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Overcoming Depression

Depression is a it is a mood disorder that frequently co-exists with schizophrenia and which also needstreatment. Feelings of depression and hopelessness arealso common with caregivers of the mentally ill. If you or someone you know with schizophrenia is feelingparticularly depressed its important to see the doctor about the condition. Also, we recommend you talk toothers about your feelings in the schizophrenia.comdiscussion areas.

• Overviews on Depression

○ Overview of Depression, what causes it andhow to treat it  - (NIMH Booklet)

○ Depression Is a Treatable Illness - A

Patient's Guide

• Personal Experiences with Depression

○  A Haze has Lifted to Reveal a New Day

○  Depression No Cause for Shame - Rafe

Mair 

• Ways to help yourself when you are feelingsuicidal.

•  If you're thinking about suicide "Start byconsidering this statement: "Suicide is not chosen;it happens when pain exceeds resources for copingwith pain." - resources about suicide and itsprevention.

• Ways to Maintain Recovery from Depression

• What Family and Friends Can Do to Help SomeoneWho is Depressed

• Strong Relationship Between Schizophrenia and

Depression• Common Treatments for Depression

○ Treatments Overview

○ Medications

 Effexor 

 Luvox

 Nefazodone

 Prozac

 Serzone

Advertisement

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 Wellbutrin

 Zoloft

• Additional Depression Resources

○ 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 andAntianxiety Drugs, Antipsychotics, Drugsannd Pregnancy, Drugs and the Elderly,Drugs and AIDS, Side-effects andWithdrawal Symptoms, and Much, MuchMore by Jack M., M.D. Gorman, Publisher:St. Martin's Press; (December 1998), ISBN:0312954581

○ Consumer's Guide to Psychiatric Drugs, byJohn D. Preston, John H. O'Neal, Mary C.Talaga, Publisher: New Harbinger Pubns;(2000) ASIN: 157224111X

 

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This site does not provide medical or any other health care or fitness advice, diagnosis, or treatment.The site and its services, including the information above, are for informational purposes only and arenot a substitute for professional medical or health advice, examination, diagnosis, or treatment.

Always seek the advice of your physician or other qualified health professional before starting anynew treatment, making any changes to existing treatment, or altering in any way your current exerciseor diet regimen. Do not delay seeking or disregard medical advice based on information on this site.Medical information changes rapidly and while Schizophrenia.com makes efforts to update thecontent on the site, some information may be out of date. No health information onSchizophrenia.com, including information about herbal therapies and other dietary supplements, isregulated or evaluated by the Food and Drug Administration and therefore the information should notbe used to diagnose, treat, cure, or prevent any disease without the supervision of a medical doctor.

 

The symptom of depression in schizophrenia and itsmanagement

1. Ciaran Mulholland and2. Stephen Cooper

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+Author Affiliations

1. Ciaran Mulholland is a consultant psychiatrist at Holywel Hospital, Antrim,

Northern Ireland. Stephen Cooper is a Senior Lecturer and Head of theDepartment 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 under-recognised 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 separatedementia praecox from manic–depressive illness. Kraepelin also recognised the importance of depression as a symptom in schizophrenia and identified several depressive subtypes of theillness. Mayer-Gross emphasised the despair that often occurs as a psychological reaction toacute 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 contributesignificantly to the suffering caused by the illness, whether ‘positive’ psychotic symptoms areactive or quiescent, but also because they exacerbate deficits in psychosocial functioning andcommonly precede attempted and completed suicide. It is important to define and clinicallyassess 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 inschizophrenia. We can assume that depression and schizophrenia are not simply twoindependent illnesses occurring together by chance, on the basis of the epidemiology of eachillness. Differential diagnoses to consider include schizoaffective disorder, organic conditions andthe negative symptoms of schizophrenia. It has been argued by some that depression may insome 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 oftenan integral part of the schizophrenic process itself.

Schizoaffective disorderDifferentiating schizophrenia with clinically significant depressive symptoms from schizoaffectivedisorder is not always easy. Clearly, the exact dividing line between the two conditions is aconceptual one. Operationalised criteria such as ICD–10 (World Health Orgnization, 1992) allowus to make such a differentiation on a day-to-day basis (see Boxes 1 and 2⇓ ⇓) and will dictatetreatment options to an extent. The nature and treatment of schizoaffective disorder fallsoutside the remit of this review.

Box 1.

ICD–10 diagnostic guidelines for post-schizophrenic depression

The patient has met general criteria for schizophrenia within past 12 monthsSome schizophrenic symptoms are still present, but no longer dominate the clinicalpicture (symptoms may be ‘positive’ or ‘negative’, though the latter are morecommon)The depressive symptoms are prominent and distressing, fulfilling at least thecriteria for a depressive episode, and have been present for at least two weeks (theyare rarely sufficiently severe or extensive to meet criteria for a severe depressiveepisode)

Box 2.

ICD–10 diagnostic guidelines for schizoaffective disorder – depressed type

Both definite schizophrenic and definite affective symptoms are prominentsimultaneously, or within a few days of each other, within the same episode of illnessAs a consequence of this, the episode of illness does not meet criteria for eitherschizophrenia or for a depressive or manic episodeThere must be prominent depression accompanied by at least two characteristicdepressive symptoms or associated behavioural abnormalities as for a depressiveepisode

At least one and preferably two typically schizophrenic symptoms, as specified forschizophrenia, must be present

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 Adjustment reactions

Schizophrenia carries a heavy psychological burden and it is not surprising that disappointmentreactions to life's vicissitudes occur commonly. Acute reactions, lasting less than two weeks, areself-limiting and require supportive treatment or manipulation of the environment only. Often, aclear precipitating cause can be identified.

 There are some patients who can be characterised as suffering from a demoralisation syndromeor a chronic disappointment reaction. Differentiating such a syndrome from depression is notalways easy. It is characterised by hopelessness and helplessness, with a lack of confidence andfeelings of incompetence. The appropriate treatment is supportive or rehabilitative rather thanpharmacological.

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 depressivesymptoms should become more common as acute psychotic symptoms respond to treatment.

 The opposite appears to be the case, however, with depressive symptoms more often resolvingas positive symptoms resolve.

