medications chart).
ALPHABETICAL LIST OF MEDICATIONS BY GENERIC NAME8 GENERIC NAME TRADE NAME

Antipsychotic Medications chlorpromazine chlorprothixene clozapine fluphenazine haloperidol loxapine mesoridazine Thorazine Taractan Clozaril Permitil, Prolixin Haldol Loxitane Serentil

molindone olanzapine perphenazine pimozide (for Tourette's syndrome) quetiapine risperidone thioridazine thiothixene trifluoperazine trifluopromazine ziprasidone

Lidone, Moban Zyprexa Trilafon Orap Seroquel Risperdal Mellaril Navane Stelazine Vesprin Geodon

Antimanic Medications carbamazepine divalproex sodium (valproic acid) gabapentin lamotrigine lithium carbonate lithium citrate topimarate Tegretol Depakote Neurontin Lamictal Eskalith, Lithane, Lithobid Cibalith-S Topamax

Antidepressant Medications amitriptyline amoxapine bupropion Elavil Asendin Wellbutrin

citalopram (SSRI) clomipramine desipramine doxepin escitalopram (SSRI) fluvoxamine (SSRI) fluoxetine (SSRI) imipramine isocarboxazid (MAOI) maprotiline mirtazapine nefazodone nortriptyline paroxetine (SSRI) phenelzine (MAOI) protriptyline sertraline (SSRI) tranylcypromine (MAOI) trazodone trimipramine venlafaxine

Celexa Anafranil Norpramin, Pertofrane Adapin, Sinequan Lexapro Luvox Prozac Tofranil Marplan Ludiomil Remeron Serzone Aventyl, Pamelor Paxil Nardil Vivactil Zoloft Parnate Desyrel Surmontil Effexor

Antianxiety Medications (All of these antianxiety medications except buspirone are benzodiazepines) alprazolam buspirone Xanax BuSpar

chlordiazepoxide clonazepam clorazepate diazepam halazepam lorazepam oxazepam prazepam

Librax, Libritabs, Librium Klonopin Azene, Tranxene Valium Paxipam Ativan Serax Centrax

ALPHABETICAL LIST OF MEDICATIONS BY TRADE NAME TRADE NAME GENERIC NAME

Antipsychotic Medications Clozaril Geodon Haldol Lidone Loxitane Mellaril Moban Navane Orap (for Tourette's syndrome) Permitil Prolixin Risperdal Serentil Seroquel clozapine ziprasidone haloperidol molindone loxapine thioridazine molindone thiothixene pimozide fluphenazine fluphenazine risperidone mesoridazine quetiapine

Stelazine Taractan Thorazine Trilafon Vesprin Zyprexa

trifluoperazine chlorprothixene chlorpromazine perphenazine trifluopromazine olanzapine

Antimanic Medications Cibalith-S Depakote Eskalith Lamictal Lithane Lithobid Neurontin Tegretol Topamax lithium citrate valproic acid, divalproex sodium lithium carbonate lamotrigine lithium carbonate lithium carbonate gabapentin carbamazepine topiramate

Antidepressant Medications Adapin Anafranil Asendin Aventyl Celexa (SSRI) Desyrel Effexor doxepin clomipramine amoxapine nortriptyline citalopram trazodone venlafaxine

Elavil Lexapro (SSRI) Ludiomil Luvox (SSRI) Marplan (MAOI) Nardil (MAOI) Norpramin Pamelor Parnate (MAOI) Paxil (SSRI) Pertofrane Prozac (SSRI) Remeron Serzone Sinequan Surmontil Tofranil Vivactil Wellbutrin Zoloft (SSRI)

amitriptyline escitalopram maprotiline fluvoxamine isocarboxazid phenelzine desipramine nortriptyline tranylcypromine paroxetine desipramine fluoxetine mirtazapine nefazodone doxepin trimipramine imipramine protriptyline bupropion sertraline

Antianxiety Medications (All of these antianxiety medications except BuSpar are benzodiazepines) Ativan Azene BuSpar lorazepam clorazepate buspirone

Centrax Librax, Libritabs, Librium Klonopin Paxipam Serax Tranxene Valium Xanax

prazepam chlordiazepoxide clonazepam halazepam oxazepam clorazepate diazepam alprazolam

CHILDREN'S MEDICATION CHART TRADE NAME GENERIC NAME APPROVED AGE

Stimulant Medications Adderall Adderall XR amphetamine amphetamine (extended release) methylphenidate (long acting) pemoline 3 and older 6 and older

Concerta Cylert* Dexedrine Dextrostat Focalin Metadate ER Ritalin

6 and older 6 and older

dextroamphetamine 3 and older dextroamphetamine 3 and older dexmethylphenidate 6 and older methylphenidate (extended release) methylphenidate 6 and older 6 and older

*Because of its potential for serious side effects affecting the liver, Cylert should not
ordinarily be considered as first-line drug therapy for ADHD.

