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Thirty-three-year-old Saritza Velilla of Frisco, Tex., was just 7 years old when she first started feeling worthless. As the years went by, these feelings intensified and she became more withdrawn from social activities. But it wasn't until 1996 that Velilla was diagnosed with clinical depression, and only recently that she found relief from her ongoing symptoms.

"I always felt outside the mainstream," she remembers. "I could feel alone in a roomful of people." Velilla grew up for the most part with a great void in what she calls "that important emotional need" for parental care, affection, or attention. "Without those bonds in place," she says, "I did not develop emotionally and had trouble relating to others."

Velilla is not alone in grappling with the consequences of mental illness. An estimated 22 percent of Americans 18 and older--about 1 in 5 adults--have a diagnosable mental disorder in any given year, according to the National Institute of Mental Health (NIMH). To complicate matters, many people struggle with more than one mental disorder at a time. The pain and suffering that goes along with these illnesses is felt not only by those who have a disorder, but also by the people who care about them.

Family members often watch their loved ones cycle in and out of treatment, on and off medications, and, in some cases, in and out of jail. Pete Earley of Fairfax, Va., says that if medical experts had responded to his son's mental condition as quickly as law enforcement reacted to his criminal behavior, his son would be receiving therapy instead of facing a possible prison term.

Earley's son has bipolar disorder--also called manic-depressive illness--a form of mental illness different from Velilla's that can cause extreme shifts in mood, energy and functioning. Earley says his son is frequently delusional, paranoid, and psychotic. If he discontinues his medications, he exhibits bizarre, irrational behavior.

According to the NIMH, most people with a depressive illness do not get the help they need, although the great majority--even those whose depression is severe--can be helped. Without treatment, the symptoms of depression can last for weeks, months, or even years. With treatment, many people can find relief from their symptoms and lead a normal, healthy life.

More Than a Mood Swing Clinical depression, one of the more common categories of mental illnesses, is a serious brain disorder that affects the way nearly 19 million American adults feel, think, and interact. In contrast to the normal emotional experiences of sadness, loss, or passing mood states, clinical depression is extreme and persistent and can interfere significantly with a person's ability to function. People with depression cannot merely "pull themselves together" and get better. Depression cannot be willed or wished away.

There are three main types of clinical depression: major depressive disorder; dysthymic disorder; and bipolar depression, the depressed phase of bipolar disorder. Within these types are variations in the number of associated mental symptoms, and their severity and persistence.

A person experiencing major depressive disorder suffers from, among other symptoms, a depressed mood or loss of interest in normal activities that lasts most of the day, nearly every day, for at least two weeks. Such episodes may occur only once, but more commonly occur several times in a lifetime.

Unlike major depressive disorder, dysthymic disorder--a chronic but less severe type--doesn't strike in episodes, but is instead characterized by milder, persistent symptoms that may last for years. Although it usually doesn't interfere with everyday tasks, people with this milder form of depression rarely feel like they are functioning at their full capacities.

Bipolar disorder cycles between episodes of major depression, similar to those seen in major depressive disorder, and highs known as mania. In a manic phase, a person might act on delusional grand schemes that could range from unwise business decisions to romantic sprees. Mania left untreated may deteriorate into a psychotic state.

For Earley, one of his son's recent psychotic episodes played out in a burglary charge. The pair was headed home from a local hospital where doctors had refused to treat him involuntarily. Earley's son suddenly leapt from their moving car, ran away, and broke into a stranger's house. After throwing a potted plant through a glass door and smashing some furniture, he then ran upstairs and drew himself a bubble bath. Earley says his son has never been in trouble with the law before and that he did not take anything from the house.

It's Not 'All In The Head' Because the symptoms, course of illness, and response to treatment vary so much among people with depression, doctors believe that depression may have a number of complex and interacting causes.

Some factors include another medical illness, losing a loved one, stressful life events, and drug or alcohol abuse. Any of these factors also may contribute to recurrent major depressive episodes.

Modern brain imaging technologies are revealing that neural circuits responsible for the regulation of moods, thinking, sleep, appetite, and behavior fail to function properly in people with depression. Imaging studies also indicate that critical neurotransmitters--chemicals used by nerve cells to communicate--are out of balance.

Moreover, genetics research suggests that vulnerability to depression results from the influence of multiple genes acting together with environmental factors. The hormonal system that regulates the body's response to stress also is overactive in many depressed people.

Research conducted in the fields of psychiatry, behavioral science, neuroscience, biology, and genetics, including studies of twins, lead scientists to believe that the risk of developing mental illness increases if another family member is similarly affected, suggesting a hereditary component.

This was the case for 34-year-old Susan Poage of Thornton, Colo. She recently was diagnosed with clinical depression, like her mother before her. Poage recalls a dismal childhood.

"There was a lot of silent crying, promiscuity, alcohol and drugs," she says, "and I don't remember having any good times." With the help of her doctor and a five-year struggle with drug therapy, Poage today is managing her symptoms of depression, including thoughts of suicide.

Despite strong evidence for genetic susceptibility, scientists still don't know the number of genes that might be involved in making someone more likely to develop a mental disorder. Identification of these genes has proved to be extremely difficult.

Similarly, the role of environmental effects in the development of mental illness remains largely unknown.

Diagnosing Depression Medical professionals generally base a diagnosis of mental illness on the presence of certain symptoms listed in the 4th edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). The symptoms listed for a major depressive episode include:

• sadness
• loss of interest or pleasure in activities once enjoyed
• change in appetite or weight
• difficulty sleeping or oversleeping
• physical slowing or agitation
• energy loss
• feelings of worthlessness or inappropriate guilt
• difficulty thinking or concentrating
• recurrent thoughts of death or suicide.

A person is clinically depressed if he or she has five or more of these symptoms and has not been functioning normally for most days during the same two-week period.

Dysthymic disorder is diagnosed when depressed mood persists for at least two years (one year in children) and is accompanied by at least two other symptoms of depression.

The episodes of depression that occur in people with bipolar disorder alternate with mania, which is characterized by abnormally and persistently elevated mood or irritability. Symptoms of mania include overly inflated self-esteem, decreased need for sleep, increased talkativeness, racing thoughts, distractibility, physical agitation, and excessive risk-taking. Because bipolar disorder requires different treatment than major depression or dysthymia, obtaining an accurate diagnosis is extremely important.

Treating Depression Finding the right treatment for depression can be as difficult as convincing someone that they need help. However, according to the NIMH, clinical depression is one of the most treatable of all medical illnesses.

Because it is currently against the law in Virginia, where the Earleys live, to force someone into medical treatment, Earley must rely on his son's willingness to take his medicines. Typically, bipolar patients periodically stop taking their medications.

"Part of my son's illness," Earley explains, "is believing he is perfectly fine when he goes off his medicines.

"Even though it was obvious that my son was clearly out of his mind, the law still insisted that he was capable of deciding whether or not he needed treatment," says Earley. "In these cases, you are asking an irrational person to make a rational decision. It's like expecting a person with a broken leg to run a marathon."

Today, most people with depression can be treated successfully with antidepressant medications, "talk" therapy (psychotherapy), or a combination of the two. Experts agree that successful treatment also hinges on early intervention. And early treatment increases the likelihood of preventing serious recurrences.

Drug Treatment Existing antidepressant drugs are known to influence the functioning primarily of either or both of two neurotransmitters in the brain--serotonin and norepinephrine. Older medications--tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs)--affect the activity of both of these neurotransmitters simultaneously. Their disadvantage is that they can be difficult to tolerate due to significant side effects, or, in the case of MAOIs, dietary and medication restrictions.

Newer medications, such as the selective serotonin reuptake inhibitors (SSRIs), have fewer side effects than the older drugs, making it easier for people, including older adults, to adhere to treatment. Both generations of medications are effective in relieving depression, although some people will respond to one type of drug, but not another.

"Clinicians tell us that different drugs seem to work for different people," says Thomas Laughren, M.D., team leader for the review of psychiatric drugs in the Food and Drug Administration's Division of Neuropharmacological Drug Products. "And it's difficult to predict which people will respond to which drug or who will experience what side effects." So, Laughren says, it may take more than one try to find the appropriate medication. "Now that we've made a distinction between different depression subtypes, this seems to have stimulated additional drug research. Drug companies are also conducting more longer-term studies in depression, and this is important since depression tends to be a chronic illness."

Although some improvement may be seen in the first few weeks, antidepressants usually must be taken regularly for three to four weeks (and sometimes longer) before full therapeutic benefits occur. "If we had a better understanding of the biological basis for depression, it would help in the discovery of newer antidepressants that hopefully would work faster and better," says Laughren. "Unfortunately we do not really understand the mechanism for the antidepressant drugs."

The medication most often used to treat bipolar disorder is lithium (Eskalith, Lithane, Lithobid, Cibalith-S). Lithium evens out mood swings in both directions--from mania to depression, and depression to mania. It is used not just for manic attacks or flare-ups of the illness, but also as an ongoing maintenance treatment for bipolar disorder.

Non-Drug Treatments In psychotherapy, also called "talk therapy," a person discusses with a mental health professional the feelings, thoughts and behaviors that seem to cause difficulty. The goal of psychotherapy is to help people understand and manage their problems so that they can function better.

"Finding a therapist who believes in recovery is the first step," says Velilla. "Someone who can teach you to think differently and learn new behaviors." She believes that her feelings of neglect, coupled with the eventual divorce of her parents, ultimately triggered many of her bouts with depression. Her own divorce some years later, she says, only heightened her feelings of worthlessness. "My therapist finally put a name to what I'd been feeling since I was 7 years old."

Psychotherapy can help people with bipolar disorder, and their families, identify early warning signs and manage emotional stress, which may help prevent a bipolar episode.

Richard O'Connor, Ph.D., a psychotherapist in Canaan, Conn., and the author of several books on depression, believes that people need to help themselves "break the bad habits in their lives that set them up for depression." Waking up and going to sleep at the same time each day, for example, might help those people prone to bouts of insomnia due to irregular sleep patterns.

A depression sufferer himself, O'Connor came to this belief after many of the people he was treating "thought it was too late for them to help themselves, and they wanted us to pick up the pieces," he says. "People are responsible for their own recovery. They must learn to take care of themselves and structure their lives so that they're less likely to trigger an episode."

When people are unresponsive to psychotherapy and medications, or the combination of the two works too slowly to relieve severe symptoms, such as psychosis or recurring thoughts of suicide, electroconvulsive therapy (ECT) may be considered. Electrodes are placed at precise locations on the head to deliver electrical impulses. The stimulation causes a 30-second seizure within the brain; however, the person does not consciously feel the stimulus. Three sessions per week typically are given for full therapeutic benefit. Like antidepressants, ECT is believed to affect the chemical balance of the brain's neurotransmitters.

Interest is rapidly growing as well in the use of herbs for treating depression. But, according to a study published in the April 10, 2002, issue of the Journal of the American Medical Association, an extract of the popular herb St. John's wort was no more effective for treating major depression of moderate severity than an inactive pill (placebo). The multi-site trial, involving 340 people, also compared the FDA-approved antidepressant drug Zoloft (sertraline) to a placebo as a way to measure how sensitive the trial was to detecting antidepressant effects. Since Zoloft was also found to be no different than the placebo in that study, Laughren says it can best be thought of as a "failed study" that isn't informative about the antidepressant effectiveness of St. John's wort.