Organic factorsDepression-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 mayoccur as a reaction to illness. A myocardial infarction, for example, may present as agitation andemotional distress in someone with schizophrenia as there can be an altered pain threshold andinability to describe symptoms adequately. The medication used to treat medical disorders mayalso 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. Inaddition, the entire range of medication that they receive, not just their psychotropicmedication, and any recent changes in medication, should be considered as possible aetiologicalfactors.

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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 mostcommon substance causing problems. Arguably, cannabis can cause depressive symptoms withlong-term use, and nicotine and caffeine may cause dysphoria upon withdrawal. Cocaine, lesscommonly used and more often associated with manic symptoms, can cause depression uponwithdrawal. 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 problemswhen attempting to differentiate between the two syndromes. Observed sadness is an unreliableindicator of depression in schizophrenia. Prominent subjectively low mood, suggestingdepression, and prominent blunting of affect, suggesting negative symptoms, are the two

features which are most helpful in differentiating the two syndromes (Siris, 1994). An emphasison the patient's view of him- or herself may thus be a useful approach in detecting importantaspects of depressive symptomatology in schizophrenia. Other symptoms that help to establishthe diagnosis of depression include some of the main psychological features that occur inprimary depressive illness, such as hopelessness, helplessness, worthlessness, guilt, anxiety andsuicidal thinking. In schizophrenia, the biological features of the depressive syndrome, such asinsomnia and retardation, are not always present – and if they are present, they can be moredifficult to disentangle from negative symptoms and can be an intrinsic part of the illnessseparate from any superimposed depressive syndrome.

The role of antipsychotic medication The role of antipsychotic medication in the aetiology of depressive symptoms in schizophrenia issomewhat controversial. There have been three principal proposed roles (Table 2⇓).

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Table 2.

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Antipsychotic medication and depressive symptoms in schizophrenia

 Thirty years ago, it was proposed that antipsychotics acted directly causing ‘pharmacogenicdepression’ (De Alarcon & Carney, 1969). There is a possible theoretical explanation for this asantipsychotics act primarily on dopaminergic pathways and dopamine plays a major role inreward and pleasure mechanisms. An alternative hypothesis proposed that akinesia, anextrapyramidal 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 isbroken’ 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 Parkinsoniansyndrome. Whether it can be reliably differentiated from Parkinsonian syndrome and is in fact aseparate clinical entity remains open to question.Although some observations have supported these hypotheses, the weight of evidence has beenagainst, suggesting that antipsychotics are responsible for relatively few cases of depression inschizophrenia. Depression can occur in antipsychotic-free patients with schizophrenia ( Johnson,1981a ), the prevalence of significant depression falls when antipsychotic treatment iscommenced (Hirsch et al, 1989) and when antipsychotics are discontinued there is an increasein the percentage of patients requiring antidepressants (Hirsch et al, 1973). Several studies haveshown no difference between depressed and non-depressed patients with schizophrenia in thedosage of antipsychotic medication received.

 Johnson (1981b) estimated that ‘akinetic depression’ accounts for 10–15% of depressive-type

symptoms. It is difficult to know how accurate this claim is, but akinetic depression shouldalways be considered as a possibility and anticholinergics as a treatment option. Depressivesymptoms are as common in patients on anticholinergics as in those who are not, andanticholinergics are not an effective treatment for depressive symptoms ( Johnson, 1981a ).More recently, attention has focused on the concept of antipsychotic-induced dysphoria. Onestudy in normal volunteers (King et al, 1995) demonstrated that dysphoria often occurs in theabsence of motor restlessness and can thus be under-diagnosed. It is possible that somepatients with schizophrenia presenting with depressive symptoms may in fact be troubled byantipsychotic-induced dysphoria, without the associated motor aspects of akathisia that makethe diagnosis more obvious. If present, dysphoria/akathisia is not a trivial side-effect and haseven been associated with suicide (Drake & Ehrlich, 1985).

Depression as a core symptom of schizophreniaAlthough the above factors must always be considered, it is probably the case that the majorityof patients with schizophrenia who also complain of significant depressive symptoms have thesesymptoms 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.View this table:

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

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MCQ answers

Depression as a prodromal syndromeDepressive symptoms are common in the prodromal period prior to acute psychotic episodes.Herz & Melville (1980) found that the symptoms most frequently mentioned by patients andtheir families were:“symptoms of dysphoria that non-psychotic individuals experience understress, such as eating less, having trouble concentrating, having trouble sleeping, depressionand 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. Theemergence of affective symptoms may represent a psychological reaction to impending relapse,may reflect an underlying biological process mediating both these symptoms and positivepsychotic symptoms, or may be an epiphenomenon. In any event, newly emerging affectivesymptoms are a useful early warning sign of impending relapse.

Depressive symptoms during acute episodesDepressive symptoms are most frequently associated with the acute phase of the illness. Such

symptoms are most prevalent before medication is commenced (Knights & Hirsch, 1981) andoccur 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,

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and occurs in approximately 25% of patients during the six months following discharge. Theclose association between depressive symptoms and acute episodes adds weight to thehypotheses that such symptoms are a core feature of schizophrenia and suggests thatdepressive symptoms and more typically schizophrenic symptoms may share commonpathophysiological processes.

Depressive symptoms in chronic schizophreniaLower rates of depressive symptoms are seen in the chronic phase of the illness with a range of 

4–25% and an estimated mean of 15% (Leff, 1990). Most of the reported studies on chronicpatients 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 sixmonths, 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 currentlydepressed. 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 beengiven close attention in recent years. The terms ‘post-psychotic depression’, ‘post-schizophrenicdepression’ and ‘secondary depression’ have been used to describe this phenomenon.Unfortunately, as Siris (1990) has argued, the term ‘post-psychotic depression’ has been used todescribe three similar, but clinically distinct, groups of patients. In one group, depressivesymptoms are clearly present during an acute psychotic episode and resolve as the positive

psychotic symptoms resolve, although sometimes more slowly. These depressive symptoms onlybecome apparent as the positive symptoms resolve, and the term ‘revealed depression’ issometimes applied. The second definition overlaps somewhat with the first but describespatients who develop depressive symptoms as their positive psychotic symptoms resolve. Thethird group of patients are those in whom significant depressive symptoms appear after theacute episode has resolved. The multiplicity of terms and the different ways in which they havebeen used has not added to the clarity of the literature. The studies in this area have variedwidely in methodology, including their definitions of significant depression.

