Perinatal Psychology

by John M Rathbun, MD


A young woman and her fiancé came to see me because they wanted to have a baby and they desired my opinion about when she should stop taking her lithium. She was also on Wellbutrin and Cytomel. What would you tell them?

A pregnant woman with a history of intractable depression came to me because she knew from past experience that one electroconvulsive therapy treatment would relieve her depression for up to a month, but several health care professionals had told her that she couldn't have ECT because it would hurt the baby. What would you tell her?

Another patient of mine called because she was close to parturition and wanted to know if she should stop her antidepressant before delivery so she could breast feed. What would you tell her?

We used to think that pregnancy somehow protected women from severe psychiatric illness, but new data indicate that women are at least as likely to show psychiatric illness during pregnancy as at any other time. A recent literature review showed rates of depression in pregnancy anywhere from 5% to nearly 30%. When ten women with previous history of panic disorder were studied during pregnancy, seven continued symptomatic throughout the pregnancy.

A retrospective study of 29 women with OCD prior to pregnancy showed that nearly 70% experienced no change in symptoms during pregnancy; the other 30% were evenly divided between those who experienced improvement during pregnancy and those whose OCD got worse during pregnancy. Discontinuation of psychotropic medications in pregnant women has been associated with high rates of relapse in numerous reported cases of mood disorders, anxiety disorders, and schizophrenia.

Psychiatric illness during pregnancy is not only common, but causes considerable distress for the mother and risk for the fetus. Compliance with recommended prenatal care is poor in proportion to the severity of the illness. Common consequences of severe psychiatric illness include malnutrition, dehydration, heavy smoking, abuse of alcohol and other toxic substances, lack of rest, lack of exercise, and chronic high levels of stress hormones such as cortisol. These are all known risk factors for poor fetal outcomes, including intellectual and behavioral problems which can persist throughout life.

Diagnosis of psychiatric illness in pregnancy is complicated by the frequency with which sleep and appetite disturbance are found in uncomplicated pregnancies. Vivien Burt, who directs the Women's Life Center at the University of California in Los Angeles, has noted that during pregnancy, women with significant depression are much more likely than healthy women to complain vociferously of total insomnia.

Given the impersonal and hurried nature of so many clinical encounters these days, I suggest routine screening of pregnant women with a psychiatric symptom questionnaire, such as the Beck Depression Inventory. The Beck is particularly useful in medical settings because it ignores neurovegetative symptoms and concentrates on depressive thinking patterns. [seereferences]

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It's important to distinguish illness which is dangerous from that which is merely uncomfortable. Pregnancy is an inherently uncomfortable condition. First pregnancies are among the most profoundly disturbing events in most people's lives. One's anatomy and physiology undergo cataclysmic changes, and one's personal identity becomes absorbed in the universal human drama of bringing a new life into the world.

Pregnancy can have many meanings, from the mysterious merger of two lives into a common biological destiny, to an experience of profound frustration, violation, and failure. The active, carefree woman may become bedfast and subject to annoying regimens which she doesn't dare resent because, of course, we all want to do what's best for the baby. Morning sickness, uncharacteristic emotional lability, and extreme dietary preferences are common stressors in the first trimester. Nicotine craving and abstinence from the solace of an occasional stiff drink may complicate the expectant mother's adjustment. As delivery approaches, women often begin to feel awkward and vulnerable, with additional discomfort from backache and from compression of abdominal organs such as the urinary bladder.

Given these stressors, it shouldn't be surprising that anxiety and depressive reactions are the most common emotional disturbances in pregnancy. They are usually manageable with counseling, support groups, environmental manipulation, and nonspecific diversions such as walking, massage, warm baths, and keeping up social contacts.

The provision of environmental support is particularly important in all phases of reproduction. Our fragmented society is seriously deficient in the supports offered to young families. Only in the past few decades has it become common for young families to relocate beyond easy reach of their families of origin. This practice leaves the expectant mother with a dearth of competent help when she most needs it.

Many young families need encouragement to ask for live-in assistance from relatives in distant cities. Pregnant women and new mothers need this kind of assistance. Provision of adequate assistance is often the most important step to resolution of emotional turmoil in a pregnant or lactating woman.

When depression and anxiety fail to respond to common-sense approaches, professional psychotherapy is indicated. Brief hospital stays and intensive outpatient programs will often be as effective as medication in moderately severe cases.

Very severe cases of depression and anxiety often will not respond to the low-risk management strategies previously discussed. Even continuous hospitalization is not a sufficient treatment for the most severely ill patients.

I hope you're now eager to hear which psychotropic medications have been approved by the FDA for use in pregnant women. It's a very short list. In fact, the list is still waiting for its first entry.

Nobody is eager to do research that involves giving psychotropic medications to pregnant women. Furthermore, the species that have been chosen for animal reproduction studies were selected because they are cheap to keep, and because they breed rapidly, not because their physiology is very similar to ours.

Cost considerations weigh against exposing a million rodents to therapeutic blood levels of psychotropic medications; the alternative is to expose a thousand rodents to very large doses. Not surprisingly, bunnies fed lovely fresh salads during pregnancy do better than those whose diet is largely pharmaceutical.

Given that corporate legal eagles have enormous influence on what gets published in a drug's prescribing information, you won't find much encouragement in the PDR for humane treatment of psychiatrically ill pregnant women.

Even those of us who practice in Indiana, where the malpractice situation is less obnoxious than elsewhere in the U.S., have reason to hesitate before medicating pregnant women. After all, congenital malformations are found at a base rate between two and seven per one hundred live births. The use of unapproved medications during a series of pregnancies seems likely to result in some cases of birth defects which might be attributed to the medication by parents whose guilt or anger can cause complications for themselves and for their physicians.

OTOH, it is not true that doing nothing is always preferable to an intervention that carries some risk. You can be sued as easily for acts of omission as for acts of commission, and our profession cannot pursue its stated goals without assuming some risk.

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Keys to avoiding litigation are:

  • be aware of reasonable standards of practice
  • be familiar with research findings which may lead to changes in the standards
  • provide written justification of departures from standard practices
  • cultivate trust in your patients by taking time to show your interest and concern for their welfare
  • refer patients for consultation in cases where there is above average potential for liability.

Malpractice litigation more commonly reflects a failure of empathy on the doctor's part than a failure of technique. Doctors are selected and schooled to be tough in the face of tough situations, but this appearance of toughness is out of place in the presence of a patient who's struggling to adjust to a bad outcome. Doctors who are truly compassionate may be so affected by grief and anxiety when things go out of control that they walk away when the patient most needs their presence.

It's much better for all concerned if you can stay around and let the patient see your sorrow over what's happened. You want to emphasize whatever hope remains in a difficult case, but not to the point of pretending that something's truly OK when it's obviously not.

You can say, "I'm sorry about how this turned out!" without it sounding like, "I'm sorry I botched your case!" Either statement would be better than abrupt withdrawal or some other defensive reaction.

Dr. Vivien Burt counsels her pregnant patients, in the presence of a significant other, about the risks, benefits, and alternatives of medical treatment. Then she asks the patient to write on one page all the reasons for taking the treatment, and on a second page all the reasons against taking the treatment. On the third page go the woman's decision and her justification of the decision. A copy is kept by the patient and another goes on the patient's chart.

Not only is this excellent documentation of informed consent, it's a very useful tool in counseling women who are later overcome by anxiety over having placed their baby at risk. The physiologic stress of pregnancy and severe psychiatric illness can virtually eliminate the patient's ability to recall, after the pregnancy, how bad she felt and what she was told. Seeing the details in her own handwriting is very helpful in such cases.

Concerns over gestational exposure to psychotropic medications have focused on three areas: teratogenicity, neonatal toxicity, and postnatal behavioral sequelae. Teratogenicity is of primary concern when exposure occurs during the first trimester, although the fetal brain develops throughout pregnancy and damage could occur after the first trimester.

A relatively small number of cases of first trimester exposure to antidepressants have been reported. These reports have suggested no increased risk of birth defects. Given that major depression occurs in nearly 10% of women, and that we've been freely treating these women with tricyclic antidepressants for over 30 years, there are probably millions of cases of accidental first trimester exposure. In this context, the dearth of reports suggesting teratogenicity is encouraging.

The newer antidepressants are generally less toxic for adults than are the tricyclics. The serotonergic antidepressants are thought to be relatively pure in their pharmacologic activity, and their main effect is rather similar to that of amitriptyline, which is one of the oldest antidepressants. Therefore, we would not expect the newer antidepressants to be more fetotoxic than the tricyclics. Observation, however, is better than theory.

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Prozac was the first of the new breed of antidepressant, having been introduced in this country by Eli Lilly ten years ago. It immediately became the most prescribed antidepressant in the U.S., and has probably been used by twenty million people, of whom two- thirds were likely to have been women. Lilly has maintained a worldwide pregnancy registry which includes pregnancies occurring during scientific studies as well as cases reported from naturalistic clinical settings. As of 1996, they had over 1700 cases on file, which showed no increase in birth defects, no suspicious clustering of abnormalities, and no increase in spontaneous abortions. Data for other serotonergic antidepressants are less voluminous, but no less reassuring.

With respect to perinatal complications, the picture is a bit less clear. Tricyclic antidepressants are known to cause an uncomfortable abstinence syndrome in some adults, lasting several days. The same sort of thing has been seen in infants exposed to these agents shortly before delivery. Interestingly, the long half- life of Prozac's active metabolite norfluoxetine may be advantageous when children are exposed to it immediately prior to delivery: no abstinence syndrome has been identified with Prozac in adults or in newborns.