Antidepressant and Antianxiety Medications

Anafranil BuSpar Effexor

clomipramine buspirone venlafaxine

10 and older (for OCD) 18 and older 18 and older 8 and older (for OCD) 18 and older 18 and older 18 and older 12 and older 6 and older (for bedwetting) 18 and older 6 and older (for OCD)

Luvox (SSRI) fluvoxamine Paxil (SSRI) paroxetine

Prozac (SSRI) fluoxetine Serzone (SSRI) Sinequan Tofranil Wellbutrin nefazodone doxepin imipramine bupropion

Zoloft (SSRI) sertraline

Antipsychotic Medications Clozaril (atypical) Haldol Risperdal (atypical) Seroquel (atypical) Mellaril Zyprexa (atypical) clozapine haloperidol risperidone 18 and older 3 and older 18 and older

quetiapine thioridazine olanzapine

18 and older 2 and older 18 and older 12 and older (for Tourette's syndrome -Data for age 2 and older indicate similar safety profile)

Orap

pimozide

Mood Stabilizing Medications Cibalith-S Depakote Eskalith Lithobid Tegretol lithium citrate valproic acid lithium carbonate lithium carbonate carbamazepine 12 and older 2 and older (for seizures) 12 and older 12 and older any age (for seizures)

Psychotic major depression (PMD) is a type of depression that can include symptoms and treatments that are different from those of non-psychotic major depressive disorder (NPMD). PMD is estimated to affect about 0.4% of the population (or one in every 250 people). PMD is sometimes "mistaken" for NPMD, schizoaffective disorder, schizophrenia or other psychotic disorders. Bipolar patients may experience PMD during depressed states. PMD is usually episodic, lasting for a defined amount of time, but in some cases can be chronic. PMD has unique biological features, which have led to innovative treatments. While PMD is often treated with a combination of antidepressants and antipsychotics, researchers have been developing new treatments that address the pathophysiology of PMD more directly.
Contents
[hide]

1 Symptoms 2 Course 3 Diagnostic criteria 4 Differential diagnosis 5 Pathophysiology 6 History of treatments 7 Established treatment strategies 8 Experimental treatment strategies 9 External links 10 References

[edit]Symptoms

Currently, PMD is considered a severe form of major depression, but patients with mild or moderate depression may still have psychotic features. Many people with PMD experience delusions, which are beliefs or feelings that are untrue or unsupported; these are usually misinterpretations of events or phenomena. Paranoid delusions or delusions of guilt may be the most common psychotic symptoms in PMD. Patients with PMD often have concerns that people are paying special attention to them or are trying to persecute them. Patients who experience delusional guilt may believe that they are being punished for past misdeeds or are responsible for problems they couldnt possibly be responsible for. Other common delusions include those in which people are concerned that something is terribly wrong with their bodies and physical health, when actually there isnt anything wrong. Unlike other psychotic disorders, the delusions in PMD may not be very obvious. Delusions appear to be more common than hallucinations in PMD, but some people with PMD do hallucinate, or see or hear things that others do not. Auditory hallucinations (sounds) are perhaps the most common hallucinations seen in PMD. While other patients may report seeing, touching or smelling things that are not there, it is less common. Other symptoms that are common in PMD are agitation, difficulty falling asleep, and frequent waking during the night. In addition, patients with PMD may have a greater suicide risk than patients withNPMD. Finally, those with PMD may have greater cognitive deficits (e.g., memory problems) than those with NPMD. [edit]Course The course of PMD may be helpful in distinguishing it from other disorders. Most PMD patients report having an initial episode between the ages of 20 and 40. Over a lifetime, it appears that PMD patients experience an average of 4 to 9 episodes. As with NPMD, the episodes of PMD tend to last for a certain amount of time and subside. While PMD can be chronic (lasting more than 2 years), most PMD episodes last less than 24 months. Unlike psychotic disorders such as schizophrenia and schizoaffective disorder, patients with PMD generally function well between episodes, both socially and professionally. [edit]Diagnostic