 The concept of post-schizophrenic (or post-psychotic) depression has now been incorporatedinto the ICD–10 (World Health Organization, 1992) classification system (and in the appendix of DSM–IV; American Psychiatric Association, 1994). ICD–10 offers an operationalised definition of post-schizophrenic depression (Box 1⇑) and attempts to avoid confusion by specifically statingthat it is immaterial to the diagnosis whether depressive symptoms have been revealed or are anew development , and it is similarly immaterial whether depression is an intrinsic part of 

schizophrenia or a psychological reaction to it.Previous Section Next 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, andevidence 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 killthemselves are more likely to have a history of depressive episodes and to have exhibiteddepressive symptoms at their last contact. Suicide in schizophrenia appears to be correlatedmore with hopelessness and the psychological aspects of depression than with vegetativefeatures (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, arethe principal symptoms causing distress to patients with chronic schizophrenia in thecommunity. Johnson (1981a) found that over a two-year follow-up period the total morbidityfrom depression was more than twice the duration of morbidity from acute schizophrenicsymptoms and that the risk of an episode of depression was over three times the risk of anacute schizophrenic relapse. Follow-up studies have shown that depression can be the mainindication for 40% of admissions (Falloon et al, 1978) and that patients who manifest post-psychotic depression are more likely to experience a psychotic relapse.Glazer et al (1981) demonstated a link between depressive symptoms and poor performance insocial roles, including difficulties in relationships with others. There also appears to be acorrelation between post-psychotic depression and poor premorbid social adjustment and withinsidious 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 areequally common in male and female patients (Addington et al, 1996). Recent work has shown an

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association between depressive symptoms and attentional impairment, suggesting frontal lobedysfunction (Kohler et al, 1998a ) and increased bilateral temporal lobe volumes and decreasedlaterality (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 clinicallychallenging. Recent advances in psychopharmacology and other treatment approaches elevatethe importance of establishing the diagnosis at an early stage. The therapeutic goal issignificantly 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, totreat any medical conditions that are present,and to consider the possibility of substance misuseas a contributing factor. Any evidence that antipsychotic medication is producing akinesiashould 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 patientsdescribing subjective mood disturbance. The akathisia/dysphoria syndrome, if present, requiresactive management. Use of an anticholinergic drug is generally effective. Other options includeβ-adrenoceptor antagonists (e.g. propranolol), a benzodiazapine or a change in antipsychoticdrug.

If the above factors have been addressed and the clinician is sure that negative symptoms arenot being mistaken for depressive symptoms, then the treatment options are largely dictated bythe 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, antipsychoticmedication should be introduced or increased if there is serious concern that an acute episode isdeveloping. Indeed, follow-up studies indicate that early intervention at the first signs of relapseimproves outcome ( Johnstone et al, 1984).

During acute episodes, depressive symptoms should not be treated separately from othersymptoms and are likely to resolve as the episode resolves. In the majority of cases increasedantipsychotic medication, increased psychosocial support and, if necessary, hospitalisation, willsuccessfully treat depression as well as positive symptoms.

 There is accumulating evidence that the new atypical antipsychotics are more efficacious intreating the depression associated with an acute episode. Olanzapine, for example, was superiorto haloperidol in this regard in a recent study ( Tollefson et al, 1997). Other atypicals, such asrisperidone, ziprasidone and zotepine, may also have a mood-elevating effect. The atypicals mayprove 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 withchronic schizophrenia (Meltzer & Okalyi, 1995).

 There is a good case for the prescription of an antidepressant when the patient has persistentdepressive symptoms and is not in a phase of acute illness. There have been 11 publisheddouble-blind, placebo-controlled trials of tricyclic antidepressants. The results of thesedemonstrated improvement v.placebo in five, and no improvement in six. Unfortunately, thesestudies 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 withthe tricyclics, however, is that occasionally there can be a worsening of the positive psychoticsymptoms.

Clinical trials of selective serotonin reuptake inhibitors (SSRIs) have overall been in favour of aneffect on depressive symptoms in schizophrenia. Some of the studies have focused more onnegative 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 designedspecifically to compare an SSRI with placebo in patients with schizophrenia with moderate orsevere 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 withantipsychotics because of the enzyme inhibitory effects of some of the SSRIs on the CYP450system.Electroconvulsive therapy (ECT) was in earlier years often advocated for patients withschizophrenia experiencing prominent affective symptoms. This practice appears to stem fromclinical observations made in the 1940s (when ECT was the only effective treatment) thatpatients 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. Chartreview studies of patients given ECT in 1950, 1970 and 1985 did not find consistent evidencethat patients with affective symptoms did better with ECT than others. Modern, placebo-

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controlled clinical trials in the 1980s did not find significant improvement in depressivesymptoms in patients with schizophrenia given ECT, but did so in patients with psychoticsymptoms (Cooper et al, 1995).Rehabilitation, social support and work opportunities are likely to lessen the demoralisation seenin 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 andmedication effects. Such symptoms are amenable to treatment and should be actively soughtout in all patients.

Previous Section Next Section

Multiple choice questions

1. Depression in schizophrenia:

1. is most often seen during periods of remission

2. is associated with an increased riskof attempted suicide

3. may be an early sign of impendingrelapse

4. is an insignificant cause of morbidity

5. is a good prognostic sign.

1. In the differential diagnoses of depression inschizophrenia:

1. alcohol misuse must beexcluded

2. confusion with negativesymptoms sometimesoccurs

3. medical conditions are notimportant

4. more consideration shouldbe given to subjectivedepression

5. the possibility of impendingrelapse should beconsidered.

1. Symptoms which help to differentiate negativefrom depressive symptoms include:

1. hopelessness

2. suicidal thinking

3. subjective low mood

4. retardation

5. anxiety.