The NIMH cautions people who think they may be depressed not to use dietary supplements without first being evaluated by a psychiatrist or examined by a physician. The risks, according to the institute, can outweigh any potential benefits.

Following Prescribed Treatment Antidepressant drugs are not considered to be candidates for abuse. However, as is the case with any type of medication, use of antidepressants must be carefully monitored to make sure the correct dosage is being given. Care also is needed when antidepressants are discontinued.

As is often seen with antibiotics, people may be tempted to stop antidepressants too soon. They may feel better and think they no longer need the medication, or they may believe the medication isn't working. But quickly stopping certain antidepressants is linked to side effects ranging from flu-like symptoms to sensory disturbances. As a result, new labeling, as specified by the FDA, recommends that patients taper off these medications slowly. If a person encounters problems going off a drug, he or she is advised to consult a physician rather than reduce dosage without supervision.

After spending 11 days in the hospital following the burglary, Earley's son was released to his parents. He is currently awaiting trial on two counts of felony breaking and entering and destruction of property. He is attending a 15-week treatment program that includes routine medications, and he now has a job and hopes to return to college to finish his education.

"He doesn't want to be delusional," says Earley. "He's embarrassed and ashamed about what happened. But now he's got no choice but to admit that he is sick and always will be. The question is, will that be enough to keep him taking his medications?"

When a patient and the health-care provider think that medication can be discontinued or scaled back, they will discuss how best to ease off the medication gradually.

The NIMH says it is important to keep taking prescribed medication until it has had a chance to work, even though side effects may appear before antidepressant activity does.

As for Velilla, "I'm still not taking any medication," she says, "but I think I may not need it after all. I continue to read books that will inspire and give me tools to deal with life. I feel like I am making progress in counseling and in all areas of my life and that makes me feel pretty good and optimistic about recovering."

By Carol Lewis
FDA Consumer Magazine
January-February 2003

Reviewed by athealth on February 5, 2014.

Helen Dearman, 52, of Houston, had a broken back for more than a decade and didn't know it. After falling from a ski lift in Mt. Hood, Ore., when she was 23, Dearman was diagnosed with a broken left arm and thought that was her only injury. Her arm healed. But she developed excruciating back pain that made it hard to sleep and move around. "I worked as a teacher, so some doctors suggested that the problem was from standing on my feet all day," Dearman says. "Others told me it was all in my head. For years, I left doctors' offices feeling desperate for help."

The pain grew worse during her 30s. One morning, Dearman woke up with stabbing pains in her back and could barely walk. This time, her husband took her to an orthopedic surgeon who specialized in back problems. The doctor ordered X-rays that revealed three old fractures in Dearman's spine.

"When the doctor showed me the X-rays, I cried," Dearman says. "Someone had finally given me the words and understanding for all the pain I had been suffering from for so long."

Pain That Persists

WBy definition, acute pain after surgery or trauma comes on suddenly and lasts for a limited time, whereas chronic pain persists. "Acute pain is a direct response to disease or injury to tissue, and presumably it will subside when you treat the disease or injury," says Sharon Hertz, M.D., deputy director in the Food and Drug Administration's Division of Anti-Inflammatory, Analgesic, and Ophthalmologic Drug Products. "Chronic pain goes on and on--for months or even years."

Common types of chronic pain include back pain, headaches, arthritis, cancer pain, and neuropathic pain, which results from injury to nerves. In Dearman's case, her untreated back injury caused her spine to twist out of place, not only resulting in severe back pain, but also putting intense pressure on the nerves in her legs. "I often felt pain shooting down my legs," she says, "like a jolt of electricity."

Experts say the first step in treating chronic pain is to identify the source of the pain, if possible. Many people with chronic pain try to tough it out, according to research from the American Academy of Pain Medicine. But persistent pain should never be ignored because it could signal disease or injury that will worsen if left untreated. Sometimes, it turns out that the cause of pain is unknown. Fibromyalgia, for example, is characterized by fatigue and widespread pain in muscles and joints. While scientists have theorized that the condition may be connected to injury, changes in muscle metabolism, or viruses, the exact cause is unclear.

Regardless of the type of chronic pain, the physical and emotional effects can be devastating. Dearman says, "My teaching career suffered, my children were confused about why I always felt bad, and our finances were ruined." Sometimes, she says, she even considered suicide.

Finding Relief

Dearman believes the first two surgeries she had to repair the fractures in her back and realign her spine were necessary. But she questions the four surgeries that followed. "I talked myself into the operating room more than once because I was desperate to feel better," Dearman says. "Even when doctors told me there was only a small chance another surgery would help, I wanted to take the chance." But after several surgeries, Dearman's pain only seemed to be getting worse.

The turning point occurred in 1995 when a physical therapist referred Dearman to a pain management specialist, a professional who takes a multidisciplinary approach to managing pain. She was treated by a team of pain experts. Doctors and nurses worked with her to manage pain medications. Psychologists addressed her depression and anger, and physical therapists helped improve her strength and mobility.

Dearman finally found effective drug treatment with a pump implanted into her abdomen that delivers morphine through a catheter into the fluid surrounding her spine. The pump, called an intrathecal drug infusion pump, is used for severe pain only after other oral and intravenous drug therapies have failed. The pump is programmed to deliver a controlled amount of medication continuously. Risks include surgical complications, such as infection, and complications with the catheter or pump. "It doesn't take away all the pain, but it's a drastic improvement and allows me to be in control of the pain," says Dearman, who also takes other pain medication as needed.

Seddon Savage, M.D., a pain specialist on the faculty of Dartmouth Medical School in Hanover, N.H., says there are times when it's impossible to eliminate pain. "The goal of pain management is to provide as much pain relief as possible and improve functioning," Savage says.

Because pain varies from person to person, treatment is individualized. Someone with arthritis may do well with occasional use of an over-the-counter pain reliever, whereas someone else with arthritis may need a prescription pain reliever and regular aerobic exercise to feel good.

"Treatment for chronic pain is about much more than medication," Savage says. It can also involve stress relief and relaxation, physical therapy, improved sleep and nutrition habits, and exercise. Dearman says that through a multidisciplinary approach to pain management, she also learned to pace her activities so that she is realistic about how much she can do in a certain time period.

Savage recommends that people seek professional help for chronic pain when they feel that pain is interfering with their quality of life. "Start with your primary care physician, who may refer you to other specialists," she says. "Consider asking your doctor about a pain management specialist if you feel that your pain is just not getting better over time." Another reason to seek advice from a specialist is if you are experiencing intolerable side effects from medications.

Concerns About Drug Abuse

One of Dearman's biggest fears was of becoming addicted to pain medications. "It's a common concern for both patients and health providers," says Savage, who specializes in addiction.

"Most forms of chronic pain respond to non-opioid drug treatments," she says. Examples of non-opioid pain relievers, which don't have addiction potential, include aspirin, acetaminophen, ibuprofen, naproxen, and other non-steroidal anti-inflammatory drugs. A combination of different types of analgesic medications at lower doses is often more effective than a single high-dose medication.

"But if opioids are prescribed for your pain, you are not abusing drugs if you are taking the medication as prescribed," Savage says. "Taking doses of drugs to relieve pain is not the same as taking drugs to get high."

Opioids are controlled substances that are potentially addictive. Pain medications containing opioids include Vicodin (hydrocodone), OxyContin and Percocet (oxycodone), MS-Contin (morphine), Tylenol #2, #3 and #4 (codeine), and the Duragesic Patch and Actiq (fentanyl).

June Dahl, Ph.D., director of the American Alliance of Cancer Pain Initiatives and professor of pharmacology at the University of Wisconsin-Madison Medical School, says she recently took a call from a man with cancer who said he stopped taking an opioid pain medication on his own for fear that he was becoming addicted. "But what he described were not signs of addiction, but signs of physical dependence," Dahl says.

Addiction is characterized by craving and compulsive use of drugs. Physical dependence occurs when a person's body adapts to the drug. If someone has become physically dependent on a drug and suddenly stops taking it, withdrawal may occur. These symptoms can include muscle aches, watery nose and eyes, irritability, sweating, and diarrhea. Physical dependence is a normal response to repeated use of opioids and is distinct from psychological addiction.

Savage says that in prescribing potentially addictive medications, doctors should consider patients' personal and family histories of addiction, as well as psychological and social stressors that may affect medication use. Also, some people who begin taking opioid medications for pain as prescribed may later discover that they are using the medication for its psychic brain effects. Physicians need to be aware of this potential adverse effect, and should educate patients and their families about appropriate use of addictive drugs.

To better guide physicians, the Federation of State Medical Boards adopted guidelines for the use of controlled substances for pain treatment in 1998. The guidelines advise physicians on patient evaluations, treatment plans, and medical records.

The use of opioids in pain treatment remains controversial for several reasons. The rate of addiction in the properly treated pain population is unknown. The media has highlighted problems of addiction to pain medicine among celebrities. And there has been considerable drug abuse involving OxyContin, which the FDA approved for moderate-to-severe pain in 1995. The FDA strengthened warnings for oxycodone in 2001, while continuing to recommend appropriate pain control for people living with severe pain.

But experts say that finding a balance between cracking down on drug abusers and protecting people in pain is an ongoing struggle. "Some doctors fear regulatory scrutiny for over-prescribing these drugs," Dahl says. "And concerns about the small segment of people who abuse drugs ends up interfering with effective pain management for others."

Sheryl Kaufman, 40, of Boston, who uses oxycodone and a fentanyl patch for severe pain associated with breast cancer, says she recently filed a grievance with a pharmacy over her struggles to get prescriptions filled. "They made me feel like a criminal," she says. "Sometimes I've had to go without pain medication for two to three days because of delays in filling prescriptions."

The Value of Support

Dearman's experiences with chronic pain led her to establish the National Chronic Pain Society in 2002. The organization provides peer support for people with chronic pain and their families.

"We give people support for dealing with all of the issues that can go along with chronic pain-not having your pain taken seriously, frustration over not finding relief, how to communicate your pain to your doctor, and how to maintain relations with your family," Dearman says.

Penney Cowan, executive director of the American Chronic Pain Association, another peer support organization in Rocklin, Calif., says support systems are important because they give people with pain the coping skills needed to take an active role in their recovery. "Sometimes doctors tell people they'll have to learn to live with the pain," Cowan says. "But too often they stop short of telling them how to accomplish that."

Dearman says finding effective treatment and gaining the skills to live with her pain made all the difference. "It's about being a person first and not letting pain define who you are," she says. "Our motto is: Pain may be unavoidable, but suffering is optional."

By Michelle Meadows, staff writer
FDA Consumer Magazine
March-April 2004

Reviewed by athealth on February 5, 2014.

What is manic-depressive disorder?

Manic-depressive disorder is the former name for bipolar disorder.