criteria

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM), a widely used manual for diagnosing mental disorders, patients who show at least six of the following symptoms in a period of two weeks may be diagnosed with PMD. In order to qualify for a PMD diagnosis, patients need to report either (1) or (3), and (11), along with three or four other symptoms (for a total of six). These symptoms also must be different from how patients felt or behaved at a previous time. 1. 2. 3. 4. 5. 6. depressed mood most of the day nearly every day noticeably increased or decreased sex drive loss of interest or pleasure in all, or almost all, activities most of the day nearly every day significant weight loss or weight gain, OR decrease or increase in appetite nearly every day insomnia OR hypersomnia (sleeping excessively) nearly everyday psychomotor agitation (moving more quickly) OR retardation (moving more slowly) nearly every day, so much that other people notice

7. 8.

fatigue OR loss of energy nearly every day feelings of worthlessness OR excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)

9.

diminished ability to think or concentrate, OR indecisiveness, nearly every day

10. recurrent thoughts of death (not just fear of dying), recurrent ideas about suicide without a specific plan, or a suicide attempt or specific plan for committing suicide 11. delusions or hallucinations 12. increased and intense daydreaming The symptoms cannot meet criteria for a Mixed Episode (diagnosed by a clinician) or be due to the effects of a substance or illness. The symptoms also must cause distress or impairment in functioning. [edit]Differential

diagnosis

See also: Depression (differential diagnoses). PMD is most frequently confused with NPMD, but it may also be mistaken for the schizophrenia spectrum disorders, including schizoaffective disorder. These are differentiated from PMD by the presence of psychotic symptoms outside of a major depressive episode. In a schizoaffective patient, hallucinations and delusions will occur in the absence of major depressive episodes. Schizophrenia generally has more disordered thinking and delusional symptoms than PMD. It is unusual for PMD patients to show flight of ideas, loose association, echolalia (repeating what others say), word salad (meaningless speech), and other elements of thought disorders that characterize schizophrenia. Likewise, the presence of bizarre delusions ("Aliens have planted a receiver in my head") appears to be less common in PMD than schizophrenia. However, neither bizarre delusions, nor marked thought disorder necessarily eliminate a diagnosis of PMD. Bipolar disorder can sometimes present with PMD. It is estimated that as many as 42% of patients with PMD in adolescence or young adulthood are likely to develop some type of manic episode later. It is important to take a history of manic symptoms in any younger patient who presents with PMD. Other psychotic disorders with which PMD is sometimes confused include delusional disorder, substance induced psychotic disorder (with MDD), post-psychotic depressive disorder of schizophrenia, and brief psychotic disorder. The primary way of distinguishing between PMD and any of these disorders lies more in evaluating the course of the illness rather than simply identifying specific symptoms. [edit]Pathophysiology There are a number of biological features that may distinguish PMD from NPMD. The most significant difference may be the presence of an abnormality in the hypothalamic pituitary adrenal (HPA) axis. The HPA axis, which is sometimes referred to as the stress hormone axis, appears to be chronically over-activated in PMD. Other abnormalities found in PMD include sleep abnormalities and changes in other areas of brain function. Finally, the incidence of psychotic depression has been reported to increase when the barometric pressure is low.[1]

[edit]History

of treatments

Before electroconvulsive therapy (ECT) was invented in the 1930s, it was frequently observed that patients experiencing delusions with depression had poorer response to medication treatment. ECT seemed to have similar effects for depressed patients both with and without psychotic symptoms. The interest in psychotic depression increased after tricyclic antidepressants (TCAs) became available, because while NPMD responded to TCAs, PMD did not. In the past 40 years there has been a renewed interest in PMD. The FDA is considering a special class of drugs for the treatment of PMD as researchers learn more about the biology of the disease. Many studies have suggested that PMD differs from MDD in treatment response. PMD is less likely than MDD to respond to placebo and to the use of only an antidepressant or an antipsychotic. The combination of an antidepressant and an antipsychotic appears to be necessary for the treatment of PMD. Early studies suggest an 80-90% response rate in PMD with combination treatment. [edit]Established