1. Antipsychotic medication:

1. frequentlycauses a

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‘pharmacogenic’depression

2. may causedysphoriawithout

associatedmotormovements

3. should be

decreasedif depressivesymptomsappear in apreviouslystablepatient

4. ‘akinetic’

depressionmayaccount forup to 25%of cases of depressivesymptomsinschizohrenia

5. will oftentreatdepressiveas well

positivesymptomspresentduringacuteepisodes.

1. Treatments likely to be useful inthe treatment of depression inschizophrenia include:

1. tricyclicant

idepressants

2. atypicalantipsychotics

3. inc

reasedpsy

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chosocialsupport

4. selectiveserotoninreuptakeinhibitors

5. hospit

alisation.

 ANTIPSYCHOTIC MEDICATIONS 

A person who is psychotic is out of touch with reality. People withpsychosis may hear "voices" or have strange and illogical ideas (forexample, thinking that others can hear their thoughts, or are trying to

harm them, or that they are the President of the United States or someother famous person). They may get excited or angry for no apparentreason, or spend a lot of time by themselves, or in bed, sleeping duringthe day and staying awake at night. The person may neglect appearance,not bathing or changing clothes, and may be hard to talk to--barelytalking or saying things that make no sense. They often are initiallyunaware that their condition is an illness.

These kinds of behaviors are symptoms of a psychotic illness such asschizophrenia. Antipsychotic medications act against these symptoms.These medications cannot "cure" the illness, but they can take awaymany of the symptoms or make them milder. In some cases, they canshorten 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 communicationbetween nerve cells. One such neurotransmitter, dopamine, is thought tobe relevant to schizophrenia symptoms. All these medications have beenshown to be effective for schizophrenia. The main differences are in thepotency--that is, the dosage (amount) prescribed to produce therapeuticeffects-and the side effects. Some people might think that the higher the

dose of medication prescribed, the more serious the illness; but this is notalways true.

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The first antipsychotic medications were introduced in the 1950s.Antipsychotic medications have helped many patients with psychosis leada more normal and fulfilling life by alleviating such symptoms ashallucinations, 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, leadingresearchers 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 effectsthan the older drugs, today they are often used as a first-line treatment.The first atypical antipsychotic, clozapine (Clozaril ), was introduced in theUnited States in 1990. In clinical trials, this medication was found to bemore effective than conventional or "typical" antipsychotic medications inindividuals with treatment-resistant schizophrenia (schizophrenia that hasnot responded to other drugs), and the risk of tardive dyskinesia (amovement disorder) was lower. However, because of the potential sideeffect of a serious blood disorder--agranulocytosis (loss of the white bloodcells that fight infection)-patients who are on clozapine must have a bloodtest every 1 or 2 weeks. The inconvenience and cost of blood tests andthe medication itself have made maintenance on clozapine difficult formany people. Clozapine, however, continues to be the drug of choice fortreatment-resistant schizophrenia patients.

Several other atypical antipsychotics have been developed since clozapinewas 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 medicationsare 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'ssymptoms, age, weight, and personal and family medication history.

Dosages and side effects. Some drugs are very potent and the doctormay prescribe a low dose. Other drugs are not as potent and a higherdose may be prescribed.

Unlike some prescription drugs, which must be taken several times duringthe day, some antipsychotic medications can be taken just once a day. Inorder to reduce daytime side effects such as sleepiness, somemedications can be taken at bedtime. Some antipsychotic medications areavailable in "depot" forms that can be injected once or twice a month.

Most side effects of antipsychotic medications are mild. Many commonones lessen or disappear after the first few weeks of treatment. Theseinclude drowsiness, rapid heartbeat, and dizziness when changingposition.

Some people gain weight while taking medications and need to pay extra

attention to diet and exercise to control their weight. Other side effectsmay include a decrease in sexual ability or interest, problems with

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menstrual periods, sunburn, or skin rashes. If a side effect occurs, thedoctor should be told. He or she may prescribe a different medication,change the dosage or schedule, or prescribe an additional medication tocontrol the side effects.

Just as people vary in their responses to antipsychotic medications, theyalso vary in how quickly they improve. Some symptoms may diminish indays; others take weeks or months. Many people see substantialimprovement by the sixth week of treatment. If there is no improvement,the doctor may try a different type of medication. The doctor cannot tellbeforehand which medication will work for a person. Sometimes a personmust try several medications before finding one that works.

If a person is feeling better or even completely well, the medicationshould not be stopped without talking to the doctor. It may be necessaryto stay on the medication to continue feeling well. If, after consultation

with the doctor, the decision is made to discontinue the medication, it isimportant to continue to see the doctor while tapering off medication.Many people with bipolar disorder, for instance, require antipsychoticmedication only for a limited time during a manic episode until mood-stabilizing medication takes effect. On the other hand, some people mayneed to take antipsychotic medication for an extended period of time.These people usually have chronic (long-term, continuous) schizophrenicdisorders, or have a history of repeated schizophrenic episodes, and arelikely to become ill again. Also, in some cases a person who hasexperienced one or two severe episodes may need medication indefinitely.

In these cases, medication may be continued in as low a dosage aspossible to maintain control of symptoms. This approach, calledmaintenance treatment, prevents relapse in many people and removes orreduces symptoms for others.

Multiple medications. Antipsychotic medications can produce unwantedeffects when taken with other medications. Therefore, the doctor shouldbe told about all medicines being taken, including over-the-countermedications and vitamin, mineral, and herbal supplements, and theextent of alcohol use. Some antipsychotic medications interfere withantihypertensive medications (taken for high blood pressure),

anticonvulsants (taken for epilepsy), and medications used for Parkinson'sdisease. Other antipsychotics add to the effect of alcohol and othercentral nervous system depressants such as antihistamines,antidepressants, barbiturates, some sleeping and pain medications, andnarcotics.