Bipolar disorder is a serious brain disease that causes extreme shifts in mood, energy, and functioning. It affects approximately 2.3 million adult Americans-about 1.2 percent of the population.² Men and women are equally likely to develop this disabling illness. The disorder typically emerges in adolescence or early adulthood, but in some cases appears in childhood.³ Cycles, or episodes, of depression, mania, or ?mixed? manic and depressive symptoms typically recur and may become more frequent, often disrupting work, school, family, and social life.

Scientists are learning about the possible causes of bipolar disorder through several kinds of studies. Most scientists now agree that there is no single cause for bipolar disorder?rather, many factors act together to produce the illness.

Because bipolar disorder tends to run in families, researchers have been searching for specific genes?the microscopic "building blocks" of DNA inside all cells that influence how the body and mind work and grow?passed down through generations that may increase a person's chance of developing the illness. But genes are not the whole story. Studies of identical twins, who share all the same genes, indicate that both genes and other factors play a role in bipolar disorder. If bipolar disorder were caused entirely by genes, then the identical twin of someone with the illness would always develop the illness, and research has shown that this is not the case. But if one twin has bipolar disorder, the other twin is more likely to develop the illness than is another sibling.

Please click on Bipolar Disorder for more information.

Additional Information

1. Medications for Mental Illness
2. Bipolar Disorder
3. Child and Adolescent Bipolar Disorder

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 5, 2014.

What is Marijuana? Are there different kinds?

Marijuana is a green, brown, or gray mixture of dried, shredded leaves, stems, seeds, and flowers of the hemp plant (Cannabis sativa). Before the 1960s, many Americans had never heard of marijuana, but today it is the most often used illegal drug in the United States.

Cannabis is a term that refers to marijuana and other drugs made from the same plant. Strong forms of cannabis include sinsemilla (sin-seh-me-yah), hashish ("hash" for short), and hash oil. All forms of cannabis are mind-altering (psychoactive) drugs; they all contain THC (delta-9-tetrahydrocannabinol), the main active chemical in marijuana. They also contain more than 400 other chemicals.

Marijuana's effect on the user depends on the strength or potency of the THC it contains. THC potency has increased since the 1970s and continues to increase still. The strength of the drug is measured by the average amount of THC in test samples confiscated by law enforcement agencies. For the year 2006, most ordinary marijuana contained, on average, 7 percent THC.

FACT: There are stronger forms of marijuana available to adolescents today than in the 1970s or 1908s. Stronger marijuana means stronger effects.

What are the current slang terms for marijuana?

There are many different names for marijuana. Slang terms for drugs change quickly, and they vary from one part of the country to another. They may even differ across sections of a large city.

Terms from years ago, such as pot, herb, grass, weed, Mary Jane, and reefer, are still used. You might also hear the names Aunt Mary, skunk, boom, gangster, kif, or ganja.

There are also street names for different strains or "brands" of marijuana, such as "Texas tea," "Maui wowie," and "chronic." One book of American slang lists more than 200 terms for various kinds of marijuana.

How is marijuana used?

Most users roll loose marijuana into a cigarette (called a joint or a nail) or smoke it in a pipe or a water pipe, sometimes referred to as a bong. Some users mix marijuana into foods or use it to brew a tea. Another method is to slice open a cigar and replace the tobacco with marijuana, making what's called a blunt. When the blunt is smoked with a 40-oz. bottle of malt liquor, it is called a "B-40."

Marijuana cigarettes or blunts sometimes contain other substances as well, including crack cocaine - a combination known by various street names, such as "primos" or "woolies." Joints and blunts sometimes are dipped in PCP and are called "happy sticks," "wicky sticks," "love boat," "dust," "wets," or "tical."

How many people smoke marijuana? At what age do children generally start?

A recent government survey tells us:

• Marijuana is the most frequently used illegal drug in the United States. Nearly 98 million Americans over the age of 12 have tried marijuana at least once.
• Over 14 million had used the drug in the month before the survey.

The Monitoring the Future Survey, which is conducted yearly, includes students from 8th, 10th, and 12th grades. In 2006, the survey found that 15.7 percent of 8th-graders have tried marijuana at least once, and among 10th-graders, 14.2 percent were "current" users (that is, have used within the past month). Among 12th-graders, 42.3 percent have tried marijuana at least once, and about 18 percent were current users.

Other researchers have found that use of marijuana and other drugs usually peaks in the late teens and early twenties, then declines in later years.

FACT: Research shows that more than 40 percent of teenagers try marijuana before they graduate from high school.

How can I tell if my child has been using marijuana?

There are some signs you might be able to see. If someone is high on marijuana, he or she might:

• seem dizzy and have trouble walking;
• seem silly and giggly for no reason;
• have very red, bloodshot eyes; and
• have a hard time remembering things that just happened.

When the early effects fade, the user can become very sleepy.

Parents should be aware of changes in their child's behavior, although this may be difficult with teens. Parents should look for withdrawal, depression, fatigue, carelessness with grooming, hostility, and deteriorating relationships with family members and friends. In addition, changes in academic performance, increased absenteeism or truancy, lost interest in sports or other favorite activities, and changes in eating or sleeping habits could be related to drug use. However, these signs may also indicate problems other than use of drugs.

In addition, parents should be aware of:

• signs of drugs and drug paraphernalia, including pipes and rolling papers.
• odor on clothes and in the bedroom
• use of incense and other deodorizers
• use of eye drops
• clothing, posters, jewelry, etc., promoting drug use

Why do young people use marijuana?

Children and young teens start using marijuana for many reasons. Curiosity and the desire to fit into a social group are common reasons. Certainly, youngsters who have already begun to smoke cigarettes and/or use alcohol are at high risk for marijuana use.

Also, our research suggests that the use of alcohol and drugs by other family members plays a strong role in whether children start using drugs. Parents, grandparents, and older brothers and sisters in the home are models for children to follow.

Some young people who take drugs do not get along with their parents. Some have a network of friends who use drugs and urge them to do the same (peer pressure). All aspects of a child's environment - home, school, neighborhood - help to determine whether the child will try drugs.

Children who become heavily involved with marijuana can become dependent, making it difficult for them to quit. Others mention psychological coping as a reason for their use - to deal with anxiety, anger, depression, boredom, and so forth. But marijuana use is not an effective method for coping with life's problems, and staying high can be a way of simply not dealing with the problems and challenges of growing up.

Researchers have found that children and teens (both male and female) who are physically and sexually abused are at greater risk than other young people of using marijuana and other drugs and of beginning drug use at an early age.

Does using marijuana lead to other drugs?

Long-term studies of high school students and their patterns of drug use show that very few young people use other drugs without first trying marijuana, alcohol, or tobacco. Though few young people use cocaine, for example, the risk of doing so is much greater for youth who have tried marijuana than for those who have never tried it. Although research has not fully explained this association, growing evidence suggests a combination of biological, social, and psychological factors is involved.

Researchers are examining the possibility that long-term marijuana use may create changes in the brain that make a person more at risk of becoming addicted to other drugs, such as alcohol or cocaine. Although many young people who use marijuana do not go on to use other drugs, further research is needed to determine who will be at greatest risk.

What are the effects of marijuana?

The effects of marijuana on each person depend on the

• type of cannabis and how much THC it contains;
• way the drug is taken (by smoking or eating);
• experience and expectations of the user;
• setting where the drug is used; and
• use of other drugs and/or alcohol.

Some people feel nothing at all when they first try marijuana. Others may feel high (intoxicated and/or euphoric).

It is common for marijuana users to become engrossed with ordinary sights, sounds, or tastes, and trivial events may seem extremely interesting or funny. Time seems to pass very slowly, so minutes feel like hours. Sometimes the drug causes users to feel thirsty and very hungry - an effect called "the munchies."

What happens after a person smokes marijuana?

Within a few minutes of inhaling marijuana smoke, the user will likely feel, along with intoxication, a dry mouth, rapid heartbeat, some loss of coordination and balance, and a slower than normal reaction time. Blood vessels in the eye expand, so the user's eyes look red.

For some people, marijuana raises blood pressure slightly and can double the normal heart rate. This effect can be greater when other drugs are mixed with marijuana, but users do not always know when that happens.

As the immediate effects fade, usually after 2 to 3 hours, the user may become sleepy.

How long does marijuana stay in the user's body?

THC in marijuana is readily absorbed by fatty tissues in various organs. Generally, traces (metabolites) of THC can be detected by standard urine testing methods several days after a smoking session. In heavy, chronic users, however, traces can sometimes be detected for weeks after they have stopped using marijuana.

Can a user have a bad reaction?

Yes. Some users, especially those who are new to the drug or in a strange setting, may suffer acute anxiety and have paranoid thoughts. This is more likely to happen with high doses of THC. These scary feelings will fade as the drug's effects wear off.

In rare cases, a user who has taken a very high dose of the drug can have severe psychotic symptoms and need emergency medical treatment.

Other kinds of bad reactions can occur when marijuana is mixed with other drugs, such as PCP or cocaine.

How is marijuana harmful?

Marijuana can be harmful in a number of ways, through immediate effects and through damage to health over time.

Marijuana hinders the user's short-term memory (memory for recent events), and he or she may have trouble handling complex tasks. With the use of more potent varieties of marijuana, even simple tasks can be difficult.

Because of the drug's effects on perceptions and reaction time, users could be involved in auto crashes. Drug users also may become involved in risky sexual behaviors, which could lead to the spread of HIV, the virus that causes AIDS.

Under the influence of marijuana, students may find it hard to study and learn. Young athletes could find their performance is off; timing, movements, and coordination are all affected by THC.

Some of the more long-range effects of marijuana use are described later in this document.

FACT: Marijuana has adverse effects on many of the skills required for driving a car. Driving while high can lead to car accidents.

How does marijuana affect driving?

Marijuana affects many skills required for safe driving: alertness, concentration, coordination, and reaction time. Marijuana use can make it difficult to judge distances and react to signals and sounds on the road.

There are data showing that marijuana can play a role in motor vehicle crashes. Studies show that approximately 4-14 percent of drivers who sustained injury or died in traffic accidents tested positive for THC. In many of these cases, alcohol was detected as well. When users combine marijuana with alcohol, as they often do, the hazards of driving can be more severe than with either drug alone. In a study conducted by the National Highway Traffic Safety Administration, a moderate dose of marijuana alone was shown to impair driving performance; however, the effects of even a low dose of marijuana combined with alcohol were markedly greater than those of either drug alone.

In one study conducted in Memphis, Tennessee, researchers found that, of 150 reckless drivers who were tested for drugs at the arrest scene, 33 percent tested positive for marijuana, and 12 percent tested positive for both marijuana and cocaine. Data also show that while smoking marijuana, people display the same lack of coordination on standard "drunk driver" tests as do people who have had too much to drink.

FACT: Marijuana users may have many of the same respiratory problems that tobacco smokers have, such as chronic cough and more frequent chest colds.

What are the long-term effects of marijuana?

Although all of the long-term effects of marijuana use are not yet known, there are studies showing serious health concerns. For example, a group of scientists in California examined the health status of 450 daily smokers of marijuana, but not tobacco. They found that the marijuana smokers had more sick days and more doctor visits for respiratory problems and other types of illness than did a similar group who did not smoke either substance.

Findings so far show that the regular use of marijuana may play a role in cancer and problems of the immune and respiratory systems.