treatment strategies

While there is some evidence that anti-depressant pharmacotherapy with selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs) may be effective in treating PMD, patients with PMD often do not respond to monotherapy and require a combination of anti-depressant and anti-psychotic medication. Electroconvulsive therapy (ECT), along with combination antidepressant-antipsychotic treatment, is the other established treatment of PMD. ECT may have a more reliable track record in improving symptoms than pharmacological treatments. However, the stigma, cost, and cognitive side effects often make it a second or third line treatment except in special circumstances. For example, if a patient's PMD is imminently life threatening as a result of suicide risk or cachexia, ECT may be considered first line treatment. In addition, a patient who cannot tolerate medications, or has responded more favorably to ECT in the past, may be considered for ECT first. [edit]Experimental

treatment strategies

The current treatments of PMD are reasonably effective but tend to carry a high side effect burden and may take a long time to work. Combination treatment with atypical antipsychotics and SSRIs tend to be associated with significant weight gain and sexual dysfunction. TCAs are lethal in overdose and some are associated with extra-pyramidal side effects including tardive dyskinesia. Finally, ECT has side effects of temporary cognitive deficits (e.g., confusion, memory problems), in addition to the burden of repeated exposures to general anesthesia. Among the newer experimental treatments is the study of glucocorticoid antagonists, including mifepristone.[2] These strategies may treat the underlying pathophysiology of PMD by correcting an overactive HPA axis. By competitively blocking certain neuro-receptors, these medications render cortisol less able to directly act on the brain. Transcranial magnetic stimulation (TMS) is being investigated as an alternative to ECT in the treatment of depression. TMS involves the administration of a focused electromagnetic field to the cortex to stimulate specific nerve pathways. A number of early studies have shown promise of TMS in MDD with few side effects. TMS does not require anesthesia and has not been associated with significant cognitive deficits. [edit]External

links

National Alliance on Mental Illness Grassroots organization providing support, advocacy, and education for patients and their families

Depression and Bipolar Support Alliance - Patient directed support, advocacy, and education Treatment Studies for Psychotic Major Depression

[edit]References

This article includes a list of references, but its sources remain unclear because it has insufficient inline citations. Please help to improvethis article by introducing more precise citations where appropriate. (May 2009)

1.

^ Radua, Joaquim; Pertusa, Alberto; Cardoner, Narcis (28 February 2010). "Climatic relationships with specific clinical subtypes of depression". Psychiatry Research 175 (3): 217 220.doi:10.1016/j.psychres.2008.10.025. PMID 20045197.

2.

^ Belanoff JK, Flores BH, Kalezhan M, Sund B, Schatzberg AF (October 2001). "Rapid reversal of psychotic depression using mifepristone". Journal of Clinical Psychopharmacology

People with schizophrenia often deal with depression as well in fact, at least half of those with schizophrenia experience a period of depression during their lifetimes.

Frank Baron has schizoaffective disorder, a type of schizophrenia that also causes profound mood swings. Baron, who lives in California, has experienced episodes of clinical depression on three occasions. He says that depression is not like grief or sadness. "When my father died a few years ago, I felt grief. Depression is a totally different sensation," says Baron. "Depression is trapped in bed for 20 hours a day with no mental energy to get out." Depression and Schizophrenia While the relationship between depression and schizophrenia has not been fully explored, there is some evidence to suggest that the two illnesses might have common causes. First, depressive symptoms are associated with the onset of schizophrenia. Many people who go on to develop schizophrenia experience depressive symptoms up to four years before they are diagnosed with schizophrenia. After the initial symptoms of depression, people with schizophrenia often become less interested in interacting with others. Hearing voices and seeing things that aren't actually there tend to occur last. While most people who experience severe depression do not develop schizophrenia, schizophrenia is more common in people who have been depressed than in the general population. And, depressive symptoms are less

common when schizophrenia is less active. One group of researchers found that only nine percent of patients judged to be stable (meaning no recent hospitalizations or medication changes) reported depressive symptoms.
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Underlying Causes of Depression in Schizophrenia In order to successfully treat depression, it is helpful to understand what is causing the condition.

Is it really depression? Depression symptoms can mimic symptoms of schizophrenia, such as disinterest in social interaction and indifference about life in general. In this situation, treating the symptoms of schizophrenia may also help with the depressive symptoms. The newer class of antipsychotic medications, called atypical antipsychotics, is better at treating these types of symptoms than older medications.