The best long-term study of antidepressant-exposed fetuses followed 80 cases up to age seven. Compared to an unexposed control group, the exposed children showed no adverse effect on IQ, no adverse effect on language development, and no adverse effect on behavior.

Antidepressants such as Nardil and Parnate, which achieve their effects through the inhibition of monoamine oxidase, are contraindicated during pregnancy. They require dietary restriction which can compromise the expectant mother's nutritional status, they can raise or lower blood pressure, and there's a severe adverse interaction with terbutaline, which is used to suppress premature labor.

Given the known risks to mother and fetus from severe depression during pregnancy, with the absence of any data suggestive of increased risk to the fetus from exposure to antidepressants that have been in widespread use for over 30 years, I would favor use of antidepressants after appropriate counseling in selected cases. The most evidence supports use of Prozac and the tricyclic antidepressants, while MAOI antidepressants are contraindicated.

These data have application to the counseling of psychiatrically ill women who wish to become pregnant. The preponderance of the evidence is that depression is a progressive illness in many cases, with a pronounced tendency to recur under stress. Although it has long been felt appropriate to subject depressed persons to repeated trials of medication reduction, that approach does more harm than good. Reduction or discontinuation of antidepressant medication is contraindicated when there's a strong family history of depression, two or more distinct episodes of major depression, minimally- provoked episodes of major depression, onset of major depression before adulthood, or a stressful life situation in a person with a history of major depression.

While there is around 15% risk of transmission of the illness to each offspring, and the risk is doubled if both parents are affected, the prognosis of major depression with appropriate treatment is now so good that few physicians would discourage conception because of this illness.

Given the high risk of relapse and low risk of fetal damage, discontinuation of antidepressant medication in women who wish to become pregnant cannot be recommended as a routine practice. Many low-threat cases can reasonably be given a trial of dose reduction, but exposing those with severe or chronic history to such risk is inappropriate.

Electro-Convulsive Therapy (ECT) is the safest and most effective treatment for severe mood disorders, and especially so in pregnant women. The risk to the fetus is no more than the risk of brief general anesthesia.

There are some drawbacks to the use of ECT. It costs nearly $500 per treatment, and usually requires six to twelve treatments in the first few months, followed by at least one treatment monthly for maintenance. It causes acute memory problems, which are almost never persistent, but which require the patient who is getting several treatments weekly to be supervised closely by friends and relatives if the patient is not in the hospital.

The effects of ECT are rapid and dramatic: the response rate is as high as 85%, even in refractory illness. Contrary to what you may think, most people don't find ECT very unpleasant, and many prefer it to medication because of its effectiveness and freedom from daily side effects.


After delivery, things become a lot more difficult. Those of you with children have probably already noticed this!

About 80% of women have mildly depressed mood during some portion of the period between days three and twelve postpartum. This is not surprising, given the stress of labor and delivery, the enormous changes in hormone levels that occur at the end of pregnancy, and the demand for the new mother to make an instant transition from being taken care of by others to being the primary caretaker for an infant that requires almost constant attention. Sleep deprivation adds considerably to the stress of the first few months after parturition.

Ordinary postpartum blues are easily managed if enough support and assistance are available to the new mother, but the outcome is not always benign. Severe postpartum psychiatric illness is the most common complication of pregnancy, and can devastate both mother and infant.

A woman is twenty times as likely to require psychiatric hospitalization in the first month after pregnancy as in any other month of her life. Between ten and fifteen per cent of women suffer significant postpartum psychiatric illness, and the severity is often extreme. Infanticide and suicide are very real risks in this situation, and failure to thrive is the best that can be expected in an infant whose mother is psychotic. A study of 700 cases indicated that these infants do poorly for years afterward, with intellectual, behavioral, and emotional problems.

The increased risk for postpartum psychiatric illness persists for at least six months, and for as long as twenty-four months in some studies. For persons with no prior psychiatric history, the risk of severe postpartum psychiatric illness is 10%. If there's a history of prior major depression, the risk rises to 25%. For women with a history of postpartum psychiatric illness, the risk of postpartum recurrence is 50%. If the prior postpartum illness was major depression, the recurrence rate following a subsequent pregnancy is 62%. If she was psychotic during her prior postpartum illness, the risk of postpartum recurrence is 75%. If a woman has postpartum psychosis and becomes pregnant again within two years, the relapse rate is nearly 100%.

Fortunately, severe postpartum psychiatric illness is largely preventable. For example, if a woman with a prior history of postpartum major depression is started on antidepressant medication within 24 hours of delivery, the recurrence rate drops from sixty- two percent to seven percent. Prompt and vigorous treatment with medications or ECT likewise improves the outcome for other severe postpartum psychiatric illness.

Some authorities have suggested that psychotropic medications be reduced or discontinued for a week or two before the expected delivery date. They base this recommendation on scattered case reports of neonatal syndromes which have been attributed to persistence of medication effects or to withdrawal effects. These problems may occur, but they are infrequent and mild compared to the high frequency and serious consequences of perinatal relapse in the mother. I believe it's inappropriate to deprive a woman of pharmacologic treatment for a severe, persistent psychiatric illness at the very time when she's most likely to experience recurrence.

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The issues surrounding treatment of psychiatric illness in women following childbirth are considerably complicated by questions related to breast feeding. This activity is highly valued by most women and apparently quite beneficial to infants.

Breast feeding is less expensive than bottle feeding, and it supplies the infant with nucleotides and enzymes which facilitate digestion and absorption of nutrients. Breast-fed infants also receive immune factors which prevent infections, with a measurable improvement in survival. The longer-chain polyunsaturated fatty acids found in human milk are thought to promote continued development of the nervous system, which is relatively immature at birth in a human infant compared to other animals. When evaluated during the first year of school, both full-term and premature infants show enhanced intellectual development if they were breast fed. Mothers who breast feed benefit from hormonal factors which shrink the uterus, suppress ovulation, and reduce risk of breast cancer.

Of course there's no such thing as a free lunch. All psychotropic medications appear in breast milk to some degree. Furthermore, the infant's liver is relatively inadequate during the first two weeks after full-term delivery. These facts cause much tension between mothers and their doctors, and between one doctor and another.

Our increasingly fragmented and litigious system of health care delivery often requires the collaboration of doctors specializing in pediatrics, obstetrics, and psychiatry, each of whom may develop a narrow focus on some issues without due consideration of competing interests. Maximizing the welfare of both mother and infant requires complex thinking.

Since major depression is the most common postpartum illness, there are substantial data on babies exposed to antidepressants in breast milk. It appears that normal newborns exposed to tricyclic antidepressants through breast feeding rarely suffer ill effects, and rarely have detectable blood levels of parent compounds or active metabolites.

The main exception is doxepin. One eight-week-old infant became sedated while being breast fed by a mother taking doxepin, and was found to have accumulated an active metabolite of doxepin to a concentration comparable to that found in his mother's blood. In another report, a 10 week-old infant was found to have a quantifiable level of desmethyldoxepin, but there was no ill effect.

One case has been reported of an infant aged four weeks being nursed by a woman taking nortriptyline, in which the infant had a serum level about 10% of the mother's; there was no apparent effect on the baby. There are numerous case reports of infants being breast fed by women taking various tricyclic antidepressants other than doxepin, of whom none had levels high enough to be quantified, and none suffered an ill effect.

The serotonergic antidepressants have less data, and these data are mixed. Fluoxetine and sertraline have the most data in this group; both agents have active metabolites with long half lives, and both have been found in the blood of infants being nursed by mothers taking these medications.

In only one case was there a report of an adverse effect on the infant: that child developed colic which got better within a few days after breast feeding was discontinued. The problem returned when the infant was given mother's milk in a bottle. This infant's blood was found to contain levels of fluoxetine and norfluoxetine comparable to those found in the mother. The accuracy of this report has been questioned because the infant's blood was drawn only two days after resumption of nursing following three weeks of formula feeding, and the mother's milk contained an insufficient amount of medication to give rise to such high serum levels in the infant. Either there was laboratory error, or that infant maintained a very high drug level for three weeks on formula, in which case one wonders why the colic got better after only a few days back on formula.

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To summarize, women with chronic or recurrent depression may require antidepressant medication during pregnancy, which may be continued up to initiation of labor and then restarted within 24 hours thereafter. There are no compelling data against breast feeding on a tricyclic antidepressant other than doxepin. Serotonergic antidepressants remain controversial because they more commonly generate substantial serum levels, even though there's only one report of a possible adverse effect.

It would be reasonable to consider reducing the doses of serotonergic antidepressants in pregnant and lactating women with augmentation by a tricyclic antidepressant other than doxepin, thereby reducing fetal and infant exposure to the newer compound while maintaining maternal health. This approach can be criticized because it involves exposure to two agents, but lower doses of both agents can be used, so the side effects may be less.

The situation I have just described calls for extensive discussion of the risks, benefits, and alternatives. While we can't promise safety, the risk of the mother going off medication so she can breast feed is unacceptably high, and this should be clearly communicated. Careful monitoring of the infant's development is mandatory, and it's reasonable to obtain a serum level if the baby's behavior changes substantially from baseline. Serum levels may also be indicated to alleviate anxiety in parents and physicians. After ten weeks of age, infants can metabolize drugs more than twice as fast as adults, so the risk of accumulation of toxic metabolites is very low.

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When it comes to bipolar disorder, the situation becomes considerably more troublesome. Bipolar disorder is a more dangerous illness to the mother and fetus, with a very high rate of relapse when medication is discontinued. Tricyclic antidepressants are known to make bipolar disorder worse, sometimes very much worse. Serotonergic antidepressants appear to be better tolerated, but have some risk of precipitating mania. Almost all the treatment options for mania are unattractive during pregnancy.