Cancer

It is hard to find out whether marijuana alone causes cancer, because many people who smoke marijuana also smoke cigarettes and use other drugs. Marijuana smoke contains some of the same cancer-causing compounds as tobacco, sometimes in higher concentrations. Studies show that someone who smokes five joints per day may be taking in as many cancer-causing chemicals as someone who smokes a full pack of cigarettes every day.

Tobacco smoke and marijuana smoke may work together to change the tissues lining the respiratory tract. Marijuana smoking could contribute to early development of head and neck cancer in some people.

Immune system

Our immune system protects the body from many agents that cause disease. It is not certain whether marijuana damages the immune system of people. But both animal and human studies have shown that marijuana impairs the ability of T-cells in the lungs' immune system to fight off some infections.

Lungs and airways

People who smoke marijuana regularly may develop many of the same breathing problems that tobacco smokers have, such as daily cough and phlegm production, more frequent chest colds, a heightened risk of lung infections, and a greater tendency toward obstructed airways. Marijuana smokers usually inhale more deeply and hold their breath longer, which increases the lungs' exposure to toxic chemicals and irritants.

What about pregnancy: Will smoking marijuana hurt the baby?

Doctors advise pregnant women not to use any drugs because they might harm the growing fetus. Although one animal study has linked marijuana use to loss of the fetus very early in pregnancy, two studies in humans found no association between marijuana use and early pregnancy loss. More research is necessary to fully understand the effects of marijuana use on pregnancy outcomes.

Some scientific studies have found that babies born to women who used marijuana during their pregnancy display altered responses to visual stimulation, increased tremors, and a high-pitched cry, which may indicate problems with nervous system development. During preschool and early school years, marijuana-exposed children have been reported to have more behavioral problems and difficulties with sustained attention and memory than nonexposed children.

Researchers are not certain whether any effects of maternal marijuana use during pregnancy persist as the child grows up; however, because some parts of the brain continue to develop into adolescence, it is also possible that certain kinds of problems will become more evident as the child matures.

What happens if a nursing mother uses marijuana?

When a nursing mother uses marijuana, some of the THC is passed to the baby through breast milk. This is a matter for concern, because the THC in the mother's milk is much more concentrated than that in the mother's blood. One study has shown that the use of marijuana by a mother during the first month of breastfeeding can impair the infant's motor development (control of muscle movement). This work has not been replicated, although similar anecdotal reports exist. Further research is needed to determine whether THC transmitted in breast milk has harmful effects on development.

FACT: Marijuana smoking affects the brain and leads to impaired short-term memory, perception, judgment and motor skills.

How does marijuana affect the brain?

THC affects the nerve cells in the part of the brain where memories are formed. This makes it hard for the user to recall recent events (such as what happened a few minutes ago). It is hard to learn while high - a working short-term memory is required for learning and performing tasks that call for more than one or two steps.

Among a group of long-time heavy marijuana users in Costa Rica, researchers found that the people had great trouble when asked to recall a short list of words (a standard test of memory). People in that study group also found it very hard to focus their attention on the tests given to them.

As people age, they normally lose nerve cells in a region of the brain that is important for remembering events. Chronic exposure to THC may hasten the age-related loss of these nerve cells. In one study, researchers found that rats exposed to THC every day for 8 months (about 1/3 of their lifespan) showed a loss of brain cells comparable to rats that were twice their age. It is not known whether a similar effect occurs in humans. Researchers are still learning about the many ways that marijuana could affect the brain.

Can the drug cause mental illness?

Scientists do not yet know whether the use of marijuana causes mental illness. Among the difficulties in this kind of research are determining whether drug use precedes or follows mental health problems; whether one causes the other; and/or whether both are due to other factors such as genetics or environmental conditions. High doses of marijuana can induce psychosis (disturbed perceptions and thoughts), and marijuana use can worsen psychotic symptoms in people who have schizophrenia. There is also evidence of increased rates of depression, anxiety, and suicidal thinking in chronic marijuana users. However, it is not yet clear whether marijuana is being used in an attempt to self-medicate an already present, but otherwise untreated, mental health problem or whether marijuana use leads to mental disorders (or both).

Do marijuana users lose their motivation?

Some frequent, long-term marijuana users show signs of a lack of motivation (sometimes termed "amotivational syndrome"). Their problems include not caring about what happens in their lives, no desire to work regularly, fatigue, and a lack of concern about how they look. As a result of these symptoms, some users tend to perform poorly in school or at work. Scientists are still studying these problems.

Can a person become addicted to marijuana?

Yes. Although not everyone who uses marijuana becomes addicted, when a user begins to seek out and take the drug compulsively, that person is said to be dependent on the drug or addicted to it. In 2004, more than 298,317 people entering drug treatment programs reported marijuana as their primary drug of abuse, showing they needed help to stop using.

Some heavy users of marijuana show signs of withdrawal when they do not use the drug. They develop symptoms such as restlessness, loss of appetite, trouble sleeping, weight loss, and shaky hands.

According to one study, marijuana use by teens who have prior serious antisocial problems can quickly lead to dependence on the drug. That study also found that, for troubled teens using tobacco, alcohol, and marijuana, progression from their first use of marijuana to regular use was about as rapid as their progression to regular tobacco use and more rapid than the progression to regular use of alcohol.

What is "tolerance" for marijuana?

"Tolerance" means that the user needs increasingly larger doses of the drug to get the same desired results that he or she previously got from smaller amounts. Some frequent, heavy users of marijuana may develop tolerance for it.

Are there treatments to help marijuana users?

Up until a few years ago, it was hard to find treatment programs specifically for marijuana users. Treatments for marijuana dependence were much the same as therapies for other drug abuse problems. These include behavioral therapies, such as cognitivebehavioral therapy; multisystemic therapy; individual and group counseling; and regular attendance at meetings of support groups, such as Narcotics Anonymous.

Recently, researchers have been testing different ways to attract marijuana users to treatment and help them abstain from drug use. There are currently no medications for treating marijuana dependence. Treatment programs focus on counseling and group support systems. From these studies, drug treatment professionals are learning which characteristics of users are predictors of success in treatment and which approaches to treatment can be most helpful.

Further progress in treatment to help marijuana users includes a number of programs set up to help adolescents in particular. Some of these programs are in university research centers, where most of the young patients report marijuana as their drug of choice. Others are in independent adolescent treatment facilities. Family physicians can be a good source for information and help in dealing with adolescents' marijuana problems.

Can marijuana be used as medicine?

There has been much debate in the media about the possible medical use of marijuana. Under U.S. law since 1970, marijuana has been a Schedule I controlled substance. This means that the drug, at least in its smoked form, has no commonly accepted medical use.

In considering possible medical uses of marijuana, it is important to distinguish between whole marijuana and pure THC or other specific chemicals derived from cannabis. Whole marijuana contains hundreds of chemicals, some of which may be harmful to health.

THC, manufactured into a pill that is taken by mouth, not smoked, can be used for treating the nausea and vomiting that go along with certain cancer treatments and is available by prescription. Another chemical related to THC (nabilone) has also been approved by the Food and Drug Administration for treating cancer patients who suffer nausea. The oral THC is also used to help AIDS patients eat more to keep up their weight.

Scientists are studying whether marijuana, THC, and related chemicals in marijuana (called cannabinoids) may have other medical uses. According to scientists, more research needs to be done on marijuana's side effects and potential benefits before it can be recommended for medical use. However, because of the adverse effects of smoking marijuana, research on other cannabinoids appears more promising for the development of new medications.

How can I prevent my child from getting involved with marijuana?

There is no magic bullet for preventing teen drug use. But parents can be influential by talking to their children about the dangers of using marijuana and other drugs, and by remaining actively engaged in their children's lives. Even after teens enter high school, parents can stay involved in schoolwork, recreation, and social activities with their children's friends. Research shows that appropriate parental monitoring can reduce future drug use, even among those adolescents who may be prone to marijuana use, such as those who are rebellious, cannot control their emotions, and experience internal distress. To address the issue of drug abuse in your area, it is important to get involved in drug abuse prevention programs in your community or your child's school. Find out what prevention programs you and your children can participate in together.

Talking to your children about marijuana

As this booklet has shown, marijuana can pose a particular threat to the health and well-being of children and adolescents at a critical point in their lives - when they are growing, learning, maturing, and laying the foundation for their adult years. As a parent, your children look to you for help and guidance in working out problems and in making decisions, including the decision not to use drugs. As a role model, your decision to not use marijuana and other illegal drugs will reinforce your message to your children.

There are numerous resources, many right in your own community, where you can obtain information so that you can talk to your children about drugs. To find these resources, you can consult your local library, school, or community service organization.

The National Institute on Drug Abuse offers an extensive collection of publications, videotapes, and educational materials to help parents talk to their children about drug use. For more information on marijuana and other drugs, contact:

National Clearinghouse for Alcohol and Drug Information (NCADI)
P.O. Box 2345
Rockville, MD 20847
1-800-729-6686
(TDD Number 1-800-487-4889)

And/or visit NIDA's Web sites at:

www.drugabuse.gov
www.marijuana-info.org
www.teens.drugabuse.gov
Source: US Deparment of Health and Human Services
NIH Publication No. 07-4036
Printed 1995, Revised November 1998, Reprinted April 2001, February 2007
Revised November 2002, September 2004, August 2007

Reviewed by athealth on February 5, 2014.

What is a mathematics disorder?

Students with a mathematics disorder have problems with their math skills. Their math skills are significantly below normal considering the student's age, intelligence, and education. The poor math skills cause problems with the student's academic success and other important areas in the student's life.

What signs indicate a mathematics disorder?

Students with mathematics disorder have problems which can include the following:

• Writing or printing numbers
• Counting
• Adding and subtracting
• Working with mathematical signs such as +, -, x, and /
• Learning names that include numbers

Students who suffer from mathematics disorders frequently have:

• Low self-esteem
• Social problems
• Increased dropout rate at school

Mathematics disorders may also be associated with:

• Conduct disorder
• ADD/ADHD
• Depression
• Other learning disorders

Are there genetic factors associated with a mathematics disorder?

It is possible that some people have problems in math because of their genetic makeup. In contrast to some families whose members have great difficulty solving math problems, there are other families who tend to have members that consistently have a very high-level of math functioning.

At what age does mathematics disorder appear?

Mathematics disorder is usually brought to the attention of the child?s parents in second or third grade when math instruction becomes a very important part of the classroom teaching.

How often is mathematics disorder seen in our society?

Although it is difficult to determine exactly, about one percent (1%) of children in the United States suffer from a mathematics disorder.

How is mathematics disorder diagnosed?

Mathematics disorder may be discovered when a student shows poor functioning in several math skills. For instance, if a student has difficulty understanding and working with various math terms and concepts or identifying arithmetic symbols and signs, the student may have mathematics disorder. Also, mathematics disorder may be indicated when the child is unable to attend to details such as carrying numbers or has problems counting and memorizing the multiplication tables.

Although standardized, group testing is important, it alone should not be relied on in making this diagnosis. It is very important that special, psychoeducational tests be individually administered to the child to determine if this learning disorder is present. In administering the test the examiner should give special attention to the child?s ethnic and cultural background.