Is it schizoaffective disorder? A person with schizoaffective disorder experiences symptoms of schizophrenia as well as mood disorder symptoms. Many people have depressive symptoms, but some may also have periods of mania or profound elation and excessive energy. Whatever the case, their medical treatment must be specially tailored to target both their mood and schizophrenia symptoms.

Is substance abuse a possibility? Substance abuse is a problem for an estimated 29 percent of people with mental illnesses. Some substances, like alcohol or barbiturates, can directly cause depressive symptoms, while other drugs, like cocaine or even milder substances like caffeine and nicotine, may cause depressive symptoms when a person stops using them and experiences withdrawal.

Are other medical conditions being treated? Medications used to treat other medical conditions can sometimes cause depression symptoms. Medications should be adjusted or antidepressants may need to be prescribed.

Is it a reaction to a diagnosis? Being diagnosed with schizophrenia itself, or another major medical illness, can be distressing and can lead to depression.

Treatment for Depression in Schizophrenia After the underlying causes of depression are addressed, antidepressants, psychotherapy, and other forms of social support can treat depression in a person with schizophrenia. It is critical that people experiencing symptoms of depression receive treatment as soon as possible. Effective management of depression could save someone's life, since research has found that patients with depression and schizophrenia are nearly three times more likely to attempt suicide than people with clinical depression alone. Baron says he knew two people who committed suicide. People who talk about suicide usually intend to follow through, he warns. "The idea that it's just a cry for help is a myth," says Baron. "When people say they want to commit suicide, they really mean it." If you or someone you know is experiencing thoughts of suicide, take action immediately. Call 911, a doctor or psychiatrist, or call the National Suicide Prevention Lifeline at SUICIDE to get help. 1-800-273-TALK or 1-800-

Seseorang didiagnosis dengan skizofrenia mungkin menunjukkan halusinasi pendengaran, delusi, dan berpikir tidak teratur dan tidak biasa dan pidato, hal ini dapat berkisar dari hilangnya kereta pemikiran dan aliran subjek, dengan kalimat hanya longgar terhubung dalam arti, untuk ketidaklogisan, dikenal sebagai salad kata, di parah kasus. Isolasi sosial biasanya terjadi karena berbagai alasan. Penurunan dalam kognisi sosial dikaitkan dengan skizofrenia, seperti juga gejala paranoia dari delusi dan halusinasi, dan gejala negatif avolition (apatis atau kekurangan motivasi). Dalam satu subtipe biasa, orang mungkin sebagian besar bisu, tetap bergerak di postur aneh, atau agitasi menunjukkan tanpa tujuan, ini adalah tanda-tanda catatonia. Tidak ada tanda satu diagnostik skizofrenia, dan semua dapat terjadi dalam kondisi medis dan psikiatris lainnya. Klasifikasi saat ini menyatakan bahwa gejala psikosis harus telah hadir untuk setidaknya satu bulan dalam jangka waktu setidaknya

enam bulan berfungsi terganggu. Sebuah psikosis seperti skizofrenia durasi yang lebih pendek disebut gangguan schizophreniform. Remaja akhir dan dewasa awal adalah tahun puncak untuk timbulnya skizofrenia. Dalam 40% pria dan 23% perempuan didiagnosa menderita skizofrenia, kondisi timbul sebelum usia 19. Ini adalah periode kritis dalam pembangunan dewasa muda sosial dan kejuruan, dan mereka dapat menjadi sangat terganggu. Untuk meminimalkan pengaruh skizofrenia, banyak pekerjaan baru-baru ini telah dilakukan untuk mengidentifikasi dan mengobati tahap (pra-onset) prodromal penyakit, yang telah terdeteksi sampai 30 bulan sebelum timbulnya gejala, tetapi dapat hadir lagi. Mereka yang terus mengembangkan skizofrenia mungkin mengalami gejala non-spesifik sosial, penarikan iritabilitas dan dysphoria pada periode prodromal, dan sementara atau membatasi diri gejala psikotik pada fase prodromal sebelum psikosis menjadi jelas.