There are four anticonvulsants with antimanic properties. Of these, carbamazepine and valproate are known teratogens. Gabapentin and lamotrigine are too new to have much data.

Lithium is the oldest known mood stabilizer. It is also a known teratogen, although the risks are manageable. Initial reports of lithium's teratogenicity came from a registry that attracted mostly problem reports and lead to substantial overestimation of the risks.

First trimester exposure to lithium causes Ebstein's anomaly, which is almost always lethal. The rate is now thought to be about one case for every 1000 exposures. This low rate of a serious outcome must be compared with the 50% relapse rate for bipolar disorder after 20 weeks off lithium. A bipolar in full relapse presents serious dangers to self and others, much more so during pregnancy. Only in the mildest cases should lithium withdrawal be considered in the first trimester.

When first-trimester exposure to lithium occurs, a level II ultrasound should be performed between 16 and 18 weeks gestation to rule out Ebstein's anomaly, which can be diagnosed reliably by this method.

Lithium doses must often be higher during pregnancy due to increased renal clearance. Maintenance of hydration during pregnancy and delivery are particularly important for pregnant women on lithium. Lithium-induced diabetes insipidus in the fetus can occasionally cause maternal respiratory embarassment due to expansion of amiotic fluid.

Bipolar disorder is the most strongly inherited illness in psychiatry. With one affected parent, the morbid risk is 33%, and with two affected parents, around 67% become ill. Any family history of bipolar disorder confers significant increased risk. Bipolar disorder is also a lot more difficult to control than unipolar depression, and more hazardous to all concerned. These facts must be made known to any woman of childbearing age who has any family or personal history of bipolar disorder, either in herself or in her partner.

Lithium is present in breast milk in rather high concentrations, so breast feeding is not recommended for mothers who must take lithium. Bipolar disorder has a high risk of catastrophic relapse, making it inappropriate to suggest stopping the lithium as an alternative to stopping the breast feeding.

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Psychosis during pregnancy is a dire situation for mother and fetus. Psychotic persons will not follow any prescribed regimen, and they are seriously deficient in basic self-care, self- protection, and common-sense restraints on behavior. Such cases often require involuntary hospitalization for diagnostic studies and initiation of pharmacologic treatment.

In cases where a diagnosis of schizophrenia has been established, there's usually no alternative to maintenance treatment with antipsychotic medication. Intermittent medical treatment of schizophrenia is unsafe because full or partial relapse is inevitable when adequate levels of antipsychotic medication are not maintained throughout the patient's life. Relapse commonly triggers a major crisis which places the patient, the fetus, and other close contacts at risk for serious injury or death.

The oldest antipsychotic medications are known as "low-potency" neuroleptics because the effective dose is on the order of 1000 mg daily. These agents have prominent anticholinergic and antiadrenergic side effects. They used to be given to nonpsychotic pregnant women in low doses to treat hyperemesis gravidarum. Data from these cases suggest that such exposure in the first trimester increases the rate of birth defects by about four cases per thousand.

The second generation antipsychotic medications are known as "high- potency" neuroleptics, because they are effective in daily doses under 100 mg. These agents are much less likely to cause anticholinergic and antiadrenergic side effects, but they can cause imbalance in the extrapyramidal motor system leading to stiffness and rigidity of voluntary muscles. There is no evidence linking these agents with birth defects, and they've been around nearly thirty years. Continuous administration throughout pregnancy is preferred, because intermittent administration carries a high risk of relapse and requires much larger doses, leading to increased fetal exposure and uncomfortable muscular side effects.

Most of the medications we use to relieve muscular side effects in persons taking neuroleptics are suspected teratogens; this includes benztropine, trihexyphenidyl, and amantadine. The safest agent for managing extrapyramidal syndromes in pregnant women appears to be diphenhydramine.

The newest group of antipsychotic medications includes clozapine, risperidone, and olanzapine. We don't yet have enough data on these agents to be reassured about fetal risk.

Current data favor using the lowest effective dose of a high- potency neuroleptic on a continuous basis throughout pregnancy for schizophrenic women. The most data in this regard are for haloperidol, which comes in a long-acting injectable form that has a half life of nearly a month and keeps serum levels as low as possible. Since medication noncompliance is a major problem in the maintenance treatment of schizophrenia, the long-acting injectable medications are strongly preferred.

Children of schizophrenic mothers are at high risk for poor outcome. There's a high rate of perinatal death, fetal malformations, and postnatal difficulties with intellectual and social development. Schizophrenia is as strongly inherited as major depression, and the consequences are so devastating as to make genetic counseling obligatory.

Those offspring who don't turn out schizophrenic have a high rate of other significant psychiatric illness. Few schizophrenic women can meet a normal child's needs for affection, stability of environment, and consistent discipline appropriate to the child's developmental level. Compliance with most forms of birth control has been poor among chronic schizophrenics; those forms of birth control which don't require the mother's consistent compliance are to be preferred despite their drawbacks.

There's little data on the safety of antipsychotic agents in breast feeding. Prudence would suggest against the practice, given what we know about the effects of antipsychotic agents on the adult brain. Stopping treatment to allow breast feeding would not be advisable in any chronic psychosis, because the risk of relapse is too high and psychotic relapse can be an irremediable disaster.

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The situation regarding use of benzodiazepine tranquilizers in pregnancy and lactation is very unclear. The best review I was able to find [McElhatten in references] indicates that diazepam accumulates in the fetus to double or triple the maternal level. Some studies have shown increased risk for oral cleft anomalies when diazepam is given in the first trimester, while others have not. Diazepam use during labor has been associated with low APGAR scores, apnea, hypotonia, poor feeding, and loss of thermoregulation. Diazepam and desmethyldiazepam were found in neonatal serum up to a week after maternal exposure. Exposure to diazepam in breast milk leads to ingestion by the infant of a dose about 5% of mother's dose on a weight adjusted basis; neonates can't clear diazepam very well in their first week, so infants exposed to diazepam in mother's milk should be observed for sedation.

Lorazepam crosses the placenta more slowly than diazepam and is metabolized more rapidly. Several studies have indicated a lack of accumulation in the fetus above maternal blood levels. There have been no reports of increased malformations in babies exposed to lorazepam. One study indicated rapid clearance of lorazepam by neonates, essentially complete within 24 hours. Apgar scores in this study were unimpaired, although another study found that when lorazepam was used during labor, the babies were often impaired in a manner similar to those whose mothers were exposed to diazepam during labor. Babies whose mothers take lorazepam and breast feed provide a clinically insignificant dose to the infant unless they ingest unusually high doses.

The situation for other benzodiazepines is intermediate between the diazepam case and the lorazepam case. In general, benzodiazepines with shorter half-lives and fewer active metabolites seem to be less toxic to the fetus and neonate. Fortunately, benzodiazepine use is rarely essential during pregnancy. For women who may become pregnant while taking a benzodiazepine, lorazepam would be preferred.

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In summary, we know a great deal more now than we did a few years ago regarding indications and contraindications for psychotropic medications in pregnant and lactating women.

Cautious optimism and thoughtful therapeutic activism are appropriate when severe mood disorders make their appearance perinatally.

Postpartum psychiatric illness is particularly common, severe, and recurrent, but can often be managed without undue disruption of bonding.

Breast feeding while taking tricyclic antidepressants is not contraindicated, and the limited data regarding the newer antidepressants is not particularly adverse.

Bipolar disorder and schizophrenia continue to present dilemmas which warrant specialty consultation in every case, the more so in conjunction with pregnancy.


Copyright 1999 John M Rathbun MD

Reviewed by athealth on February 6, 2014.

Personality Disorders

Treatment of Personality Disorders in an Era of Limited Resources

By Eric M. Plakun, MD

Our field is at a moment of great excitement, opportunity and risk. Faced with the reality that resources for treatment have limits, a revolution in funding of mental health benefits has begun. In order to contain costs new strategies are emerging, like capitation, case rates, case management and utilization review, that closely limit or oversee treatment provided and/or ask providers to bear the financial risk of treatment. The attention of psychiatrists has been powerfully drawn to the financial arena, where the introduction of close management of benefits has introduced a sometimes dizzying array of hoops through which a clinician must leap, dragging the patient behind, in order to persuade a case manager or utilization reviewer that a particular treatment is indicated. Quality is in danger of falling by the wayside in favor of cost containment as the watchword by which clinicians practice their art.

The impact of managed care on psychiatry has the potential for positive effects through better resource management, but the turning of psychiatrists' attention away from quality to cost containment is worrisome if it means only minimal treatment will be authorized for patients. A recent Rand Corporation study of prepaid versus fee for service mental health benefits showed that depressed outpatients in prepaid plans were more likely to acquire new limitations in role or in their physical functioning than those treated in a fee for service model (1). The authors suggest that the presence of Axis II disorders may account for the finding. The shift to new reimbursement strategies is here to stay, but we ought to pay attention to the clinical consequences. One danger, which may explain some of the Rand Corporation study findings, is the way many of the new reimbursement strategies leave the patient out of the terribly important negotiations around the treatment plan and its funding. The crucial clinical and financial dialogues about treatment have increasingly been reassigned to the doctor or other clinician and case manager, without the patient's true participation. This has the potential to leave the patient in the position of being a passive recipient of treatment, rather than an active agent in it (2).