How is a mathematics disorder treated?

Treatment for mathematics disorder includes individual tutoring, placement in special math classrooms with expert math teachers, and other educational aids that focus on math skills.

What happens to someone with a mathematics disorder?

The course of mathematics disorder is varied. Some students go on to do well in math. Others, even with early intervention and remedial attention, continue to struggle with math in their adult years.

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.

Source: John L. Miller, MD

Reviewed by athealth on February 5, 2014.

A brown paper bag may hold the key to safer use of medications, according to health experts.

"A 'brown bag checkup' is the single best thing that patients can do to avoid medication mistakes and cut down on unnecessary medications," says Douglas Paauw, M.D., professor of medicine at the University of Washington in Seattle. "But I would estimate that only about 10 percent of people actually do it."

The checkup involves putting all of your medications and over-the-counter products in a brown paper bag and bringing them into your doctor's office. The bag should include any over-the-counter or prescription drugs, herbs, vitamins, dietary supplements, and topical treatments such as ointments and creams. "This kind of checkup is a good idea for anyone who takes medication, but particularly for older people who are the most likely to be taking several medications," Paauw says. The average 75-year-old has three chronic conditions and uses five prescription drugs, according to a report from the Merck Institute of Aging & Health.

Researchers at Pennsylvania State University found that when adults ages 65 to 91 were asked to bring in the brown paper bag containing their medicines, the list of medications in the bag was more complete than their official pharmacy records. And people with worse health consistently had poorer matches between the brown bags and the paperwork.

"If not a paper bag, then write out a list and bring that in," Paauw says. You could also share the information with your pharmacist, who can check for drug duplications, interaction problems, inappropriate dosing, and whether each drug is being given for the right indication.

The idea is to have at least one health care professional informed about everything that you take. "This should be done at least every year and preferably more often," Paauw says. "Some of my patients do it at every visit."

When the bottles and tubes are spread out on the table, the picture becomes clear. "When someone pulls out 10 bottles, then something might not be right and we can make adjustments," Paauw says. The doctor can also see that your multivitamin with iron is the reason your thyroid treatment isn't working. "Both iron and calcium supplements can interfere with the absorption of thyroid medicine," says Paauw, who gave a talk on common drug errors at the annual meeting of the American College of Physicians in April 2006.

Stephen Setter, Pharm.D., associate professor of pharmacotherapy at Washington State University in Spokane, says doubling up on therapy is another common problem. "Someone may be taking two products containing acetaminophen," which raises the risk of liver damage. Other common problems include expired medications and medications that are no longer needed, but were never reevaluated.

After you and your doctor settle on what you should be taking, then the next thing is for you to know the name of your medication and what it's for, says Karen Gunning, Pharm.D., associate professor of pharmacy practice at the University of Utah in Salt Lake City. "If an older person has memory problems or difficulty with comprehension, a family member or caregiver could help," Gunning says.

Setter cites an example in which one of his older patients mistakenly thought her glaucoma medication was for treating headaches. "So she was taking her eye medication only when she had a headache, but she should have been taking it every day to treat her eye disease," Setter says. Experts say that it's important to understand your medications because you are more likely to take the medicine correctly, more likely to know what to expect from the medication, and better able to report what you are taking to your doctors and pharmacist.

"Keep the list of medications in your wallet and let a family member know that you have it," Gunning suggests. "Patients should be able to take that list out at the dentist's office, an appointment with a specialist, or in an emergency," she says. "But it's not uncommon for an older patient to come to the hospital and say that their doctor gave them a white pill and that's all they know."

John Lowery, 87, Delphi, Ind., carries his medication list in his wallet, keeps it on his computer at home, and gives a copy of it to his primary care doctor every time he sees her. His oldest son, 65, lives nearby and also knows about the list.

Sticking With the Plan Setter, a pharmacist who helps older people manage their lives at home, says he often discovers that patients stray from their medication plan and that their doctor isn't aware of it. "I've seen a person's blood pressure go up because the patient hasn't been taking the medication, but the doctor thinks the drug isn't working," Setter says. "So a second medication is added or the dose is increased when the problem is really a compliance issue." Setter says that when this happens, he contacts the doctor and talks with the patient to reinforce the importance of two-way communication.

Robert Ferguson, M.D., chief of internal medicine at Union Memorial Hospital in Baltimore, says that intentional noncompliance with the regimen typically occurs because the patient can't afford the medicine or is worried about side effects. "When noncompliance is unintentional," Ferguson says, "it's usually because complying with the regimen became too difficult. It's so complex that it's too hard to keep it up."

Ferguson says he teaches medical residents that the regimen should be as simple as possible and effective, and should result in minimal side effects. "Sometimes, we can reduce the number of medications by treating two problems with one medication," Ferguson says. There also are ways to make the schedule simpler such as switching from a medicine that's given three times a day to another medicine that can be given once a day.

You can make sticking to a schedule easier by attaching the medications to meals or other daily activities. Lowery says this works for him. "The three medications that I need to take in the morning go on top of the refrigerator and I have them with breakfast," he says. "I take the others at night before bedtime."

For more complicated regimens, pill boxes with compartments can help. Pill boxes are also useful for people who have trouble opening pill bottles. Setter says, "You can ask for pre-filled pill boxes or request bottles without child-proof caps if no children live in or visit the home." Pharmacies usually charge a nominal fee for pre-filled pill boxes.

Everything from gadgets that beep to simple medication charts posted on the refrigerator can serve as reminders. "For some people, we color code the medication bottles or use a big picture of the sun to signal morning medications," Setter says.

Setter says he talks with many older people who are confused about the purpose of the drug and the instructions. "The typical scenario is that a patient has three new prescriptions and had to wait in the pharmacy for 30 minutes, so they just want to get the prescriptions filled and go," he says. "Health providers need to speak more slowly and take the time to explain, which can be a challenge," Setter says. "And patients should ask questions. But people get intimidated and don't want to ask or they feel like they don't have time to ask questions." Writing questions down is always a good idea, Setter says. "Family members and caregivers can help with this."

Examples of questions to ask about a new medication: What should I do if I forget a dose? Should I take the medicine before, during, or after meals? What should the timing be between each dose?

With some diseases, people may stop taking medication because they don't understand why they are taking it or don't feel that it helps. "But we don't want people to stop taking an osteoporosis drug and then have a fracture a year later," Setter says. "And with a diabetes drug, we are hoping to prevent blindness, amputation, and kidney disease."

Lowery, who has survived a heart attack and kidney failure, says he is diligent about managing his medications because he feels they improve his quality of life. From the pills that ease his joint pain to the drops that soothe his dry eyes, medications help him stay active. "I keep up a garden and go to bluegrass music festivals," Lowery says. He also visits Helen, his wife of 66 years, every day at the nursing home.

Managing Side Effects Most medication side effects are mild and may lessen over time. But if they are bothersome, you should discuss them with your doctor. The doctor may switch to a different drug or change the dose. "Neither patients nor physicians should shrug off side effects by chalking them up to old age," Setter says. "And side effects shouldn't be treated with more drugs."

Compared with younger people, older people can be more likely to experience some side effects, Ferguson says. Side effects may also be more troublesome than they would be for someone younger. There are no absolutes here. Some robust 85-year-olds can handle a medication better than a 50-year-old who has a lot of health problems. But generally, older people have a decline in liver and kidney function, which affects the way a drug is broken down and removed from the body. "The kidneys decline about 1 percent each year starting at age 40," Ferguson says. "Medication stays in the body longer and side effects can have bigger consequences in older people."

Examples of side effects that may affect older people more than younger people are dizziness, dry mouth, drowsiness, falls, depression, insomnia, nausea, and diarrhea. David Greeley, M.D., a neurologist at Northwest Neurological Institute in Spokane, says the effects of sedating antihistamines such as diphenhydramine can be disastrous in older people.

Diphenhydramine is commonly found in over-the-counter sleep aids such as Unisom Sleep Gels, Tylenol PM, and cold and allergy medicines such as Benadryl. Greeley says, "Whereas a younger person can take it at night and feel back to normal by morning, the medication can linger in the system of someone older, which may result in falls and confusion."

Paauw says diphenhydramine can also affect a man's prostate gland. "An older person who already has trouble urinating can end up in the emergency room with urinary retention," he says.

Another example is the drug Mirapex (pramipexole), a treatment for Parkinson's disease, for which there is an increased risk of hallucinations in people older than 65 compared with people younger than 65. "Quinolone antibiotics may also cause hallucinations," Paauw says. Examples of quinolone antibiotics include Cipro (ciprofloxacin), Levaquin (levofloxacin), and Floxin (ofloxacin).

In 2005, the Food and Drug Administration warned the public about the use of certain drugs called atypical antipsychotic drugs. The drugs are approved to treat schizophrenia and mania, but clinical studies of the drugs to treat behavioral disorders in older patients with dementia showed a higher death rate associated with their use when compared with patients receiving an inactive pill (placebo). The advisory applies to these antipsychotic drugs: Abilify (aripiprazole), Risperdal (risperidone), Zyprexa (olanzapine), Geodon (ziprasidone), Seroquel (quetiapine), and Clozaril (clozapine). Symbyax (olanzapine and fluoxetine), which is approved to treat depressive episodes associated with bipolar disorders, was also part of the advisory. The causes of death in older patients were varied, but most appeared to be related to the heart or pneumonia.

Reducing Errors Setter says that older adults sometimes inadvertently receive an initial dose of medication that's too high. "The dose may be totally appropriate for a younger adult," Setter says, "but with the aging process, an older adult is less able to tolerate the typical starting dose."

Health care providers try to find a balance that gives older people appropriate medications and appropriate doses. Experts say the philosophy has always been "start low and go slow" with dosing for older people because there are not enough clinical trial data in this age group for many drugs, especially in people ages 75 and older.

And because of the use of multiple medications, drug interactions are of concern. "Some interactions aren't necessarily harmful and can be easily managed," Setter says. "We want to prevent drug interactions that are dangerous."

Improving the knowledge base about how drugs work together is helpful, Setter says. "We have clinical guidelines that address individual diseases like Alzheimer's disease, Parkinson's, or diabetes. But there is a need for clinical guidelines with a geriatric slant--guidelines that can apply to a person who may have five co-existing diseases."

Drug-drug interactions occur when a drug may increase the effect of another drug or render it ineffective. Paauw says interactions involving warfarin (Coumadin) are the most common ones that result in hospitalization. Warfarin, a medication that thins the blood and helps prevent clots, is commonly prescribed to older people with an irregular heartbeat (atrial fibrillation) who are at risk of blood clots that can cause strokes.

Warfarin should not be taken with aspirin, ibuprofen, or other nonsteroidal anti-inflammatory drugs because of the increased risk of gastrointestinal bleeding. Warfarin also interacts with the antibiotic Bactrim (sulfamethoxazole), which is commonly used in older people. This combination can result in severe increased bleeding. The supplements Ginkgo biloba, garlic, ginger, and ginseng can also interact with warfarin.