Schneiderian Klasifikasi
Psikiater Kurt Schneider (1887-1967) yang terdaftar bentuk gejala psikotik yang ia berpikir skizofrenia dibedakan dari gangguan psikotik lainnya. Ini disebut pertama-peringkat gejala atau pertama-peringkat Schneider gejala, dan mereka termasuk delusi menjadi dikontrol oleh kekuatan eksternal; keyakinan bahwa pikiran sedang dimasukkan ke dalam atau ditarik dari pikiran sadar seseorang, keyakinan bahwa pikiran seseorang sedang disiarkan ke orang lain, dan suara-suara halusinasi pendengaran yang mengomentari pikiran seseorang atau tindakan atau yang melakukan percakapan dengan suara halusinasi lain. Meskipun mereka telah memberikan kontribusi untuk kriteria diagnostik saat ini, kekhususan pertama-peringkat gejala telah dipertanyakan. Sebuah tinjauan dari studi diagnostik yang dilakukan antara 1970 dan 2005 menemukan bahwa studi ini memungkinkan bukanlah sebuah konfirmasi ulang atau penolakan terhadap klaim Schneider, dan menyarankan bahwa peringkat pertama-gejala menjadi de-ditekankan dalam revisi masa depan sistem diagnostik.

Positif dan Negatif Gejala

Skizofrenia sering dijelaskan dalam hal positif dan negatif (atau defisit) gejala. Gejala-gejala positifmerujuk pada gejala-gejala yang sebagian besar individu biasanya tidak pengalaman. Mereka termasuk delusi, halusinasi pendengaran, dan gangguan berpikir, dan biasanya dianggap sebagai manifestasi psikosis. Gejala negatif dinamakan demikian karena mereka dianggap sebagai kerugian atau tidak adanya sifat normal atau kemampuan, dan termasuk fitur seperti mempengaruhi datar atau tumpul dan emosi, kemiskinan berbicara (alogia), ketidakmampuan untuk mengalami kenikmatan (anhedonia), kurangnya keinginan untuk membentuk hubungan (asociality), dan kurangnya motivasi (avolition). Penelitian menunjukkan bahwa gejala negatif memberikan kontribusi lebih terhadap kualitas hidup yang buruk, cacat fungsional, dan beban pada orang lain daripada gejala positif. Meskipun penampilan mempengaruhi tumpul, studi terbaru menunjukkan bahwa sering ada tingkat normal atau bahkan meningkat dari emosionalitas dalam skizofrenia, terutama dalam menanggapi peristiwa stres atau negatif. Sebuah pengelompokan gejala ketiga, sindrom ketidakteraturan,umumnya dijelaskan, dan termasuk pidato kacau, pikiran, dan perilaku. Ada bukti untuk sejumlah klasifikasi gejala lainSakit

jiwa

Sakit Jiwa Prof.Dr. Zakiah Daradjat

Seorang yang diserang penyakit jiwa (Psychose), kepribadiannya terganggu, dan selanjutkan kurang mampu menyesuaikan diri dengan wajar, dan tidak sanggup memahami problemnya. Seringkali orang yang sakit jiwa, tidak merasa bahwa ia sakit, sebaliknya ia menganggap bahwa dirinya normal saja, bahkan lebih baik, lebih unggul dan lebih penting dari orang lain.

Sakit jiwa itu ada 2 macam, yaitu : Pertama : yang disebabkan oleh adanya kerusakan pada anggota tubuh. Misalnya otak, sentral saraf atau hilangnya kemampuan berbagai kelenjar. hal ini mungkin disebabkan oleh karena keracunan akibat minuman keras, obat-obatan perangsang atau narkotik, akibat penyakit kotor dan sebagainya.

Kedua : disebabkan oleh gangguan-gangguan jiwa yang telah berlarutlarut sehingga mencapai puncaknya tanpa suatu penyelesaian secara wajar

atau hilangnya keseimbangan mental secara menyeluruh, akibat lingkungan yang sangat menekan, ketegangan batin dan sebagainya.

suasana

1.Schizophrenia Schizophrenia adalah penyakit jiwa yang paling banyak terjadi dibandingkan dengan penyakit jiwa lainnya, penyakit ini menyebabkan kemunduran kepribadian pada umumnya, yang biasanya mulai tampak pada masa puber, dan paling banyak adalah orang yang berumur antara 15 30 tahun.