Other effects. Long-term treatment of schizophrenia with one of theolder, or "conventional," antipsychotics may cause a person to developtardive dyskinesia (TD). Tardive dyskinesia is a condition characterized byinvoluntary movements, most often around the mouth. It may range frommild to severe. In some people, it cannot be reversed, while others

recover partially or completely. Tardive dyskinesia is sometimes seen inpeople with schizophrenia who have never been treated with an

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antipsychotic medication; this is called "spontaneousdyskinesia."1 However, it is most often seen after long-term treatmentwith older antipsychotic medications. The risk has been reduced with thenewer "atypical" medications. There is a higher incidence in women, andthe risk rises with age. The possible risks of long-term treatment with an

antipsychotic medication must be weighed against the benefits in eachcase. The risk for TD is 5 percent per year with older medications; it isless with the newer medications.

 ANTIMANIC MEDICATIONS 

Bipolar disorder is characterized by cycling mood changes: severe highs(mania) and lows (depression). Episodes may be predominantly manic ordepressive, with normal mood between episodes. Mood swings may followeach other very closely, within days (rapid cycling), or may be separatedby 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, overlytalkative, have a great deal of energy, and have much less need for sleepthan normal. They may switch quickly from one topic to another, as if they cannot get their thoughts out fast enough. Their attention span isoften short, and they can be easily distracted. Sometimes people who are"high" are irritable or angry and have false or inflated ideas about theirposition 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 difficultyconcentrating; lack of energy, with slowed thinking and movements;changes in eating and sleeping patterns (usually increases of both inbipolar depression); feelings of hopelessness, helplessness, sadness,worthlessness, guilt; and, sometimes, thoughts of suicide.

Lithium. The medication used most often to treat bipolar disorder islithium. Lithium evens out mood swings in both directions--from mania todepression, and depression to mania--so it is used not just for manic

attacks or flare-ups of the illness but also as an ongoing maintenancetreatment for bipolar disorder.

Although lithium will reduce severe manic symptoms in about 5 to 14days, it may be weeks to several months before the condition is fullycontrolled. Antipsychotic medications are sometimes used in the firstseveral days of treatment to control manic symptoms until the lithiumbegins to take effect. Antidepressants may also be added to lithiumduring the depressive phase of bipolar disorder. If given in the absence of lithium or another mood stabilizer, antidepressants may provoke a switchinto mania in people with bipolar disorder.

A person may have one episode of bipolar disorder and never haveanother, or be free of illness for several years. But for those who have

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more than one manic episode, doctors usually give serious considerationto maintenance (continuing) treatment with lithium.

Some people respond well to maintenance treatment and have no furtherepisodes. 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 allby lithium. Response to treatment with lithium varies, and it cannot bedetermined beforehand who will or will not respond to treatment.

Regular blood tests are an important part of treatment with lithium. If toolittle is taken, lithium will not be effective. If too much is taken, a varietyof side effects may occur. The range between an effective dose and atoxic one is small. Blood lithium levels are checked at the beginning of treatment to determine the best lithium dosage. Once a person is stableand 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 physicalcondition.

Side effects of lithium. When people first take lithium, they mayexperience side effects such as drowsiness, weakness, nausea, fatigue,hand tremor, or increased thirst and urination. Some may disappear ordecrease quickly, although hand tremor may persist. Weight gain mayalso occur. Dieting will help, but crash diets should be avoided becausethey may raise or lower the lithium level. Drinking low-calorie or no-calorie 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 manageableand are reduced by lowering the dosage. Because lithium may cause thethyroid gland to become underactive (hypothyroidism) or sometimesenlarged (goiter), thyroid function monitoring is a part of the therapy. Torestore normal thyroid function, thyroid hormone may be given along withlithium.

Because of possible complications, doctors either may not recommendlithium 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 takenduring 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 unusualamount of exercise or a very hot climate, fever, vomiting, or diarrhea--may cause a lithium buildup and lead to toxicity. It is important to beaware of conditions that lower sodium or cause dehydration and to tell thedoctor if any of these conditions are present so the dose can be changed.

Lithium, when combined with certain other medications, can haveunwanted effects. Some diuretics--substances that remove water from

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the body--increase the level of lithium and can cause toxicity. Otherdiuretics, like coffee and tea, can lower the level of lithium. Signs of lithium toxicity may include nausea, vomiting, drowsiness, mentaldullness, slurred speech, blurred vision, confusion, dizziness, muscletwitching, 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 enablesmany people, who otherwise would suffer from incapacitating moodswings, to lead normal lives.

 Anticonvulsants. Some people with symptoms of mania who do notbenefit from or would prefer to avoid lithium have been found to respondto anticonvulsant medications commonly prescribed to treat seizures.

The anticonvulsant valproic acid (Depakote, divalproex sodium) is themain alternative therapy for bipolar disorder. It is as effective in non-rapid-cycling bipolar disorder as lithium and appears to be superior tolithium in rapid-cycling bipolar disorder.2 Although valproic acid can causegastrointestinal side effects, the incidence is low. Other adverse effectsoccasionally reported are headache, double vision, dizziness, anxiety, orconfusion. Because in some cases valproic acid has caused liverdysfunction, liver function tests should be performed before therapy andat frequent intervals thereafter, particularly during the first 6 months of therapy.

Studies conducted in Finland in patients with epilepsy have shown that valproicacid may increase testosterone levels in teenage girls and produce polycysticovary 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), andtopiramate (Topamax ). The evidence for anticonvulsant effectiveness isstronger for acute mania than for long-term maintenance of bipolardisorder. Some studies suggest particular efficacy of lamotrigine in bipolardepression. At present, the lack of formal FDA approval of anticonvulsantsother than valproic acid for bipolar disorder may limit insurance coveragefor these medications.