Many interactions can be prevented with more communication between doctors and patients, as well as better coordination between all the health care professionals who see a particular patient, says Nicole Brandt, Pharm.D., director of clinical and educational programs at the Peter Lamy Center for Drug Therapy and Aging in Baltimore. She and her colleagues are partnering with a managed care system to study medication management in older patients who have been discharged from five hospitals. As part of the study, a pharmacist visits newly discharged patients to conduct a medication evaluation.

"The goal is to create a more integrated social and health care support system to improve adherence and reduce errors," Brandt says. "Ultimately, we want to decrease readmissions to the hospital."

Sarah Ray, Pharm.D., ambulatory clinical coordinator of pharmaceutical services at Aurora Health Care in Milwaukee, says that technology is increasingly playing a role in improving patient safety. "We'll notice if patients are discharged from the hospital on a different dose than what they were on when they were in the hospital or before entering the hospital," Ray says. "I then have to clarify with the doctor, and the prescription may have been written incorrectly." Ray says she's able to catch that kind of error because she works in an integrated health care system and has access to computerized information about what the patient was taking in the hospital. But that kind of error might not be caught at an independent pharmacy that does not have access to hospital records.

Ray says she thinks electronic prescribing will make a big difference in reducing medication errors. Electronic prescribing allows doctors to transmit prescriptions to pharmacies electronically. This method decreases errors caused by hard-to-read handwriting and automates the process of checking for drug interactions and allergies. The Medicare Prescription Drug Improvement and Modernization Act of 2003 established standards for electronic prescribing. Final standards will be set by the U.S. Department of Health and Human Services no later than April 2008.

By Michelle Meadows
FDA Consumer Magazine
July-August 2006

Reviewed by athealth on February 5, 2014.

Introduction: Mental Health Medications

Medications are used to treat the symptoms of mental disorders such as schizophrenia, depression, bipolar disorder (sometimes called manic-depressive illness), anxiety disorders, and attention deficit-hyperactivity disorder (ADHD). Sometimes medications are used with other treatments such as psychotherapy. This guide describes:

• Types of medications used to treat mental disorders
• Side effects of medications
• Directions for taking medications
• Warnings about medications from the U.S. Food and Drug Administration (FDA).

This booklet does not provide information about diagnosing mental disorders. Choosing the right medication, medication dose, and treatment plan should be based on a person's individual needs and medical situation, and under a doctor's care.

Information about medications is frequently updated. Check the FDA Web site  for the latest information on warnings, patient medication guides, or newly approved medications. Throughout this document you will see two names for medications—the generic name and in parenthesis, the trade name. An example is fluoxetine (Prozac). See the end of this document for a complete alphabetical listing of medications.

What are psychiatric medications?

Psychiatric medications treat mental disorders. Sometimes called psychotropic or psychotherapeutic medications, they have changed the lives of people with mental disorders for the better. Many people with mental disorders live fulfilling lives with the help of these medications. Without them, people with mental disorders might suffer serious and disabling symptoms.

How are medications used to treat mental disorders?

Medications treat the symptoms of mental disorders. They cannot cure the disorder, but they make people feel better so they can function.

Medications work differently for different people. Some people get great results from medications and only need them for a short time. For example, a person with depression may feel much better after taking a medication for a few months, and may never need it again. People with disorders like schizophrenia or bipolar disorder, or people who have long-term or severe depression or anxiety may need to take medication for a much longer time.

Some people get side effects from medications and other people don't. Doses can be small or large, depending on the medication and the person. Factors that can affect how medications work in people include:

• Type of mental disorder, such as depression, anxiety, bipolar disorder, and schizophrenia
• Age, sex, and body size
• Physical illnesses
• Habits like smoking and drinking
• Liver and kidney function
• Genetics
• Other medications and herbal/vitamin supplements
• Diet
• Whether medications are taken as prescribed.

What medications are used to treat schizophrenia?

Antipsychotic medications are used to treat schizophrenia and schizophrenia-related disorders. Some of these medications have been available since the mid-1950's. They are also called conventional "typical" antipsychotics. Some of the more commonly used medications include:

• Chlorpromazine (Thorazine)
• Haloperidol (Haldol)
• Perphenazine (generic only)
• Fluphenazine (generic only).

In the 1990's, new antipsychotic medications were developed. These new medications are called second generation, or "atypical" antipsychotics.

One of these medications was clozapine (Clozaril). It is a very effective medication that treats psychotic symptoms, hallucinations, and breaks with reality, such as when a person believes he or she is the president. But clozapine can sometimes cause a serious problem called agranulocytosis, which is a loss of the white blood cells that help a person fight infection. Therefore, people who take clozapine must get their white blood cell counts checked every week or two. This problem and the cost of blood tests make treatment with clozapine difficult for many people. Still, clozapine is potentially helpful for people who do not respond to other antipsychotic medications.

Other atypical antipsychotics were developed. All of them are effective. Agranulocytosis is less likely to occur with these medications than with clozapine, but it has been reported. These include:

• Risperidone (Risperdal)
• Olanzapine (Zyprexa)
• Quetiapine (Seroquel)
• Ziprasidone (Geodon)
• Aripiprazole (Abilify)
• Paliperidone (Invega)
• Lurasidone (Latuda)

The antipsychotics listed here are some of the medications used to treat symptoms of schizophrenia. Additional antipsychotics and other medications used for schizophrenia are listed in the chart at the end.

Note: The FDA issued a Public Health Advisory for atypical antipsychotic medications. The FDA determined that death rates are higher for elderly people with dementia when taking this medication. A review of data has found a risk with conventional antipsychotics as well. Antipsychotic medications are not FDA-approved for the treatment of behavioral disorders in patients with dementia.

What are the side effects?

Some people have side effects when they start taking these medications. Most side effects go away after a few days and often can be managed successfully. People who are taking antipsychotics should not drive until they adjust to their new medication. Side effects of many antipsychotics include:

• Drowsiness
• Dizziness when changing positions
• Blurred vision
• Rapid heartbeat
• Sensitivity to the sun
• Skin rashes
• Menstrual problems for women.

Atypical antipsychotic medications can cause major weight gain and changes in a person's metabolism. This may increase a person's risk of getting diabetes and high cholesterol.¹ A person's weight, glucose levels, and lipid levels should be monitored regularly by a doctor while taking an atypical antipsychotic medication.

Typical antipsychotic medications can cause side effects related to physical movement, such as:

• Rigidity
• Persistent muscle spasms
• Tremors
• Restlessness.

Long-term use of typical antipsychotic medications may lead to a condition called tardive dyskinesia (TD). TD causes muscle movements a person can't control. The movements commonly happen around the mouth. TD can range from mild to severe, and in some people the problem cannot be cured. Sometimes people with TD recover partially or fully after they stop taking the medication.

Every year, an estimated 5 percent of people taking typical antipsychotics get TD. The condition happens to fewer people who take the new, atypical antipsychotics, but some people may still get TD. People who think that they might have TD should check with their doctor before stopping their medication.

How are antipsychotics taken and how do people respond to them?

Antipsychotics are usually pills that people swallow, or liquid they can drink. Some antipsychotics are shots that are given once or twice a month.

Symptoms of schizophrenia, such as feeling agitated and having hallucinations, usually go away within days. Symptoms like delusions usually go away within a few weeks. After about six weeks, many people will see a lot of improvement.

However, people respond in different ways to antipsychotic medications, and no one can tell beforehand how a person will respond. Sometimes a person needs to try several medications before finding the right one. Doctors and patients can work together to find the best medication or medication combination, and dose.

Some people may have a relapse—their symptoms come back or get worse. Usually, relapses happen when people stop taking their medication, or when they only take it sometimes. Some people stop taking the medication because they feel better or they may feel they don't need it anymore. But no one should stop taking an antipsychotic medication without talking to his or her doctor. When a doctor says it is okay to stop taking a medication, it should be gradually tapered off, never stopped suddenly.

How do antipsychotics interact with other medications?

Antipsychotics can produce unpleasant or dangerous side effects when taken with certain medications. For this reason, all doctors treating a patient need to be aware of all the medications that person is taking. Doctors need to know about prescription and over-the-counter medicine, vitamins, minerals, and herbal supplements. People also need to discuss any alcohol or other drug use with their doctor.

To find out more about how antipsychotics work, the National Institute of Mental Health (NIMH) funded a study called CATIE (Clinical Antipsychotic Trials of Intervention Effectiveness). This study compared the effectiveness and side effects of five antipsychotics used to treat people with schizophrenia. In general, the study found that the older medication perphenazine worked as well as the newer, atypical medications. But because people respond differently to different medications, it is important that treatments be designed carefully for each person. You can find more information on CATIE here.

What medications are used to treat depression?

Depression is commonly treated with antidepressant medications. Antidepressants work to balance some of the natural chemicals in our brains. These chemicals are called neurotransmitters, and they affect our mood and emotional responses. Antidepressants work on neurotransmitters such as serotonin, norepinephrine, and dopamine.

The most popular types of antidepressants are called selective serotonin reuptake inhibitors (SSRIs). These include:

• Fluoxetine (Prozac)
• Citalopram (Celexa)
• Sertraline (Zoloft)
• Paroxetine (Paxil)
• Escitalopram (Lexapro).

Other types of antidepressants are serotonin and norepinephrine reuptake inhibitors (SNRIs). SNRIs are similar to SSRIs and include venlafaxine (Effexor) and duloxetine (Cymbalta). Another antidepressant that is commonly used is bupropion (Wellbutrin). Bupropion, which works on the neurotransmitter dopamine, is unique in that it does not fit into any specific drug type.

SSRIs and SNRIs are popular because they do not cause as many side effects as older classes of antidepressants. Older antidepressant medications include tricyclics, tetracyclics, and monoamine oxidase inhibitors (MAOIs). For some people, tricyclics, tetracyclics, or MAOIs may be the best medications.

What are the side effects?

Antidepressants may cause mild side effects that usually do not last long.Any unusual reactions or side effects should be reported to a doctor immediately.

The most common side effects associated with SSRIs and SNRIs include:

• Headache, which usually goes away within a few days.
• Nausea (feeling sick to your stomach), which usually goes away within a few days.
• Sleeplessness or drowsiness, which may happen during the first few weeks but then goes away. Sometimes the medication dose needs to be reduced or the time of day it is taken needs to be adjusted to help lessen these side effects.
• Agitation (feeling jittery).
• Sexual problems, which can affect both men and women and may include reduced sex drive, and problems having and enjoying sex.

Tricyclic antidepressants can cause side effects, including:

• Dry mouth.
• Constipation.
• Bladder problems. It may be hard to empty the bladder, or the urine stream may not be as strong as usual. Older men with enlarged prostate conditions may be more affected.
• Sexual problems, which can affect both men and women and may include reduced sex drive, and problems having and enjoying sex.
• Blurred vision, which usually goes away quickly.
• Drowsiness. Usually, antidepressants that make you drowsy are taken at bedtime.

People taking MAOIs need to be careful about the foods they eat and the medicines they take. Foods and medicines that contain high levels of a chemical called tyramine are dangerous for people taking MAOIs. Tyramine is found in some cheeses, wines, and pickles. The chemical is also in some medications, including decongestants and over-the-counter cold medicine.