This may work fine for the treatment of medical or surgical problems, and may even work reasonably well for treatment of a number of Axis I psychiatric disorders uncomplicated by Axis II comorbidity, like major depression, when a defined syndrome is well treated with medication and/or psychotherapy. However, leaving the patient out of the negotiation process is ill advised in the treatment of Axis I disorders comorbid with personality disorders or in the treatment of pure personality disorders. After all, by definition personality disorders reflect chronic impairment in adaptive functioning in social, interpersonal and/or occupational roles. They are manifest by repeated and enduring patterns of behavior that often induce marked consternation in treaters. This consternation is usefully understood as countertransference. For the most part, personality disorders do not respond well to treatment plans based primarily on medication (3). In fact, personality disorders can be understood as involving a mixture of maladaptive traits into the identity of the patient, so that the borderline patient's impulsivity or rage proneness or fear of abandonment can scarcely be separated from the rest of their personality, unlike the depressed patient's neurovegetative symptoms. As a result, it is ill advised to leave a patient with a personality disorder out of the dialogue about treatment or to spare them from experiencing the financial tension to provide treatment within the limits of available resources, because one clear goal of treatment for these patients is enhancement of the capacity to adapt better to the reality of resource limitation.

Understanding the Clinical/Financial Interface

This point of view suggests that the most appropriate treatment approach to personality disorder patients includes interpretation of the meaning of maladaptive behaviors within a collaborative therapeutic alliance that is part of a multidisciplinary treatment approach. Certain psychodynamic concepts are crucial to understanding and working with these patients. These include the concepts of countertransference, mentioned above, and of enactment, a modern reworking of Freud's "repetition compulsion." Personality disorder patients constantly repeat and reenact scenarios from their past which reflect their core issues, as when the borderline patient with a history of abuse repeatedly experiences revictimization in the present, including, especially importantly, in the transference. The interpretation of the meaning of these transference enactments and of the accompanying countertransference responses is central to the clinical approach to personality disorder pati ents described herein, regardless of whether the treatment is of long or short duration. Treatment is a collaborative endeavor with a patient who is an active agent, with responsibility for utilizing limited resources to improve his or her capacity to adapt to reality.

It is not often easy to persuade case managers in managed care companies that personality disorder patients are worth treating. The least sophisticated points of view regard borderline and other personality disorder patients as if they were willfully choosing to be ill and could straighten out any time, or as chronic and hopeless. A more enlightened view recognizes the suffering and disability of these patients, their 5 to 10% lifetime suicide risk (4, 5) and the reasons for therapeutic optimism (4, 6-8). Clinicians must carefully steer their way through the numerous pitfalls in treatment of personality disorders in an era of resource limitation. Well meaning clinicians may unhelpfully join a patient in projecting blame onto a payor (whether parent, insurer, HMO or case manager) as if resource limitation should not exist. Other clinicians may abdicate their therapeutic role by projecting blame onto the patient for engaging in recurrently maladaptive behavior (i.e., for having a personality disorder at all) instead of getting better within the time frame "authorized." Finally, other clinicians are in danger of blaming themselves for not having a quick fix for chronically maladaptive patterns, feeling frustrated, guilty and defeated. As a result, a treatment plan may be developed which omits the personality disorder altogether. The remainder of this column describes a strategy developed at the Austin Riggs Center for focusing on the resource limitation as an opportunity for new learning and for a patient's better adaptation to reality.

The Rate Review Committee

At the Austin Riggs Center, an up to date continuum of psychiatric treatment from inpatient through outpatient programs that specializes in psychodynamically based work with treatment resistant patients, a clinical/financial interface group called the rate review committee was formed in 1991. This group is composed of the Chief Financial Officer (CFO), the Utilization Review Coordinator, the Clinical Director (a psychiatrist with an internal focus,) and the Director of Admissions (a psychiatrist with an external boundary focus.) The task of this group is to define the clinical issues in patients' resource limitations and to help therapists bring these issues into the individual therapy through interpretation. This task is achieved by finding a way to include the patient as an active agent who feels the tension between his or her need for treatment and the limitation of resources. The intent is to provide patients an opportunity to enhance their adaptation to reality. When the tension over resource limitation is left with the provider or, for that matter, with the payor, the patient has been abandoned and put in a passive position which does nothing to enhance growth or adaptation. The functioning of the rate review committee is best illustrated by the specific clinical examples which follow:

Mr. A, a 25 year old man with a mixed personality disorder with narcissistic and dependent traits and a generalized anxiety disorder, was admitted to a thirty day treatment and evaluation program at Riggs because of overwhelming anxiety and a collapse of the ability to care for himself. This man had been the only child of an intrusively overprotective mother, who anticipated his every need, and a paranoid father, who had warned the patient not to trust anyone. The patient's father died when Mr. A was quite young. Mr. A was bright, earning bachelors and graduate degrees. As if in reaction to his mother's overprotectiveness, although born on one coast, Mr. A attended college on the other and graduate school overseas. Mr. A earned exciting overseas job opportunities, but the same pattern kept unfolding in each job. After a period of good functioning and success he would suddenly and inexplicably become overwhelmed with anxiety, then become unable to meet his own bodily needs, including forgetting to eat or use the bathroom, spending days prostrate on the floor of his apartment. When several trials of outpatient treatment and numerous medications proved of no help, Mr. A sought admission to Riggs. The admitting doctor pointed out that the patient's symptoms of anxiety and inability to meet his own bodily needs for nourishment, sleep and excretion were like a cry for his mother once again to be there anticipating his every need. At the time of admission Mr. A was told that, when insurance benefits ended, he would likely again find it difficult to meet his own needs and might expect others to meet them for him. Mr. A had trouble grasping any significance in this prediction.

After the patient's month of insurance benefits was exhausted he had made gains, but wanted to stay in treatment for another two months. Mr. A and his therapist asked the rate review committee to provide a fee reduction for Mr. A's mother, who would pay for additional treatment. Mr. A's therapist felt that he was making progress and that this plan was clinically appropriate. The CFO, concerned about the census and eager to provide an environment in which patients could continue in longer term treatment through fee reductions, was inclined to grant the request. In the rate review committee, though, a clinician member pointed out the missed opportunity for interpretation and improvement in adaptive functioning that would come from simply granting the request. By asking the hospital to grant a fee reduction to his mother so that she could pay for his continued treatment, Mr. A was reenacting the lifelong pattern of inviting his mother's overprotective but inevitably infantilizing rescues, which deprived him of the experience of struggling to meet his own needs. Further, not only would his mother be spending some of her retirement savings to meet his needs, but the hospital would also be sacrificing for Mr. A by offering a fee reduction. The admitting doctor's prediction had come true.

It was suggested to the therapist that this be interpreted to the patient. Mr. A was reminded of the admission prediction and was advised to step down to a less expensive program that required more autonomous functioning as a way of continuing treatment, while preserving some of his mother's resources. The hospital offered a modest fee reduction appropriate to the mother's financial status. As part of the package, the patient was expected to get a job in order to contribute toward the cost of treatment. Although he initially protested that his mother owed him more because of bad parenting, Mr. A was able to hear the interpretation. He made the appropriate moves, and found and held a job which allowed him to be an active participant in his treatment, rather than simply blaming his mother for her overprotectiveness, while demanding that she continue to meet his needs. It is now more than two years since Mr. A was discharged. He is working, self-supporting and no longer in treatment.

Ms. B was a 52 year old divorced woman with recurrent major depression, a borderline personality disorder and a history of severe and recurrent sexual abuse. As a young child she was sexually abused by a clergyman and a family member. Her mother did not believe Ms. B when she reported this. The patient married quite young as a means of escape from home. Her husband was sexually demeaning and physically and emotionally abusive. On one occasion early in the marriage the patient was raped, then told her husband, who beat her up, protesting that it must have happened because she wanted it to. The patient eventually left the marriage and completed college. She was able to function marginally as a human service worker in part because of an enduring, stable relationship with a lover. When the patient developed a physical illness, the relationship with her lover began to fail. Ms. B began a spiral of self-destructive and suicidal behavior with multiple short-term hospitalizations. Eventually Ms. B made a highl y lethal suicide attempt by an overdose in the woods, surviving only because she was found accidentally by hunters. Ms. B was referred to Riggs for treatment.

In addition to a borderline personality disorder, a post-traumatic stress disorder and recurrent major depression, Ms. B manifested brief paranoid delusional episodes. She was particularly fearful of men and had difficulty interacting with male patients or providers. Ms. B's treatment was followed closely by an enlightened case management company which supported treatment at the Center for a number of months as the patient made gradual gains, but with frequent setbacks heralded by transient paranoid episodes. After extended treatment, though, a new case manager imposed a retroactive denial of months of benefits and insisted on discharge. The Center's CFO was prepared to recommend discharge, feeling that the treatment had unraveled financially. The therapist felt strongly that the patient was making gains, urging the rate review committee to offer free treatment because the patient would be unable to function in outpatient treatment alone. The Utilization Revie w Coordinator noted the patient met criteria for continued treatment in at least a partial or residential level of care.

In rate review committee discussions it was noted that Ms. B was being treated as if too fragile to be an active agent in dealing with her predicament. It was recommended that the therapist include the patient in discussions, treating her as someone who had the ultimate stake in the resolution of this financial crisis in the treatment. It was also noted to the trainee therapist that the sudden and arbitrary termination of benefits was another instance of abuse of the patient. When the therapist reframed and interpreted the situation as the patient's predicament, Ms. B spontaneously noted that this sudden retroactive denial felt like the kind of abuse that she was determined not to put up with again. Ms. B felt she had gained enough in treatment to see the way she repeatedly passively submitted to revictimization, and was determined not to let this happen again. Ms. B decided that, if necessary, she would hire an attorney to fight the denial of benefits. With the support and help of the rate review comm ittee, a detailed appeal letter was written to the case management company by the therapist and patient. The letter presented a careful explanation to the case management company of how the sudden retroactive denial of benefits was inevitably and realistically experienced by the patient as another episode of abuse, enacting her core dynamic paradigm. During the extended appeal process the rate review committee agreed to carry the financial risk of Ms. B's ongoing treatment because she had no resources beyond her insurance. The case management company psychiatrist who reviewed the appeal agreed with the Center's treatment plan and reversed the retroactive denial of benefits. More than a year later, Ms. B has been discharged and is functioning well in outpatient treatment still supported by the case management company.