Most people who have bipolar disorder take more than one medication.Along with the mood stabilizer--lithium and/or an anticonvulsant--theymay take a medication for accompanying agitation, anxiety, insomnia, ordepression. It is important to continue taking the mood stabilizer whentaking an antidepressant because research has shown that treatment withan antidepressant alone increases the risk that the patient will switch to

mania or hypomania, or develop rapid cycling.5

Sometimes, when abipolar patient is not responsive to other medications, an atypical

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

 ANTIDEPRESSANT MEDICATIONS 

Major depression, the kind of depression that will most likely benefit fromtreatment with medications, is more than just "the blues." It is a conditionthat lasts 2 weeks or more, and interferes with a person's ability to carryon daily tasks and enjoy activities that previously brought pleasure.Depression is associated with abnormal functioning of the brain. Aninteraction between genetic tendency and life history appears todetermine 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 enjoytheir normal activities. They may have no appetite and lose weight(although some people eat more and gain weight when depressed). Theymay sleep too much or too little, have difficulty going to sleep, sleeprestlessly, or awaken very early in the morning. They may speak of feeling guilty, worthless, or hopeless; they may lack energy or be jumpyand agitated. They may think about killing themselves and may evenmake 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 everyonewho is depressed has at least some of them, co-existing, on most days.Depression can range in intensity from mild to severe. Depression can co-occur with other medical disorders such as cancer, heart disease, stroke,Parkinson's disease, Alzheimer's disease, and diabetes. In such cases, thedepression is often overlooked and is not treated. If the depression isrecognized and treated, a person's quality of life can be greatly improved.

Antidepressants are used most often for serious depressions, but they canalso 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 theybecame depressed.

The doctor chooses an antidepressant based on the individual'ssymptoms. Some people notice improvement in the first couple of weeks;but usually the medication must be taken regularly for at least 6 weeksand, in some cases, as many as 8 weeks before the full therapeutic effectoccurs. 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 medicationsuch as lithium, to augment the action of the original antidepressant.

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Because there is no way of knowing beforehand which medication will beeffective, the doctor may have to prescribe first one and then another. Togive a medication time to be effective and to prevent a relapse of thedepression once the patient is responding to an antidepressant, themedication should be continued for 6 to 12 months, or in some cases

longer, carefully following the doctor's instructions. When a patient andthe doctor feel that medication can be discontinued, withdrawal should bediscussed as to how best to taper off the medication gradually. Never discontinue medication without talking to the doctor about it. For thosewho have had several bouts of depression, long-term treatment withmedication is the most effective means of preventing more episodes.

Dosage of antidepressants varies, depending on the type of drug and theperson's body chemistry, age, and, sometimes, body weight.Traditionally, antidepressant dosages are started low and raised graduallyover time until the desired effect is reached without the appearance of troublesome side effects. Newer antidepressants may be started at ornear therapeutic doses.

Early antidepressants. From the 1960s through the 1980s, tricyclicantidepressants(named for their chemical structure) were the first lineof treatment for major depression. Most of these medications affected twochemical neurotransmitters, norepinephrine and serotonin. Though thetricyclics are as effective in treating depression as the newerantidepressants, 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. Otherantidepressants introduced during this period were monoamine oxidaseinhibitors (MAOIs). MAOIs are effective for some people with majordepression who do not respond to other antidepressants. They are alsoeffective for the treatment of panic disorder and bipolar depression.MAOIs approved for the treatment of depression are phenelzine (Nardil),tranylcypromine (Parnate), and isocarboxazid (Marplan). Becausesubstances in certain foods, beverages, and medications can causedangerous interactions when combined with MAOIs, people on theseagents must adhere to dietary restrictions. This has deterred manyclinicians and patients from using these effective medications, which arein fact quite safe when used as directed.

The past decade has seen the introduction of many new antidepressantsthat work as well as the older ones but have fewer side effects. Some of these medications primarily affect one neurotransmitter, serotonin, andare called selective serotonin reuptake inhibitors (SSRIs). Theseinclude fluoxetine (Prozac ), sertraline (Zoloft ), fluvoxamine (Luvox ),paroxetine (Paxil ), and citalopram (Celexa).

The late 1990s ushered in new medications that, like the tricyclics, affectboth norepinephrine and serotonin but have fewer side effects. These new

medications include venlafaxine (Effexor ) and nefazadone (Serzone).

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Cases of life-threatening hepatic failure have been reported in patients treated

with nefazodone (Serzone). Patients should call the doctor if the followingsymptoms of liver dysfunction occur - yellowing of the skin or white of eyes,

unusually dark urine, loss of appetite that lasts for several days, nausea, orabdominal pain.

Other newer medications chemically unrelated to the otherantidepressants are the sedating mirtazepine (Remeron) and the moreactivating bupropion (Wellbutrin). Wellbutrin has not been associated withweight gain or sexual dysfunction but is not used for people with, or atrisk for, a seizure disorder.

Each antidepressant differs in its side effects and in its effectiveness intreating an individual person, but the majority of people with depressioncan 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 areunusual, annoying, or that interfere with functioning should be reported tothe doctor immediately. The most common side effects of tricyclicantidepressants, and ways to deal with them, are as follows:

• Dry mouth--it is helpful to drink sips of water; chew sugarless gum; brushteeth 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 enlargedprostate conditions may be at particular risk for this problem. The doctorshould be notified if there is any pain.

• Sexual problems--sexual functioning may be impaired; if this isworrisome, it should be discussed with the doctor.

• Blurred vision--this is usually temporary and will not necessitate newglasses. Glaucoma patients should report any change in vision to thedoctor.

• Dizziness--rising from the bed or chair slowly is helpful.

• Drowsiness as a daytime problem--this usually passes soon. A person whofeels drowsy or sedated should not drive or operate heavy equipment. Themore sedating antidepressants are generally taken at bedtime to helpsleep and to minimize daytime drowsiness.

• Increased heart rate--pulse rate is often elevated. Older patients shouldhave an electrocardiogram (EKG) before beginning tricyclic treatment.

The newer antidepressants, including SSRIs, have different types of sideeffects, 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.

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• 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 duringthe 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 withother medications that affect serotonin. In the most extreme cases, sucha combination of medications (e.g., an SSRI and an MAOI) may result in apotentially serious or even fatal "serotonin syndrome," characterized byfever, confusion, muscle rigidity, and cardiac, liver, or kidney problems.

The small number of people for whom MAOIs are the best treatmentneed to avoid taking decongestants and consuming certain foods that

contain high levels of tyramine, such as many cheeses, wines, andpickles. The interaction of tyramine with MAOIs can bring on a sharpincrease in blood pressure that can lead to a stroke. The doctor shouldfurnish a complete list of prohibited foods that the individual should carryat all times. Other forms of antidepressants require no food restrictions.MAOIs also should not be combined with other antidepressants, especiallySSRIs, due to the risk of serotonin syndrome.