Gejala-gejala diantaranya : Dingin perasaan, tak ada perhatian pada apa yang terjadi di sekitarnya. Tidak terlihat padanya reaksi emosional terhadap orang yang terdekat kepadanya, baik emosi marah, sedih dan takut. Segala sesuatu dihadapinya dengan acuh tak acuh. Banyak tenggelam dalam lamunan yang jauh dari kenyataan, sangat sukar bagi orang untuk memahami pikirannya. Dan ia lebih suka menjauhi pergaulan dengan orang banyak dan suka menyendiri. mempunyai prasangka-prasangka yang tidak benar dan tidak beralasan, misalnya apabila ia melihat orang yang menulis atau membicarakan sesuatu, disangkanya bahwa tulisan atau pembicaraan itu ditujukan untuk mencelanya. Sering terjadi salah tanggapan atau terhentinya pikiran, misalnya orang sedang berbicara tiba-tiba lupa apa yang dikatakannya itu. Kadang-kadang dalam pembicaraan ia pindah dari suatu masalah ke masalah lain yang tak ada hubungannya sama sekali atau perkataannya tidak jelas ujung pangkalnya. Halusinasi pendengaran, penciuman atau penglihatan, dimana penderita seolah-olah mendengar, mencium atau melihat sesuatu yang sebenarnya tidak ada. Ia seakan-akan mendengar orang lain (tetangga) membicarakannya, atau melihat sesuatu yang menakutkannya. Banyak putus asa dan merasa bahwa ia adalah korban kejahatan orang banyak atau masyarakat. Merasa bahwa semua orang bersalah dan meyebabkan penderitaannya. keinginan menjauhkan diri dari masyarakat , tidak mau bertemu dengan orang lain dan sebagainya, bahkan kadang-kadang sampai kepada tidak mau makan atau minum dan sebagainya, sehingga dalam hal ini ia harus diinjeksi supaya tertolong.

Demikian antara lain gejala Schizophrenia, dan tiap-tiap pasien mungkin hanya mengalami satu atau dua macam saja dari gejala tersebut, sedangkan dalam hal lain terlihat jauh dari kenyataan.

Sampai sekarang menimbulkan

belum

diketahui

dengan

pasti

apa

sesungguhnya

yang

Schizophrenia itu. Ada yang berpendapat bahwa keturunanlah yang besar peranannya. Menurut hasil beberapa penelitian terbukti bahwa 60% dari orang yang sakit ini berasal dari keluarga yang pernah dihinggapi sakit jiwa. Adapula yang mengatakan bahwa sebabnya adalah rusaknya kelenjar-kelenjar tertentu dalam tubuh. Ada yang menitik beratkan pandangannya pada penyesuaian diri yaitu karena orang tidak mampu menghadapai kesukaran hidup , tidak bisa menyesuaikan diri sedemikian rupa sehingga sering menemui kegagalan dalam usaha menghadapi kesukaran.

Apapun sebab sesungguhnya, namun terbukti bahwa kebanyakan penyakit ini mulai menyerang setelah orang setelah menghadapi satu peristiwa yang menekan, yang berakibat munculnya penyakit yang mungkin sudah terdapat secara tersembunyi di dalam orang itu. Faktor pendorong lain ialah kesukaran ekonomi, keluarga, hubungan cinta, selain itu terdapat kegelisahan yang timbul akibat terlalu lama melakukan onani, sehingga merasa berdosa dan menyesal, sedang menghentikannya tak sanggup.

Penyakit ini biasnya lama sekali perkembangannya, mungkin dalam beberapa bulan atau beberapa tahun, baru ia menunjukkan gejala-gejala ringan, tapi akhirnya setelah peristiwa tertentu, tiba-tiba terlihat gejala yang hebat sekaligus.

2.Paranoia Paranoia merupakan penyakit gila kebesaran atau gila menuduh orang. Diantara ciri-ciri penyakit ini adalah delusi yaitu satu pikiran salah yang menguasai orang yang diserangnya. Delusi ini berbeda bentuk dan macamnya sesuai dengan suasana dan kepribadian penderita, misalnya :

Penderita mempunyai satu pendapat (keyakinan) yang salah, segala perhatiannya ditujukan ke sana dan yang satu itu pula yang menjadi buah tuturnya, sehingga setiap orang yang ditemuinya akan diyakinkannya pula akan kebenarannya pendapatnya itu. Misalnya ada seorang suami yang menyangka bahwa istrinya berniat jahat meracuninya. Maka selalu menghindar makan di rumah, karena takut akan terkena racun itu. Penderita merasa bahwa ada orang yang jahat kepadanya dan selalu berusaha untuk menjatuhkannya atau menganiayanya. Penderita merasa bahwa dirinya orang besar, hebat tidak ada bandingannya, meyakini dirinya adalah seorang pemimpin besar atau mungkin mengaku Nabi.