These examples illustrate clinical instances in which the rate review committee was able to identify the latent clinical enactment buried in the manifest financial issues that emerged in each case. In each case an effort was made to bring the patient into the process in a way that [1] encourages the patient to experience the tension of the financial difficulty, while [2] interpreting the underlying enactment in a way that helps the patient discover meaning in his or her life situation, take ownership of the treatment, exercise authority and adapt better to reality. The rate review committee approach need not be applied by a committee, although this may be helpful within institutions. Our experience suggests that once introduced to the concepts involved, most clinicians can develop the capacity to include this approach in their work with patients.

The meaning of issues buried in the clinical financial interface is too important to allow to become invisible in a changing health care reimbursement system. We must not let patients be excluded from the opportunity to grapple with the way issues related to resource limitation may represent enactments of underlying clinical issues. Use of the approach described here with outpatients, as well as with patients in residential or hospital settings, offers them an opportunity to grapple with the determinants of these problems in a way that can lead to resolution, growth and better adaptation to reality.


  1. Rogers, W.H., Wells, K.B., Meredith L.S., Sturm, R. And Burnam, A. (1993). Outcomes for adult outpatients with depression under prepaid or fee-for-service financing. Archives of General Psychiatry, 50, 517-525.
  2. Shapiro, E.R. (In press). The boundaries are changing: Renegotiating the therapeutic frame. In Shapiro, E.R. (Ed.), The Inner World and the Outer World: Psychoanalytic Perspectives. New Haven: Yale University Press.
  3. Gunderson, J.G. (1986). Pharmacotherapy for patients with borderline personality disorder. Archives of General Psychiatry, 43, 698-700.
  4. Stone, M.H., Hurt, S.W., Stone, D.K. (1987). The PI 500: Long-term follow-up of borderline inpatients meeting DSM-III criteria, I: Global outcome. Journal of Personality Disorders, 1, 291-298.
  5. Paris, J., Brown, R., Nowlis, D. (1987). Long-term follow-up of borderline patients in a general hospital. Comprehensive Psychiatry, 28, 530-535.
  6. McGlashan, T.H. (1985). The prediction of outcome in borderline personality disorder: Part V of the Chestnut Lodge follow-up study. In McGlashan, T.H. (Ed.), The Borderline: Current Empirical Research. Washington, D.C.: American Psychiatric Press, 63-98.
  7. Plakun, E.M.(1989). Narcissistic Personality Disorder: A validity study and comparison to borderline personality disorder. Psychiatric Clinics of North America, 12, 603-620.
  8. Plakun, E.M. (1991). Prediction of outcome in borderline personality disorders. Journal of Personality Disorders, 5, 93-101. This article is published with permission from Austin Riggs Center, Psychiatric Services

To contact:

Eric M. Plakun, MD

Austin Riggs Center

P.O. Box 962

25 Main Street

Stockbridge, MA 01262

(413) 298-5511

FAX (413) 298-4020

For admissions: 1-800-51-RiGGS (1-800-517-4447)

Reviewed by athealth on February 6, 2014.


What is a phobia?

A phobia is a fear which is caused by a specific object or situation. The fear can be caused by the actual presence of or by the anticipation of the presence of that object or situation. Anxiety, triggered by the fear, can approach the intensity of panic.

The following is a list of the most common phobias

  • Achluophobia - fear of being in darkness
  • Acrophobia - fear of heights
  • Agoraphobia - fear of open spaces or fear of leaving home
  • Claustrophobia - fear of being in closed spaces
  • Demophobia - fear of being in crowded places
  • Mysophobia - fear of germs or dirt
  • Social phobia - fear of being around unfamiliar people in social situations
  • Xenophobia - fear of strangers

Other phobias include:

  • Fear of public speaking
  • Fear of insects
  • Fear of certain animals
  • Fear of flying on planes
  • Fear of the sight of blood
  • Fear of certain foods
  • Fear of using public restrooms
  • Fear of the dentist

What characteristics are associated with phobias?

Phobias cause characteristics of anxiety. To avoid anxiety, people with phobias try to avoid any situation they know would cause them to feel anxious and/or which might lead to a panic attack.

Are there genetic factors associated with phobias?

Yes, there are genetic factors associated with phobias. Many people who have phobias have relatives with similar phobias or symptoms such as fears and/or a tendency to avoid certain situations.

Do phobias affect males, females, or both?

In the United States more women than men suffer from phobias.

At what age do phobias appear?

Phobias frequently begin in childhood. A toddler who throws tantrums by crying and clinging to his/her parents may have a phobia. Personal trauma and stress can sometimes trigger a phobia. For instance, a person who was once trapped in a small room might later become frightened of closed spaces.

How common are phobias?

More than ten percent (10%) of the population in the United States has some form of phobia. It is the most common mental disorder in the United States.

How are phobias diagnosed?

Phobias are usually diagnosed when people find that their schoolwork, job, or personal relationships are in trouble because of their heightened fears, and they seek professional help. However, phobias are often not diagnosed because people simply learn to avoid situations which cause them anxiety.

How are phobias treated?

The treatment of phobias usually has a behavior therapy focus. In the safety of the therapeutic situation, people with phobias are gradually introduced into the very situation that normally causes them anxiety. They learn that they can control their anxiety while gaining greater and greater exposure to their phobic situation. Cognitive or behavior therapy can be very effective when used in conjunction with relaxation training.

Medication is sometimes prescribed for people with phobias to help them control their anxiety. Some people do well on medications such as monoamine oxidase inhibitors (MAOIs) or imipramine. Also, mild tranquilizers, like benzodiazepines, can be effective in helping people control the anxiety caused by their phobia.

What happens to someone with a phobia?

The course of a phobia may be quite varied. Some people have mild phobias which can be easily treated and which last only a short time. Others have severe anxieties, and they suffer from their phobias for many years. Chronic phobias can cause major disruptions in school, at work, and/or with personal relationships.

What can people do if they need help?

If you, a friend, or a family member would like more information and you have a therapist or a physician, please discuss your concerns with that person.

Reviewed by athealth on February 6, 2014.

Planning for Long Term Care

Most older people are independent. But later in life--especially in the 80s and 90s--you or someone you know may begin to need help with everyday activities like shopping, cooking, walking, or bathing. For many people, regular or "long-term" care may mean a little help from family and friends or regular visits by a home health aide. For others who are frail or suffering from dementia, long-term care may involve moving to a place where professional care is available 24 hours a day.

The good news is that families have more choices in long-term care than ever before. Today, services can provide the needed help while letting you stay active and connected with family, friends, and neighbors. These services include home health care, adult day care, and transportation services for frail seniors as well as foster care, assisted living and retirement communities, and traditional nursing homes.

Planning Ahead

The key to successful long-term care is planning. You or your family may need to make a decision in a hurry, often after an unexpected emergency like a broken hip. Be prepared by getting information ahead of time. That way, you will know what's available and affordable before there is a crisis. To start:

  • If you are having trouble with things like bathing, managing finances, or driving, talk with your doctor and other health care professionals about your need for help. A special type of social worker, called a geriatric case manager, can help you and your family through this complex time by developing a long-term care plan and locating appropriate services.

Geriatric case managers can be particularly helpful when family members live a long distance apart.

  • If you are helping a family member or friend, talk about the best way to meet his or her needs. If you need help for yourself, talk with your family. For instance, if you are having trouble making your meals, do you want meals delivered by a local program or would you like family and friends to help? Would you let a paid aide in your home? If you don't drive, would you like a friend or bus service to take you to the doctor or other appointments?
  • Learn about the types of services and care in your community. Doctors, social workers, and others who see you for regular care may have suggestions. The Area Agency on Aging and local and state offices of aging or social services can give you lists of adult day care centers, meal programs, companion programs, transportation services, or places providing more care.
  • Find out how you may--or may not--be covered by insurance. The Federal Medicare program and private "Medigap" insurance only offer short-term home health and nursing home benefits. Contact your state-run Medicaid program about long-term nursing home coverage for people with limited means. Also, your state's insurance commission can tell you more about private long-term care policies and offer tips on how to buy this complicated insurance. These agencies are listed in your telephone book, under "Government."

    Be aware that figuring out care for the long term isn't easy. Needs may change over time. What worked 6 months ago may no longer apply. Insurance coverage is often very limited and families may have problems paying for services. In addition, rules about programs and benefits change, and it's hard to know from one year to the next what may be available.