Medications of any kind --prescribed, over-the-counter, or herbalsupplements--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 othermedical specialist-should be told that the person is taking a specificantidepressant and the dosage. Some drugs, although safe when takenalone, can cause severe and dangerous side effects if taken with otherdrugs. Alcohol (wine, beer, and hard liquor) or street drugs, may reducethe effectiveness of antidepressants and their use should be minimized or,preferably, avoided by anyone taking antidepressants. Some people whohave not had a problem with alcohol use may be permitted by their doctorto use a modest amount of alcohol while taking one of the newerantidepressants. 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 intervieware common symptoms. Other symptoms include irritability, uneasiness,

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 jumpiness, feelings of apprehension, rapid or irregular heartbeat,stomachache, nausea, faintness, and breathing problems.

Anxiety is often manageable and mild, but sometimes it can presentserious problems. A high level or prolonged state of anxiety can make the

activities of daily life difficult or impossible. People may have generalizedanxiety disorder (GAD) or more specific anxiety disorders such as panic,phobias, obsessive-compulsive disorder (OCD), or post-traumatic stressdisorder (PTSD).

Both antidepressants and antianxiety medications are used to treatanxiety disorders. The broad-spectrum activity of most antidepressantsprovides effectiveness in anxiety disorders as well as depression. The firstmedication specifically approved for use in the treatment of OCD was thetricyclic 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 beenapproved for social anxiety disorder (social phobia), GAD, and panicdisorder; and sertraline is approved for panic disorder and PTSD.Venlafaxine (Effexor ) has been approved for GAD.

Antianxiety medications include the benzodiazepines, which can relievesymptoms within a short time. They have relatively few side effects:drowsiness and loss of coordination are most common; fatigue andmental slowing or confusion can also occur. These effects make itdangerous for people taking benzodiazepines to drive or operate somemachinery. Other side effects are rare.

Benzodiazepines vary in duration of action in different people; they maybe taken two or three times a day, sometimes only once a day, or just onan "as-needed" basis. Dosage is generally started at a low level andgradually raised until symptoms are diminished or removed. The dosagewill vary a great deal depending on the symptoms and the individual'sbody chemistry.

It is wise to abstain from alcohol when taking benzodiazepines, becausethe interaction between benzodiazepines and alcohol can lead to seriousand possibly life-threatening complications. It is also important to tell thedoctor about other medications being taken.

People taking benzodiazepines for weeks or months may developtolerance for and dependence on these drugs. Abuse and withdrawalreactions are also possible. For these reasons, the medications aregenerally prescribed for brief periods of time--days or weeks--andsometimes just for stressful situations or anxiety attacks. However, somepatients may need long-term treatment.

It is essential to talk with the doctor before discontinuing abenzodiazepine. A withdrawal reaction may occur if the treatment isstopped abruptly. Symptoms may include anxiety, shakiness, headache,

dizziness, sleeplessness, loss of appetite, or in extreme cases, seizures. Awithdrawal reaction may be mistaken for a return of the anxiety because

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many of the symptoms are similar. After a person has takenbenzodiazepines for an extended period, the dosage is gradually reducedbefore it is stopped completely. Commonly used benzodiazepines includeclonazepam (Klonopin), alprazolam ( Xanax ), diazepam (Valium), andlorazepam ( Ativan).

The only medication specifically for anxiety disorders other than thebenzodiazepines is buspirone (BuSpar ). Unlike the benzodiazepines,buspirone must be taken consistently for at least 2 weeks to achieve anantianxiety effect and therefore cannot be used on an "as-needed" basis.

Beta blockers, medications often used to treat heart conditions and highblood pressure, are sometimes used to control "performance anxiety"when the individual must face a specific stressful situation--a speech, apresentation 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 thelists below, find the generic (chemical) name and look it up on the firstlist or find the trade (brand) name and look it up on the second list. If thename of the medication does not appear on the prescription label, ask thedoctor or pharmacist for it. (Note: Some drugs are marketed undernumerous trade names, not all of which can be listed in a shortpublication like this one. If your medication's trade name does not appearin 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 pharmacistfor more information.) Stimulant medications that are used by bothchildren and adults with ADHD are listed in the children's medicationschart).

 ALPHABETICAL LIST OF MEDICATIONS BY GENERIC NAME 8 

GENERIC NAME TRADE NAME

 

 Antipsychotic Medications

chlorpromazine Thorazine

chlorprothixene Taractan

clozapine Clozaril

fluphenazine Permitil, Prolixin

haloperidol Haldol

loxapine Loxitane

mesoridazine Serentil

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molindone Lidone, Moban

olanzapine Zyprexa

perphenazine Trilafon

pimozide (for Tourette's syndrome) Orap

quetiapine Seroquel

risperidone Risperdal

thioridazine Mellaril

thiothixene Navane

trifluoperazine Stelazine

trifluopromazine Vesprin

ziprasidone Geodon

 

 Antimanic Medications

carbamazepine Tegretol

divalproex sodium (valproic acid) Depakote

gabapentin Neurontin

lamotrigine Lamictal

lithium carbonate Eskalith, Lithane, Lithobid

lithium citrate Cibalith-S

topimarate Topamax

 

 Antidepressant Medications

amitriptyline Elavil

amoxapine Asendin

bupropion Wellbutrin

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citalopram (SSRI) Celexa

clomipramine Anafranil

desipramine Norpramin, Pertofrane

doxepin Adapin, Sinequan

escitalopram (SSRI) Lexapro

fluvoxamine (SSRI) Luvox

fluoxetine (SSRI) Prozac

imipramine Tofranil

isocarboxazid (MAOI) Marplan

maprotiline Ludiomil

mirtazapine Remeron

nefazodone Serzone

nortriptyline Aventyl, Pamelor

paroxetine (SSRI) Paxil

phenelzine (MAOI) Nardil

protriptyline Vivactil

sertraline (SSRI) Zoloft

tranylcypromine (MAOI) Parnate

trazodone Desyrel

trimipramine Surmontil

venlafaxine Effexor

 