Delusi atau pikiran salah yang dirasakan oleh penderita sangat menguasainya dan tidak bisa hilang. Kecuali itu jalan pikirannya terlihat teratur dan tetap. Pada permulaan orang menyangka bahwa pikirannya itu logis dan benar., biasanya orang yang diserang paranoia ia cerdas, ingatannya kuat, emosinya terlihat berimbang dan cocok dengan pikirannya. Hanya saja ia mempunai suatu kepercayaan salah, sehingga perhatiaan dan perkataannya selalu dikendalikan oleh pikirannya yang salah itu.

Sebenarnya kita harus membedakan antara antara sakit jiwa paranoia yang sungguh-sungguh dengan kelakuan paranoid. Kelakuan paranoid yang juga abnormal juga diantaranya : Terlihat sekali dalam segala tindakannya, bahwa ia egois, keras kepala dan sangat keras pendirian dan pendapatnya. Tidak mau mengakui kesalahan atau kekurangannya, selalu melempar kesalahan pada orang lain, dan segala kegagalannya disangkannya akibat dari campur tangan orang lain.

Ia berkeyakinan bahwa dia mempunyai kemampuan dan kecerdasan yang luar biasa. Ia berasal dari keturunan yang jauh lebih baik dari orang lain dan merasa bahwa setiap orang iri, dengki dan takut kepadanya. Dalam persaudaraan ia tidak setia, orang tadinya sangat dicintainya, akan dapat berubah menjadi orang yang sangat dibencinya oleh sebabsebab yang remeh saja. Orang ini tidak dapat bekerja dan mempunyai kepatuhan pada pimpinan. Karena ia suka membantah atau melawan dan mempnuayai pendapat sendiri, tidak mau menerima nasehat atau pandangan dari orang lain.

3. Manicdepressive Penderita mengalami rasa besar/gembira sedih/tertekan. Gejalanya yaitu : yang kemudian kemudian menjadi

a.Mania, yangmempunyai tiga tingkatan yaitu ringan (hipo), berat (acute) dan sangat berat (hyper). Dalam tindakannya orang yang diserang oleh mania ringan terlihat selalu aktif, tidak kenal payah, suka penguasai pembicaraan, pantang ditegur baik perkataan maupun perbuatannya, tidak tahan mendengar kecaman terhadap dirinya.biasanya orang ini suka mencampuri urusan orang lain.

Dalam mania yang berat (acute), orang biasanya di serang oleh delusi-delusi pada waktu-waktu tertentu, sehingga sukar baginya untuk melakukan suatu pekerjaan dengan teratur. Penderita mengungkapkan rasa gembira dan bahagianya secara berlebihan. kadang-kadang diserang lamunan yang dalam sekali, sehingga tidak dapat membedakan tempat, waktu dan orang disekelilingnya.

Dalam hal mania yang sangat berat (hyper) orang yang diserangnya kadangkadang membahayakan dirinya sendiri dan mungkin membahayakan orang lain dalam sikap dan perbuatannya.

Penyakit ini dinamakan juga gila kumat-kumatan, karena penderita berubahubah dari rasa gembira yang berlebihan, sudah itu bisa kembali atau menurun menjadi sedih, muram dan tak berdaya.

Dalam hal pertama penderita berteriak, mencai-maki, marah marah dan sebagainya, kemudian kembali pada ketenangan biasa dan bekerja seperti tidakl ada apa-apa.

b.Melancholia penderita terlihat muram, sedih dan putus asa. Ia merasa diserang oleh berbagai macam penyakit yang tidak bisa sembuh,atau merasa berbuat dosa yang tak mungkin diampuni lagi. Kadang-kadang ia menyakiti dirinya sendiri.

Orang yang diserang penyakit melancholia ringan sering mengeluh nasibnya tidak baik dan merasa tidak ada harapan lagi. Dan bagi penderita melancholia berat menjauhkan dirinya dari masyarakat.

Demikianlah antara lain gejala-gejala gangguan dan penyakit jiwa yang membuktikan betapa besar akibat terganggunya kesehatan mental seseorang, yang akan menghilangkan kebahagiaan dan ketenangan hidupnya.

nya.

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