Mixing MAOIs and tyramine can cause a sharp increase in blood pressure, which can lead to stroke. People taking MAOIs should ask their doctors for a complete list of foods, medicines, and other substances to avoid. An MAOI skin patch has recently been developed and may help reduce some of these risks. A doctor can help a person figure out if a patch or a pill will work for him or her.

How should antidepressants be taken?

People taking antidepressants need to follow their doctors' directions. The medication should be taken in the right dose for the right amount of time. It can take three or four weeks until the medicine takes effect. Some people take the medications for a short time, and some people take them for much longer periods. People with long-term or severe depression may need to take medication for a long time.

Once a person is taking antidepressants, it is important not to stop taking them without the help of a doctor. Sometimes people taking antidepressants feel better and stop taking the medication too soon, and the depression may return. When it is time to stop the medication, the doctor will help the person slowly and safely decrease the dose. It's important to give the body time to adjust to the change. People don't get addicted, or "hooked," on the medications, but stopping them abruptly can cause withdrawal symptoms.

If a medication does not work, it is helpful to be open to trying another one. A study funded by NIMH found that if a person with difficult-to-treat depression did not get better with a first medication, chances of getting better increased when the person tried a new one or added a second medication to his or her treatment. The study was called STAR*D (Sequenced Treatment Alternatives to Relieve Depression).^2,3.

Are herbal medicines used to treat depression?

The herbal medicine St. John's wort has been used for centuries in many folk and herbal remedies. Today in Europe, it is used widely to treat mild-to-moderate depression. In the United States, it is one of the top-selling botanical products.

The National Institutes of Health conducted a clinical trial to determine the effectiveness of treating adults who have major depression with St. Johns wort. The study included 340 people diagnosed with major depression. One-third of the people took the herbal medicine, one-third took an SSRI, and one-third took a placebo, or "sugar pill." The people did not know what they were taking. The study found that St. John's wort was no more effective than the placebo in treating major depression.⁴ A study currently in progress is looking at the effectiveness of St. John's wort for treating mild or minor depression.

Other research has shown that St. John's wort can dangerously interact with other medications, including those used to control HIV. On February 10, 2000, the FDA issued a Public Health Advisory letter stating that the herb appears to interfere with certain medications used to treat heart disease, depression, seizures, certain cancers, and organ transplant rejection. Also, St. Johns wort may interfere with oral contraceptives.

Because St. John's wort may not mix well with other medications, people should always talk with their doctors before taking it or any herbal supplement.

FDA warning on antidepressants

Antidepressants are safe and popular, but some studies have suggested that they may have unintentional effects, especially in young people. In 2004, the FDA looked at published and unpublished data on trials of antidepressants that involved nearly 4,400 children and adolescents. They found that 4 percent of those taking antidepressants thought about or tried suicide (although no suicides occurred), compared to 2 percent of those receiving placebos (sugar pill).

In 2005, the FDA decided to adopt a "black box" warning label—the most serious type of warning—on all antidepressant medications. The warning says there is an increased risk of suicidal thinking or attempts in children and adolescents taking antidepressants. In 2007, the FDA proposed that makers of all antidepressant medications extend the warning to include young adults up through age 24.

The warning also says that patients of all ages taking antidepressants should be watched closely, especially during the first few weeks of treatment. Possible side effects to look for are depression that gets worse, suicidal thinking or behavior, or any unusual changes in behavior such as trouble sleeping, agitation, or withdrawal from normal social situations. Families and caregivers should report any changes to the doctor. To find the latest information visit the FDA website .

Results of a comprehensive review of pediatric trials conducted between 1988 and 2006 suggested that the benefits of antidepressant medications likely outweigh their risks to children and adolescents with major depression and anxiety disorders.⁵ The study was funded in part by NIMH.

Finally, the FDA has warned that combining the newer SSRI or SNRI antidepressants with one of the commonly-used "triptan" medications used to treat migraine headaches could cause a life-threatening illness called "serotonin syndrome." A person with serotonin syndrome may be agitated, have hallucinations (see or hear things that are not real), have a high temperature, or have unusual blood pressure changes. Serotonin syndrome is usually associated with the older antidepressants called MAOIs, but it can happen with the newer antidepressants as well, if they are mixed with the wrong medications.

What medications are used to treat bipolar disorder?

Bipolar disorder, also called manic-depressive illness, is commonly treated with mood stabilizers. Sometimes, antipsychotics and antidepressants are used along with a mood stabilizer.

Mood stabilizers

People with bipolar disorder usually try mood stabilizers first. In general, people continue treatment with mood stabilizers for years. Lithium is a very effective mood stabilizer. It was the first mood stabilizer approved by the FDA in the 1970's for treating both manic and depressive episodes.

Anticonvulsant medications also are used as mood stabilizers. They were originally developed to treat seizures, but they were found to help control moods as well. One anticonvulsant commonly used as a mood stabilizer is valproic acid, also called divalproex sodium (Depakote). For some people, it may work better than lithium.⁶ Other anticonvulsants used as mood stabilizers are carbamazepine (Tegretol), lamotrigine (Lamictal) and oxcarbazepine (Trileptal).

Atypical antipsychotics

Atypical antipsychotic medications are sometimes used to treat symptoms of bipolar disorder. Often, antipsychotics are used along with other medications.

Antipsychotics used to treat people with bipolar disorder include:

• Olanzapine (Zyprexa), which helps people with severe or psychotic depression, which often is accompanied by a break with reality, hallucinations, or delusions⁷
• Aripiprazole (Abilify), which can be taken as a pill or as a shot
• Risperidone (Risperdal)
• Ziprasidone (Geodon)
• Clozapine (Clorazil), which is often used for people who do not respond to lithium or anticonvulsants.⁸
• Lurasidone (Latuda)

Antidepressants

Antidepressants are sometimes used to treat symptoms of depression in bipolar disorder. Fluoxetine (Prozac), paroxetine (Paxil), or sertraline (Zoloft) are a few that are used. However, people with bipolar disorder should not take an antidepressant on its own. Doing so can cause the person to rapidly switch from depression to mania, which can be dangerous.⁹ To prevent this problem, doctors give patients a mood stabilizer or an antipsychotic along with an antidepressant.

Research on whether antidepressants help people with bipolar depression is mixed. An NIMH-funded study found that antidepressants were no more effective than a placebo to help treat depression in people with bipolar disorder. The people were taking mood stabilizers along with the antidepressants. You can find out more about this study, called STEP-BD (Systematic Treatment Enhancement Program for Bipolar Disorder)¹⁰

What are the side effects?

Treatments for bipolar disorder have improved over the last 10 years. But everyone responds differently to medications. If you have any side effects, tell your doctor right away. He or she may change the dose or prescribe a different medication.

Different medications for treating bipolar disorder may cause different side effects. Some medications used for treating bipolar disorder have been linked to unique and serious symptoms, which are described below.

Lithium can cause several side effects, and some of them may become serious. They include:

• Loss of coordination
• Excessive thirst
• Frequent urination
• Blackouts
• Seizures
• Slurred speech
• Fast, slow, irregular, or pounding heartbeat
• Hallucinations (seeing things or hearing voices that do not exist)
• Changes in vision
• Itching, rash
• Swelling of the eyes, face, lips, tongue, throat, hands, feet, ankles, or lower legs.

If a person with bipolar disorder is being treated with lithium, he or she should visit the doctor regularly to check the levels of lithium in the blood, and make sure the kidneys and the thyroid are working normally.

Some possible side effects linked with valproic acid/divalproex sodium include:

• Changes in weight
• Nausea
• Stomach pain
• Vomiting
• Anorexia
• Loss of appetite.

Valproic acid may cause damage to the liver or pancreas, so people taking it should see their doctors regularly.

Valproic acid may affect young girls and women in unique ways. Sometimes, valproic acid may increase testosterone (a male hormone) levels in teenage girls and lead to a condition called polycystic ovarian syndrome (PCOS).^11,12 PCOS is a disease that can affect fertility and make the menstrual cycle become irregular, but symptoms tend to go away after valproic acid is stopped.¹³ It also may cause birth defects in women who are pregnant.

Lamotrigine can cause a rare but serious skin rash that needs to be treated in a hospital. In some cases, this rash can cause permanent disability or be life-threatening.

In addition, valproic acid, lamotrigine, carbamazepine, oxcarbazepine and other anticonvulsant medications (listed in the chart at the end of this document) have an FDA warning. The warning states that their use may increase the risk of suicidal thoughts and behaviors. People taking anticonvulsant medications for bipolar or other illnesses should be closely monitored for new or worsening symptoms of depression, suicidal thoughts or behavior, or any unusual changes in mood or behavior. People taking these medications should not make any changes without talking to their health care professional.

Other medications for bipolar disorder may also be linked with rare but serious side effects. Always talk with the doctor or pharmacist about any potential side effects before taking the medication.

For information on side effects of antipsychotics, see the section on medications for treating schizophrenia.

For information on side effects and FDA warnings of antidepressants, see the section on medications for treating depression.

How should medications for bipolar disorder be taken?

Medications should be taken as directed by a doctor. Sometimes a person's treatment plan needs to be changed. When changes in medicine are needed, the doctor will guide the change. A person should never stop taking a medication without asking a doctor for help.

There is no cure for bipolar disorder, but treatment works for many people. Treatment works best when it is continuous, rather than on and off. However, mood changes can happen even when there are no breaks in treatment. Patients should be open with their doctors about treatment. Talking about how treatment is working can help it be more effective.

It may be helpful for people or their family members to keep a daily chart of mood symptoms, treatments, sleep patterns, and life events. This chart can help patients and doctors track the illness. Doctors can use the chart to treat the illness most effectively.

Because medications for bipolar disorder can have serious side effects, it is important for anyone taking them to see the doctor regularly to check for possibly dangerous changes in the body.

What medications are used to treat anxiety disorders?

Antidepressants, anti-anxiety medications, and beta-blockers are the most common medications used for anxiety disorders.

Anxiety disorders include:

• Obsessive compulsive disorder (OCD)
• Post-traumatic stress disorder (PTSD)
• Generalized anxiety disorder (GAD)
• Panic disorder
• Social phobia.

Antidepressants

Antidepressants were developed to treat depression, but they also help people with anxiety disorders. SSRIs such as fluoxetine (Prozac), sertraline (Zoloft), escitalopram (Lexapro), paroxetine (Paxil), and citalopram (Celexa) are commonly prescribed for panic disorder, OCD, PTSD, and social phobia. The SNRI venlafaxine (Effexor) is commonly used to treat GAD. The antidepressant bupropion (Wellbutrin) is also sometimes used. When treating anxiety disorders, antidepressants generally are started at low doses and increased over time.

Some tricyclic antidepressants work well for anxiety. For example, imipramine (Tofranil) is prescribed for panic disorder and GAD. Clomipramine (Anafranil) is used to treat OCD. Tricyclics are also started at low doses and increased over time.

MAOIs are also used for anxiety disorders. Doctors sometimes prescribe phenelzine (Nardil), tranylcypromine (Parnate), and isocarboxazid (Marplan). People who take MAOIs must avoid certain food and medicines that can interact with their medicine and cause dangerous increases in blood pressure. For more information, see the section on medications used to treat depression.