    A Need for More Care

    At some point, support from family, friends, or local meal or transportation programs may not be enough. If you need a lot of help with everyday activities, you may need to move to a place where care is available around-the-clock. There are two types of residential care:

    • Assisted living arrangements are available in large apartment or hotel-like buildings or can be set up as "board and care" homes for a small number of people. They offer different levels of care, but often include meals, recreation, security, and help with bathing, dressing, medication, and housekeeping.
    • Skilled nursing facilities--"nursing homes"--provide 24-hour services and supervision. They provide medical care and rehabilitation for residents, who are mostly very frail or suffer from the later stages of dementia.Sometimes, health care providers offer different levels of care at one site. These "continuing care communities" often locate an assisted living facility next to a nursing home so that people can move from one type of care to another if necessary. Several offer programs for couples, trying to meet needs when one spouse is doing well but the other has become disabled.
  • Finding the Right Place

    To find the residential program that's best for you:

    • Ask Questions. Find out about specific facilities in your area. Doctors, friends and relatives, local hospital discharge planners and social workers, and religious organizations can help. Your state's Office of the Long-Term Care Ombudsman has information about specific nursing homes and can let you know whether there have been problems at a particular home. Other types of residential arrangements, like "board and care" homes, do not follow the same Federal, state, or local licensing requirements or regulations as nursing homes. Talk to people in your community or local social service agencies to find out which facilities seem to be well run.
    • Call. Contact the places that interest you. Ask basic questions about vacancies, number of residents, costs and method of payment, and participation in Medicare and Medicaid. Also think about what's important to you, such as transportation, meals, housekeeping, activities, special units for Alzheimer's disease, or medication policies.
    • Visit. When you find a place that seems right, go talk to the staff, residents, and, if possible, family members of residents. Set up an appointment, but also go unannounced and at different times of the day. See if the staff treats residents with respect and tries to meet the needs of each person. Check if the building is clean and safe. Are residents restrained in any way? Are social activities and exercise programs offered--and enjoyed? Do residents have personal privacy? Is the facility secure for people and their belongings? Eat a meal there to see if you like the food.
    • Understand. Once you have made a choice, be sure you understand the facility's contract and financial agreement. It's a good idea to have a lawyer look them over before you sign.
    • A Smooth TransitionMoving from home to a long-term care facility or nursing home is a big change. It affects the whole family. Some facilities or community groups have a social worker who can help you prepare for the change. Allow some time to adjust after the move has taken place.
    • Regular visits by family and friends are important. They can be reassuring and comforting. Visits are necessary, too, for keeping an eye on the care that is being given.


    The following organizations and agencies can provide information about assistance and long-term care:

    • The Eldercare Locator
    • The Nursing Home Information Service
      National Council of Senior Citizens
      8403 Colesville Road, Suite 1200
      Silver Spring, MD 20910
    • The Health Care Financing Administration
      "Guide to Choosing a Nursing Home"
      "Guide to Health Insurance for People with Medicare."
    • Office of the Long-Term Care Ombudsman
      National Association of State Units on Aging

    Other sources of information include:

    • The American Association of Homes and Services for the Aging
      901 E Street, N.W., Suite 500
      Washington, D.C. 20004-2011
    • The Assisted Living Federation of America
      Suite 400, 10300 Eaton Place
      Fairfax, VA 22030
    • The American Health Care Association
      1201 L Street, N.W.
      Washington D.C. 20005
    • The National Citizens' Coalition for Nursing Home Reform
      Suite 202, 1424 16th Street, N.W.
      Washington, D.C. 20036-2211
    • National Institute on Aging
      Information Center
      P.O. Box 8057
      Gaithersburg, MD
      1-800-222-4225 (TTY)
    • Alzheimer's Disease Education and Referral (ADEAR) Center
      P.O. Box 8250
      Silver Spring, MD 20907-8250


    National Institute on Aging

    Reviewed by athealth on February 6, 2014.

Positive Discipline

How do young children learn self-control, self-help, ways to get along with others, and family and school procedures? Such learning occurs when parents and teachers of infants, toddlers, or preschoolers are continuously involved in setting limits, encouraging desired behaviors, and making decisions about managing children.

When making these decisions, caregivers often ask themselves these questions: Am I disciplining in a way that hurts or helps this child's self-esteem? Will my discipline help the child develop self-control? This digest suggests methods and language that can be used in handling common situations involving young children.

Methods of Discipline that Promote Self Worth

    • Show that you recognize and accept the reason the child is doing what, in your judgment, is the wrong thing:
      • "You want to play with the truck but..."
      • "You want me to stay with you but..."

      This validates the legitimacy of the child's desires and illustrates that you are an understanding person. It also is honest from the outset: The adult is wiser, in charge, not afraid to be the leader, and occasionally has priorities other than those of the child.

    • State the "but":
      • "You want to play with the truck, but Jerisa is using it right now."
      • "You want me to stay with you, but right now I need to (go out, help Jill, serve lunch, etc.)."

      This lets the child know that others have needs, too. It teaches perspective taking and may lead the child to develop the ability to put himself in other people's shoes. It will also gain you the child's respect, for it shows you are fair. And it will make the child feel safe; you are able to keep him safe.

    • Offer a solution:
      • "Soon you can play with the truck."

      One-year-olds can begin to understand "just a minute" and will wait patiently if we always follow through 60 seconds later. Two- and three-year-olds can learn to understand, "I'll tell you when it's your turn," if we always follow through within two or three minutes. This helps children learn how to delay gratification but does not thwart their short-term understanding of time.

    • Say something indicating your confidence in the child's ability and willingness to learn:
      • "When you get older, I know you will (whatever it is you expect)."
      • "Next time you can (restate what is expected in a positive manner)."

      This affirms your faith in the child, lets her know that you assume she has the capacity to grow and mature, and transmits your belief in her good intentions.

    • After firmly stating what is not to be done, demonstrate how we do it, or a better way:
      • "We don't hit. Pat my face gently." (Gently stroke).
      • "Puzzle pieces are not for throwing. Let's put them in their places together." (Offer help).

      This sets firm limits, yet helps the child feel that you two are a team, not enemies.

    • Distract by redirecting the child to something that is similar but OK. Carry or lead the child by the hand, saying,
      • "That's the gerbil's paper. Here's your paper."
      • "Peter needs that toy. Here's a toy for you."

      This endorses the child's right to choose what she will do, yet begins to teach that others have rights, too.

    • Avoid accusation. Even with babies, communicate in respectful tones and words. This prevents a lowering of the child's self -image and promotes his tendency to cooperate.For every no, offer two acceptable choices:
      • "No! Rosie cannot bite Esther. Rosie can bite the rubber duck or the cracker."
      • "No, Jackie. That book is for teachers. You can have this book or this book."

      This encourages the child's independence and emerging decision-making skills, but sets boundaries. Children should never be allowed to hurt each other. It's bad for the self-image of the one who hurts and the one who is hurt.

    • If children have enough language, help them express their feelings, including anger, and their wishes. Help them think about alternatives and solutions to problems. Adults should never fear children's anger:
      • "You're mad at me because you're so tired. It's hard to feel loving when you need to sleep. When you wake up, I think you'll feel more friendly."
      • "You feel angry because I won't let you have candy. I will let you choose a banana or an apple. Which do you want?"

      This encourages characteristics we want to see emerge in children, such as awareness of feelings and reasonable assertiveness, and gives children tools for solving problems without unpleasant scenes.

  • Establish firm limits and standards as needed. Until a child is 1 1/2 or almost 2 years old, adults are completely responsible for his safety and comfort, and for creating the conditions that encourage good behavior. After this age, while adults are still responsible for the child's safety, they increasingly, though extremely gradually, begin to transfer responsibility for behaving acceptably to the child. They start expecting the child to become aware of others' feelings. They begin to expect the child to think simple cause/effect thoughts (provided the child is guided quietly through the thinking process). This is teaching the rudiments of self-discipline.
  • To avoid confusion when talking to very young children, give clear, simple directions in a firm, friendly voice. This will ensure that children are not overwhelmed with a blizzard of words and refuse to comply as a result.

Remember that the job of a toddler, and to some extent the job of all young children, is to taste, touch, smell, squeeze, tote, poke, pour, sort, explore, and test. At times toddlers are greedy, at times grandiose. They do not share well; they need time to experience ownership before they are expected to share. They need to assert themselves ("No," "I can't," "I won't," and "Do it myself"). They need to separate to a degree from their parents, that is, to individuate. One way they do this is to say no and not to do what is asked; another is to do what is not wanted. If adults understand children in this age range, they will create circumstances and develop attitudes that permit and promote development. Self discipline is better learned through guidance than through punishment. It's better learned through a "We are a team, I am the leader, it's my job to help you grow up" approach than through a "me against you" approach.

Creating a Positive Climate Promotes Self Discipline

Creating a positive climate for the very young involves:

  • Spending lots of leisurely time with an infant or child;
  • Sharing important activities and meaningful play;
  • Listening and answering as an equal, not as an instructor (for example, using labeling words when a toddler points inquiringly toward something, or discussing whatever topic the 2-year-old is trying to tell you about);
  • Complimenting the child's efforts: "William is feeding himself!" "Juana is putting on her shoe!" (even if what you are seeing is only clumsy stabs in the right direction); and
  • Smiling, touching, caressing, kissing, cuddling, holding, rocking, hugging.

Harmful, Negative Discipline Methods

Criticizing, discouraging, creating obstacles and barriers, blaming, shaming, using sarcastic or cruel humor, or using physical punishment are some negative disciplinary methods used with young children. Often saying, "Stop that!" "Don't do it that way!" or "You never..." is harmful to children's self-esteem.

Any adult might occasionally do any of these things. Doing any or all of them more than once in a while means that a negative approach to discipline has become a habit and urgently needs to be altered before the child experiences low self-esteem as a permanent part of her personality.

Sidebar: Children with ADHD, ODD, and other behavioral disorders are particularly vulnerable to low self-esteem. They frequently experience school problems, have difficulty making friends, and lag behind their peers in psychosocial development. They are more likely than other children to bully and to be bullied. Parents of children with behavior problems experience highly elevated levels of child-rearing stress, and this may make it more difficult for them to respond to their children in positive, consistent, and supportive ways.

Positive Approaches to Discipline

  • Increase a child's self-esteem,
  • Allow her to feel valued,
  • Encourage her to feel cooperative,
  • Enable her to learn gradually the many skills involved in taking some responsibility for what happens to her,
  • Motivate her to change her strategy rather than to blame others,
  • Help her to take initiative, relate successfully to others, and solve problems.