 Antianxiety Medications

(All of these antianxiety medications except buspirone are benzodiazepines)

alprazolam Xanax

buspirone BuSpar

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chlordiazepoxide Librax, Libritabs, Librium

clonazepam Klonopin

clorazepate Azene, Tranxene

diazepam Valium

halazepam Paxipam

lorazepam Ativan

oxazepam Serax

prazepam Centrax

ALPHABETICAL LIST OF MEDICATIONS BY TRADE NAME

TRADE NAME GENERIC NAME

 

 Antipsychotic Medications

Clozaril clozapine

Geodon ziprasidone

Haldol haloperidol

Lidone molindone

Loxitane loxapine

Mellaril thioridazine

Moban molindone

Navane thiothixene

Orap (for Tourette's syndrome) pimozide

Permitil fluphenazine

Prolixin fluphenazine

Risperdal risperidone

Serentil mesoridazine

Seroquel quetiapine

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Stelazine trifluoperazine

Taractan chlorprothixene

Thorazine chlorpromazine

Trilafon perphenazine

Vesprin trifluopromazine

Zyprexa olanzapine

 

 Antimanic Medications

Cibalith-S lithium citrate

Depakote valproic acid, divalproex sodium

Eskalith lithium carbonate

Lamictal lamotrigine

Lithane lithium carbonate

Lithobid lithium carbonate

Neurontin gabapentin

Tegretol carbamazepine

Topamax topiramate

 

 Antidepressant Medications

Adapin doxepin

Anafranil clomipramine

Asendin amoxapine

Aventyl nortriptyline

Celexa (SSRI) citalopram

Desyrel trazodone

Effexor venlafaxine

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Elavil amitriptyline

Lexapro (SSRI) escitalopram

Ludiomil maprotiline

Luvox (SSRI) fluvoxamine

Marplan (MAOI) isocarboxazid

Nardil (MAOI) phenelzine

Norpramin desipramine

Pamelor nortriptyline

Parnate (MAOI) tranylcypromine

Paxil (SSRI) paroxetine

Pertofrane desipramine

Prozac (SSRI) fluoxetine

Remeron mirtazapine

Serzone nefazodone

Sinequan doxepin

Surmontil trimipramine

Tofranil imipramine

Vivactil protriptyline

Wellbutrin bupropion

Zoloft (SSRI) sertraline

 

 Antianxiety Medications

(All of these antianxiety medications except BuSpar are benzodiazepines)

Ativan lorazepam

Azene clorazepate

BuSpar buspirone

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Centrax prazepam

Librax, Libritabs, Librium chlordiazepoxide

Klonopin clonazepam

Paxipam halazepam

Serax oxazepam

Tranxene clorazepate

Valium diazepam

Xanax alprazolam

CHILDREN'S MEDICATION CHART 

TRADE NAME GENERIC NAME APPROVED AGE

 

Stimulant Medications

Adderall amphetamine 3 and older

Adderall XR

amphetamine

(extended release) 6 and older

Concertamethylphenidate

(long acting)6 and older

Cylert* pemoline 6 and older

Dexedrine dextroamphetamine 3 and older

Dextrostat dextroamphetamine 3 and older

Focalin dexmethylphenidate 6 and older

Metadate ERmethylphenidate

(extended release)6 and older

Ritalin methylphenidate 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

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Anafranil clomipramine 10 and older (for OCD)

BuSpar buspirone 18 and older

Effexor venlafaxine 18 and older

Luvox (SSRI) fluvoxamine 8 and older (for OCD)

Paxil (SSRI) paroxetine 18 and older

Prozac (SSRI) fluoxetine 18 and older

Serzone

(SSRI)nefazodone 18 and older

Sinequan doxepin 12 and older

Tofranil imipramine 6 and older (for bedwetting)

Wellbutrin bupropion 18 and older

Zoloft (SSRI) sertraline 6 and older (for OCD)

 

 Antipsychotic Medications

Clozaril

(atypical)clozapine 18 and older

Haldol haloperidol 3 and older

Risperdal

(atypical)risperidone 18 and older

Seroquel

(atypical)

quetiapine 18 and older

Mellaril thioridazine 2 and older

Zyprexa

(atypical)olanzapine 18 and older

Orap pimozide

12 and older (for Tourette's syndrome --

Data for age 2 and older indicate similar

safety profile)

 

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Mood Stabilizing Medications

Cibalith-S lithium citrate 12 and older

Depakote valproic acid 2 and older (for seizures)

Eskalith lithium carbonate 12 and older

Lithobid lithium carbonate 12 and older

Tegretol carbamazepine 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

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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 couldn’t 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 isn’t 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 smell ing 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. depressed mood most of the day nearly every day

2. noticeably increased or decreased sex drive

3. loss of interest or pleasure in all, or almost all, activities most of the day nearly every day

4. significant weight loss or weight gain, OR decrease or increase in appetite nearly every day

5. insomnia OR hypersomnia (sleeping excessively) nearly everyday

6. psychomotor agitation (moving more quickly) OR retardation (moving more slowly) nearly every day, so much

that other people notice

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7. fatigue OR loss of energy nearly every day

8. 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]

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[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

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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

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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.

There's more content below this advertisement. Jump to the content.

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 1-800-273-TALK or 1-800-

SUICIDE to get help.

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

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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 bahwaperingkat 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 positif merujuk 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 jiwaSakit 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 berlarut-

larut sehingga mencapai puncaknya tanpa suatu penyelesaian secara wajar

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atau hilangnya keseimbangan mental secara menyeluruh, akibat suasana

lingkungan yang sangat menekan, ketegangan batin dan sebagainya.

 

1.Schizophrenia

Schizophrenia adalah penyakit jiwa yang paling banyak terjadi dibandingkandengan 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 sukarbagi 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 sebenarnyatidak 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 belum diketahui dengan pasti apa sesungguhnya yang

menimbulkan

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.

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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.

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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 sebab-

sebab 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 yang kemudian kemudian menjadi

sedih/tertekan. Gejalanya yaitu :

 

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 kadang-

kadang membahayakan dirinya sendiri dan mungkin membahayakan orang lain

dalam sikap dan perbuatannya.

 

Penyakit ini dinamakan juga ‘gila kumat-kumatan’, karena penderita berubah-

ubah 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.

 

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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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