Source: ERIC Clearinghouse on Elementary and Early Childhood Education

Reviewed by athealth on February 6, 2014.

Positive Thinking: Do You Know Your Own Mind

Our mind contains a steady flow of thoughts, which are filled with experiences, memories, images, judgments, desires and expectations. We can get up in the morning and look at the clock and think; I am not going to get everything done I have to do today; Gosh, I hate this weather; I wonder if I am going to have enough money to pay the bills this month; etc. Or, you can get up and look at the clock and say; I have a good day planned and I am going to move through it the best I can; I know I will figure out how best to budget my finances this month, the weather will help me move slower today; etc. Given these two scenarios, what kind of a day are you likely to have?

Just as you heal and develop a relationship with your body through awareness, you can and must develop a relationship with your mind. By understanding the nature of your thoughts, especially your negative thoughts, you may understand why you are feeling hopeless and helpless. You will learn about your fear-based message that somehow suggests, "you are not enough; not smart enough, pretty enough, outgoing enough, fast enough or whatever enough. With this mindset you can become defensive and have an attitude about life and yourself that perpetuates failure or self-defeating behavior. You want to be able to create positive thoughts that give you a sense of trust in yourself and in the world.

There are three common negative themes that can create restlessness:

  1. persistent worry
  2. catastrophic thinking
  3. self-critical thinking

This type of thinking is fear based. The first step is to identify the kind of thinker you are.

Worrisome Thinker - Distressing over a situation for a long period of time. An obsessive and incessant thought that is intrusive and persistent.

Catastrophic Thinker - Looking at a situation and immediately taken it out of proportion and anticipating an extreme misfortune or utter disaster.

Self-Critical Thinker - Whatever you do, you tell yourself it is not good enough, or you should have done it differently, or could have done it better. You judge yourself in a harsh manner without compassion or acceptance of your imperfections.

No matter what type of negative thinker you are it is "fear" based. This means underneath the thinking is fear of making a mistake, fear of something bad happening, fear of others, fear of self, fear of life, fear of the future, fear of not being happy, fear of being on your own, fear of rejection etc.

Here is how to begin to change your negative and fear based thinking.

Learning to Listen - For the next week, pay close attention to the thoughts that are occupying your mind. Do this as you get up in the morning and proceed through your day. Listen while you are driving to work, taking the kids to school, cooking, shopping, or waiting in line at the coffee house. Instruct yourself to stop, turn your attention to your thoughts and make a mental note of what you are telling yourself at that moment.

Vary the above technique by giving yourself ten minutes to sit in solitude and stillness without any distraction and just listen to the thoughts that are running through your mind. Are they positive or negative? Are they repetitive, confused, critical, or catastrophic? Are they about the past the future?

As you do these two exercises for a few weeks, you will begin to see five basic negative themes and fearful thoughts that occupy your mind most of the time; and probably have been there since you were a child (in fact it is the hidden fear of your inner child). Write them down. Now when they come up during your day you will be able to identify them quickly.

Honor, Update and Change Your Thinking. The first step is to recognize the negative theme, stop the thinking and honor the fear by being compassionate with yourself. Do not berate, yell or get angry with yourself. Then tell yourself you are not going to go down that thinking path. Remind yourself that you are doing the best you can, compliment yourself on the things you do well, tell yourself you will find the good in every part of your day and experiences. Even if you don't believe it tell yourself you are going to try and see this differently and let go of the negative thoughts.

Under your fears, self-doubts, and negative thinking lies the strength of your spirit. Do not abandon yourself. As you learn to regularly give yourself support and encouragement, you will begin to see that strength, courage and wisdom that lies deep within your being.

Author: Michele Germain, LCSW, LMFT, CBT. Michele Germain, is an author, psychotherapist, educational and motivational speaker recognized as a relationship expert on men and woman's issues. Her approach focuses on integrating emotional, physical, intellectual and spiritual aspects of an individual. She has developed a step by step approach that helps people work through their pain and find the spiritual gift in their crisis, developing greater soul awareness. This results in improved self-esteem and strengthens all interpersonal relationships. For information about her book, The Jill Principle, visit her Web site at

Reviewed by athealth on February 6, 2014.

Postpartum Depression

Why do women get postpartum depression?

Having a baby can be one of the biggest and happiest events in a woman's life. While life with a new baby can be thrilling and rewarding, it can also be hard and stressful at times. Many physical and emotional changes can happen to a woman when she is pregnant and after she gives birth. These changes can leave new mothers feeling sad, anxious, afraid, or confused. For many women, these feelings (called the baby blues) go away quickly. But when these feelings do not go away or get worse, a woman may have postpartum depression. This is a serious condition that requires quick treatment from a health care provider.

What is postpartum depression? Are the "baby blues" the same thing as postpartum depression?

Postpartum depression (PPD) is a condition that describes a range of physical and emotional changes that many mothers can have after having a baby. PPD can be treated with medication and counseling. Talk with your health care provider right away if you think you have PPD.

There are three types of PPD women can have after giving birth:

  • The baby blues happen in many women in the days right after childbirth. A new mother can have sudden mood swings, such as feeling very happy and then feeling very sad. She may cry for no reason and can feel impatient, irritable, restless, anxious, lonely, and sad. The baby blues may last only a few hours or as long as 1 to 2 weeks after delivery. The baby blues do not always require treatment from a health care provider. Often, joining a support group of new moms or talking with other moms helps.
  • Postpartum depression (PPD) can happen a few days or even months after childbirth. PPD can happen after the birth of any child, not just the first child. A woman can have feelings similar to the baby blues - sadness, despair, anxiety, irritability - but she feels them much more strongly than she would with the baby blues. PPD often keeps a woman from doing the things she needs to do every day. When a woman's ability to function is affected, this is a sure sign that she needs to see her health care provider right away. If a woman does not get treatment for PPD, symptoms can get worse and last for as long as 1 year. While PPD is a serious condition, it can be treated with medication and counseling.
  • Postpartum psychosis is a very serious mental illness that can affect new mothers. This illness can happen quickly, often within the first 3 months after childbirth. Women can lose touch with reality, often having auditory hallucinations (hearing things that aren't actually happening, like a person talking) and delusions (seeing things differently from what they are). Visual hallucinations (seeing things that aren't there) are less common. Other symptoms include insomnia (not being able to sleep), feeling agitated (unsettled) and angry, and strange feelings and behaviors. Women who have postpartum psychosis need treatment right away and almost always need medication. Sometimes women are put into the hospital because they are at risk for hurting themselves or someone else.

What are the signs of postpartum depression?

The signs of postpartum depression include:

  • Feeling restless or irritable.
  • Feeling sad, depressed or crying a lot.
  • Having no energy.
  • Having headaches, chest pains, heart palpitations (the heart being fast and feeling like it is skipping beats), numbness, or hyperventilation (fast and shallow breathing).
  • Not being able to sleep or being very tired, or both.
  • Not being able to eat and weight loss.
  • Overeating and weight gain.
  • Trouble focusing, remembering, or making decisions.
  • Being overly worried about the baby.
  • Not having any interest in the baby.
  • Feeling worthless and guilty.
  • Being afraid of hurting the baby or yourself.
  • No interest or pleasure in activities, including sex.

A woman may feel anxious after childbirth but not have PPD. She may have what is called postpartum anxiety or panic disorder. Signs of this condition include strong anxiety and fear, rapid breathing, fast heart rate, hot or cold flashes, chest pain, and feeling shaky or dizzy. Talk with your health care provider right away if you have any of these signs. Medication and counseling can be used to treat postpartum anxiety.

Who is at risk for getting postpartum depression?

Postpartum depression (PPD) affects women of all ages, economic status, and racial/ethnic backgrounds. Any woman who is pregnant, had a baby within the past few months, miscarried, or recently weaned a child from breastfeeding can develop PPD. The number of children a woman has does not change her chances of getting PPD. New mothers and women with more than one child have equal chances of getting PPD. Research has shown that women who have had problems with depression are more at risk for PPD than women who have not had a history of depression.

What causes postpartum depression?

No one knows for sure what causes postpartum depression (PPD). Hormonal changes in a woman's body may trigger its symptoms. During pregnancy, the amount of two female hormones, estrogen and progesterone, in a woman's body increase greatly. In the first 24 hours after childbirth, the amount of these hormones rapidly drops and keeps dropping to the amount they were before the woman became pregnant. Researchers think these changes in hormones may lead to depression, just as smaller changes in hormones can affect a woman's moods before she gets her menstrual period.

Thyroid levels may also drop sharply after giving birth. (The thyroid is a small gland in the neck that helps to regulate how your body uses and stores energy from foods eaten.) Low thyroid levels can cause symptoms that can feel like depression, such as mood swings, fatigue, agitation, insomnia, and anxiety. A simple thyroid test can tell if this condition is causing a woman's PPD. If so, thyroid medication can be prescribed by a health care provider.

Other things can contribute to PPD, such as:

  • Feeling tired after delivery, broken sleep patterns, and not enough rest often keeps a new mother from regaining her full strength for weeks. This is particularly so if she has had a cesarean (C-section) delivery.
  • Feeling overwhelmed with a new, or another, baby to take care of and doubting your ability to be a good mother.
  • Feeling stress from changes in work and home routines. Sometimes women think they have to be "super mom" or perfect, which is not realistic and can add stress.
  • Having feelings of loss - loss of identity (who you are, or were, before having the baby), loss of control, loss of a slim figure, and feeling less attractive.
  • Having less free time and less control over time. Having to stay home indoors for longer periods of time and having less time to spend with the baby's father.

How is postpartum depression treated?

It is important to know that postpartum depression (PPD) is treatable and that it will go away. The type of treatment will depend on how severe the PPD is. PPD can be treated with medication (antidepressants) and psychotherapy. Women with PPD are often advised to attend a support group to talk with other women who are going through the same thing. If a woman is breastfeeding, she needs to talk with her health care provider about taking antidepressants. Some of these drugs affect breast milk and should not be used.

What can I do to take better care of myself if I get postpartum depression?

The good news is that if you have PPD, there are things you can do to take care of yourself.

  • Get good, old-fashioned rest. Always try to nap when the baby naps.
  • Stop putting pressure on yourself to do everything. Do as much as you can and leave the rest! Ask for help with household chores and nighttime feedings.
  • Talk to your husband, partner, family, and friends about how you are feeling.
  • Do not spend a lot of time alone. Get dressed and leave the house - run an errand or take a short walk.
  • Spend time alone with your husband or partner.
  • Talk to your health care provider about medical treatment. Do not be shy about telling them your concerns. Not all health care providers know how to tell if you have PPD. Ask for a referral to a mental health professional who specializes in treating depression.
  • Talk with other mothers, so you can learn from their experiences.
  • Join a support group for women with PPD. Call a local hotline or look in your telephone book for information and services.

Source: The National Women's Health Information Center
US Department of Health and Human Services
Last Update: 2002

Reviewed by athealth on February 6, 2014.

Posttraumatic Stress Disorder (PTSD)

What is PTSD?

Posttraumatic stress disorder, which is commonly referred to as PTSD, is a condition which some people develop after they experience a very traumatic, sometimes life threatening, event. For instance, a person might develop PTSD after observing another person or group of people being seriously injured or killed. Natural disasters and wars are likely to cause some of its victims to experience post-traumatic stress disorder.

How soon does post-traumatic stress disorder develop?

In some people PTSD develops immediately after they experience the unusually traumatic event. However, in other people, signs of the disorder do not develop until several weeks, months, or even years after the event.

What characteristics are associated with post-traumatic stress disorder?

PTSD develops when a person witnesses or experiences a traumatic event and later experiences some of the following for a prolonged period of time:

  • Relives the traumatic event by thinking or dreaming about it frequently
  • Is unsettled or distressed in other areas of his/her life such as in school, at work, or in personal relationships
  • Avoids any situation that might cause his/her to relive the trauma
  • Demonstrates a certain amount of generalized emotional numbness.
  • Shows a heightened sense of being on guard

PTSD victims may have such additional emotional manifestations as a sense of hopelessness, a sense of fear, insomnia, irritability, and/or difficulty in concentrating.

Children with PTSD may show unexplained, emotional distress, or they might complain of pain.

Examples of traumatic events known to lead to PTSD include:

  • Military combat
  • Violent criminal attacks
  • Sexual assaults
  • Serious accidents
  • Life threatening natural disasters

At what age does post-traumatic stress disorder appear?

PTSD can occur at any age.

How often is post-traumatic stress disorder seen in our society?

PTSD is very common in the United States. Some studies report that more than ten percent (10%) of the population will suffer from post-traumatic stress disorder at some point in their lives.
How is post-traumatic stress disorder diagnosed?

In adults, PTSD is usually diagnosed when they seek professional help because they are suffering, and their emotional state is having a negative impact on their schoolwork, on their job, or in their social relationships. Children may be brought in for evaluation because of unexpected behavior changes or unexplained physical problems.

How is post-traumatic stress disorder treated?

Individual or group therapy, in addition to some medications, may be used in the treatment of PTSD. Therapy helps those with post-traumatic stress disorder work through the traumatic event that caused the condition. With the help of the therapist, the person with PTSD can gently examine and review the traumatic events of the past and learn to conquer his/her feelings of anxiety. Certain antidepressant medications and mild tranquilizers are sometimes prescribed to help lessen some of the painful symptoms associated with PTSD.

What happens to someone with post-traumatic stress disorder?

The course of PTSD is quite variable. With adequate treatment, about one-third of the people with PTSD will recover within a few months. Some of these people have no further problems. Many people take longer, sometimes a year or more, to recover from PTSD. Despite treatment, other people continue to have mild to moderate symptoms for a more prolonged period of time.

What can people do if they need help?

If you, a friend, or a family member would like more information and you have a therapist or a physician, please discuss your concerns with that person.

Page last modified or reviewed by on January 11, 2010

Prescription Medicine for the Treatment of Obesity

Obesity is a chronic disease that affects many people. To lose weight and maintain weight loss over the long term, it is necessary to modify one's diet and engage in regular physical activity. Some people, however, may require additional treatment. As with other chronic conditions, such as diabetes or high blood pressure, the use of prescription medications may be appropriate for some people who are overweight or obese.Prescription weight-loss medications should be used only by patients who are at increased medical risk because of their weight. They should not be used for "cosmetic" weight loss. In addition, patients should have previously tried to lose weight through diet and physical activity.

Prescription weight-loss drugs are approved only for those with:

  • A body mass index (BMI) of 30 and above.
  • A BMI of 27 and above with an obesity-related condition, such as high blood pressure, type 2 diabetes, or dyslipidemia (abnormal amounts of fat in the blood).

BMI is a measure of weight in relation to height that helps determine if your weight places your health at risk. A BMI of 18.5 to 24.9 is considered healthy. A BMI of 25 to 30 is considered overweight, and a BMI over 30 is considered obese.

Although most side effects of prescription medications for obesity are mild, serious complications have been reported. Also, few studies have evaluated the long-term safety or effectiveness of weight-loss medications. Weight-loss medications should always be combined with a program of healthy eating and regular physical activity.

For additional information on prescription medications for obesity, click on

Source: NIH Publication No. 07-4191
Updated December 2010

Reviewed by athealth on February 6, 2014.

Problem Solving Skills

One of the most exciting aspects of life is the array of choices that we have on a daily basis. Some of our decisions are simple, like deciding what to eat for dinner or what shirt to wear. However, some choices are challenging and take careful thought and consideration.

When we are confronted with these types of decisions, it can be very difficult to decide on the best option, and we may be plagued by indecision. We may be forced to choose between two equally good options, or perhaps, we may have to pick between two choices that both have drawbacks. We may waver back and forth between different alternatives and may feel paralyzed to make the decision.

This is a very normal reaction to tough choices in our lives, and we all, at times, experience a sense of being unable to decide on some option. However, researchers have developed a technique that many people have found useful when they are trying to make a difficult decision or solve a problem that seems unsolvable. This procedure involves a series of steps that you can go through on your own when you are confronted with a decision or problem that needs to be solved. This approach may not work perfectly for all difficulties, but it may help with many of the problems you are confronted with in your life.

Step 1: Problem Orientation

This step involves recognizing that a problem exists and that solving the difficulty is a worthwhile endeavor. It is important that you approach the decision-making process with a positive attitude and view the situation as an opportunity or challenge. You should try to approach the situation with confidence and with a willingness to devote some time and effort to finding an appropriate solution to your problem. Remember, you are a competent person, and the problem you are facing can likely be solved with a little hard work.

Step 2: Problem Definition

Before you start to tackle the current problem, it is important to clearly understand the difficulty and why you are unhappy with the current situation. This may seem obvious, but it is important that you really think about and gather information about the problem, and make sure that the problem you are trying to solve is the "real" problem. That is, sometimes people find a different problem than the one that is really distressing them, and focus on this one, since it is easier than dealing with the real problem. This step really involves your thinking about the difficulty you are having, understanding the problem, and contemplating why the situation is distressing. Some people think of problems as a discrepancy between what they want and what the current situation is like. It is useful during this stage to think about how the current situation is different from how you would like it to be, and what your goals are for the state of affairs. If you are currently facing many difficult decisions, it may be helpful to prioritize those problems and deal with them one at a time.

Step 3: Generation of Alternative Solutions

During this stage, you should ask yourself, "What have I done in this situation in the past, and how well has that worked?" If you find that what you have done in the past has not been as effective as you would like, it would be useful to generate some other solutions that may work better. Even if your behavior in the past has worked like you wanted it to, you should think of other solutions as well, because you may come up with an even better idea. When you start to think of possible solutions, don't limit yourself; think of as many possible options as you can, even if they seem unrealistic. You can always discard implausible ideas later, and coming up with these may help generate even better solutions. You may want to write a list of possible options, or ask others what some solutions they might have for your problem.

Step 4: Decision Making

Now you are ready to narrow down some of the options that you have generated in the previous step. It is important that you examine each of the options, and think about how realistic each is, how likely you would be to implement that solution, and the potential drawbacks of each. For example, if your solution costs a great deal of money or requires many hours of effort each day, this may be too difficult to implement. You should also consider the likelihood that each option has in terms of your being able to achieve the goals that you want regarding the solution. As you start to narrow down your choices, remember, no problem solution is perfect and all will have drawbacks, but you can always revise the solution if it does not work the way you want it to work.

Step 5: Solution Implementation and Verification

Once you have examined all your options and decided on one that seems to accomplish your goals and minimizes the costs, it is time to test it out. Make sure that when you implement this solution, you do so whole-heartedly and give it your best effort. During this stage, you should continue to examine the chosen solution and the degree to which it is "solving" your problem. If you find that the solution is too hard to implement or it is just not working, revise it or try something else. Trying to solve these problems is never an easy task, and it may take several solutions before something works. But, don't give up hope, because with persistence and your best effort, many difficult decisions and problems can be made better!

Adapted from Positive Coping Skills Toolbox
VA Mental Illness Research, Education, and Clinical Centers (MIRECC)
Page last modified or reviewed on September 21, 2012