Benzodiazepines (anti-anxiety medications)

The anti-anxiety medications called benzodiazepines can start working more quickly than antidepressants. The ones used to treat anxiety disorders include:

• Clonazepam (Klonopin), which is used for social phobia and GAD
• Lorazepam (Ativan), which is used for panic disorder
• Alprazolam (Xanax), which is used for panic disorder and GAD.

Buspirone (Buspar) is an anti-anxiety medication used to treat GAD. Unlike benzodiazepines, however, it takes at least two weeks for buspirone to begin working.

Clonazepam, listed above, is an anticonvulsant medication. See FDA warning on anticonvulsants under the bipolar disorder section.

Beta-blockers

Beta-blockers control some of the physical symptoms of anxiety, such as trembling and sweating. Propranolol (Inderal) is a beta-blocker usually used to treat heart conditions and high blood pressure. The medicine also helps people who have physical problems related to anxiety. For example, when a person with social phobia must face a stressful situation, such as giving a speech, or attending an important meeting, a doctor may prescribe a beta-blocker. Taking the medicine for a short period of time can help the person keep physical symptoms under control.

What are the side effects?

See the section on antidepressants for a discussion on side effects. The most common side effects for benzodiazepines are drowsiness and dizziness. Other possible side effects include:

• Upset stomach
• Blurred vision
• Headache
• Confusion
• Grogginess
• Nightmares.

Possible side effects from buspirone (BuSpar) include:

• Dizziness
• Headaches
• Nausea
• Nervousness
• Lightheadedness
• Excitement
• Trouble sleeping.

Common side effects from beta-blockers include:

• Fatigue
• Cold hands
• Dizziness
• Weakness.

In addition, beta-blockers generally are not recommended for people with asthma or diabetes because they may worsen symptoms.

How should medications for anxiety disorders be taken?

People can build a tolerance to benzodiazepines if they are taken over a long period of time and may need higher and higher doses to get the same effect. Some people may become dependent on them. To avoid these problems, doctors usually prescribe the medication for short periods, a practice that is especially helpful for people who have substance abuse problems or who become dependent on medication easily. If people suddenly stop taking benzodiazepines, they may get withdrawal symptoms, or their anxiety may return. Therefore, they should be tapered off slowly.

Buspirone and beta-blockers are similar. They are usually taken on a short-term basis for anxiety. Both should be tapered off slowly. Talk to the doctor before stopping any anti-anxiety medication.

What medications are used to treat ADHD?

Attention deficit/hyperactivity disorder (ADHD) occurs in both children and adults. ADHD is commonly treated with stimulants, such as:

• Methylphenidate (Ritalin, Metadate, Concerta, Daytrana)
• Amphetamine (Adderall)
• Dextroamphetamine (Dexedrine, Dextrostat).

In 2002, the FDA approved the nonstimulant medication atomoxetine (Strattera) for use as a treatment for ADHD. In February 2007, the FDA approved the use of the stimulant lisdexamfetamine dimesylate (Vyvanse) for the treatment of ADHD in children ages 6 to 12 years.

What are the side effects?

Most side effects are minor and disappear when dosage levels are lowered. The most common side effects include:

• Decreased appetite. Children seem to be less hungry during the middle of the day, but they are often hungry by dinnertime as the medication wears off.
• Sleep problems. If a child cannot fall asleep, the doctor may prescribe a lower dose. The doctor might also suggest that parents give the medication to their child earlier in the day, or stop the afternoon or evening dose. To help ease sleeping problems, a doctor may add a prescription for a low dose of an antidepressant or a medication called clonidine.
• Stomachaches and headaches.
• Less common side effects. A few children develop sudden, repetitive movements or sounds called tics. These tics may or may not be noticeable. Changing the medication dosage may make tics go away. Some children also may appear to have a personality change, such as appearing "flat" or without emotion. Talk with your child's doctor if you see any of these side effects.

How are ADHD medications taken?

Stimulant medications can be short-acting or long-acting, and can be taken in different forms such as a pill, patch, or powder. Long-acting, sustained and extended release forms allow children to take the medication just once a day before school. Parents and doctors should decide together which medication is best for the child and whether the child needs medication only for school hours or for evenings and weekends too.

ADHD medications help many children and adults who are hyperactive and impulsive. They help people focus, work, and learn. Stimulant medication also may improve physical coordination. However, different people respond differently to medications, so children taking ADHD medications should be watched closely.

Are ADHD medications safe?

Stimulant medications are safe when given under a doctor's supervision. Some children taking them may feel slightly different or "funny."

Some parents worry that stimulant medications may lead to drug abuse or dependence, but there is little evidence of this. Research shows that teens with ADHD who took stimulant medications were less likely to abuse drugs than those who did not take stimulant medications.¹⁴

FDA warning on possible rare side effects

In 2007, the FDA required that all makers of ADHD medications develop Patient Medication Guides. The guides must alert patients to possible heart and psychiatric problems related to ADHD medicine. The FDA required the Patient Medication Guides because a review of data found that ADHD patients with heart conditions had a slightly higher risk of strokes, heart attacks, and sudden death when taking the medications. The review also found a slightly higher risk (about 1 in 1,000) for medication-related psychiatric problems, such as hearing voices, having hallucinations, becoming suspicious for no reason, or becoming manic. This happened to patients who had no history of psychiatric problems.

The FDA recommends that any treatment plan for ADHD include an initial health and family history examination. This exam should look for existing heart and psychiatric problems.

The non-stimulant ADHD medication called atomoxetine (Strattera) carries another warning. Studies show that children and teenagers with ADHD who take atomoxetine are more likely to have suicidal thoughts than children and teenagers with ADHD who do not take atomoxetine. If your child is taking atomoxetine, watch his or her behavior carefully. A child may develop serious symptoms suddenly, so it is important to pay attention to your child's behavior every day. Ask other people who spend a lot of time with your child, such as brothers, sisters, and teachers, to tell you if they notice changes in your child's behavior. Call a doctor right away if your child shows any of the following symptoms:

• Acting more subdued or withdrawn than usual
• Feeling helpless, hopeless, or worthless
• New or worsening depression
• Thinking or talking about hurting himself or herself
• Extreme worry
• Agitation
• Panic attacks
• Trouble sleeping
• Irritability
• Aggressive or violent behavior
• Acting without thinking
• Extreme increase in activity or talking
• Frenzied, abnormal excitement
• Any sudden or unusual changes in behavior.

While taking atomoxetine, your child should see a doctor often, especially at the beginning of treatment. Be sure that your child keeps all appointments with his or her doctor.

Which groups have special needs when taking psychiatric medications?

Psychiatric medications are taken by all types of people, but some groups have special needs, including:

• Children and adolescents
• Older adults
• Women who are pregnant or may become pregnant.

Children and adolescents

Most medications used to treat young people with mental illness are safe and effective. However, many medications have not been studied or approved for use with children. Researchers are not sure how these medications affect a child's growing body. Still, a doctor can give a young person an FDA-approved medication on an "off-label" basis. This means that the doctor prescribes the medication to help the patient even though the medicine is not approved for the specific mental disorder or age.

For these reasons, it is important to watch young people who take these medications. Young people may have different reactions and side effects than adults. Also, some medications, including antidepressants and ADHD medications, carry FDA warnings about potentially dangerous side effects for young people. See the sections on antidepressants and ADHD medications for more information about these warnings.

More research is needed on how these medications affect children and adolescents. NIMH has funded studies on this topic. For example, NIMH funded the Preschoolers with ADHD Treatment Study (PATS), which involved 300 preschoolers (3 to 5 years old) diagnosed with ADHD. The study found that low doses of the stimulant methylphenidate are safe and effective for preschoolers. However, children of this age are more sensitive to the side effects of the medication, including slower growth rates. Children taking methylphenidate should be watched closely.^15,16,17

In addition to medications, other treatments for young people with mental disorders should be considered. Psychotherapy, family therapy, educational courses, and behavior management techniques can help everyone involved cope with the disorder. See information on child and adolescent mental health research.

Older adults

Because older people often have more medical problems than other groups, they tend to take more medications than younger people, including prescribed, over-the-counter, and herbal medications. As a result, older people have a higher risk for experiencing bad drug interactions, missing doses, or overdosing.

Older people also tend to be more sensitive to medications. Even healthy older people react to medications differently than younger people because their bodies process it more slowly. Therefore, lower or less frequent doses may be needed.

Sometimes memory problems affect older people who take medications for mental disorders. An older adult may forget his or her regular dose and take too much or not enough. A good way to keep track of medicine is to use a seven-day pill box, which can be bought at any pharmacy. At the beginning of each week, older adults and their caregivers fill the box so that it is easy to remember what medicine to take. Many pharmacies also have pillboxes with sections for medications that must be taken more than once a day.

Women who are pregnant or may become pregnant

The research on the use of psychiatric medications during pregnancy is limited. The risks are different depending on what medication is taken, and at what point during the pregnancy the medication is taken. Research has shown that antidepressants, especially SSRIs, are safe during pregnancy. Birth defects or other problems are possible, but they are very rare.^18,19

However, antidepressant medications do cross the placental barrier and may reach the fetus. Some research suggests the use of SSRIs during pregnancy is associated with miscarriage or birth defects, but other studies do not support this.²⁰ Studies have also found that fetuses exposed to SSRIs during the third trimester may be born with "withdrawal" symptoms such as breathing problems, jitteriness, irritability, trouble feeding, or hypoglycemia (low blood sugar).

Most studies have found that these symptoms in babies are generally mild and short-lived, and no deaths have been reported. On the flip side, women who stop taking their antidepressant medication during pregnancy may get depression again and may put both themselves and their infant at risk.^20,21

In 2004, the FDA issued a warning against the use of certain antidepressants in the late third trimester. The warning said that doctors may want to gradually taper pregnant women off antidepressants in the third trimester so that the baby is not affected.²² After a woman delivers, she should consult with her doctor to decide whether to return to a full dose during the period when she is most vulnerable to postpartum depression.

Some medications should not be taken during pregnancy. Benzodiazepines may cause birth defects or other infant problems, especially if taken during the first trimester. Mood stabilizers are known to cause birth defects. Benzodiazepines and lithium have been shown to cause "floppy baby syndrome," which is when a baby is drowsy and limp, and cannot breathe or feed well.

Research suggests that taking antipsychotic medications during pregnancy can lead to birth defects, especially if they are taken during the first trimester. But results vary widely depending on the type of antipsychotic. The conventional antipsychotic haloperidol has been studied more than others, and has been found not to cause birth defects.^23,24

After the baby is born, women and their doctors should watch for postpartum depression, especially if they stopped taking their medication during pregnancy. In addition, women who nurse while taking psychiatric medications should know that a small amount of the medication passes into the breast milk. However, the medication may or may not affect the baby. It depends on the medication and when it is taken. Women taking psychiatric medications and who intend to breastfeed should discuss the potential risks and benefits with their doctors.

Decisions on medication should be based on each woman's needs and circumstances. Medications should be selected based on available scientific research, and they should be taken at the lowest possible dose. Pregnant women should be watched closely throughout their pregnancy and after delivery.

What should I ask my doctor if I am prescribed a psychiatric medication?

You and your family can help your doctor find the right medications for you. The doctor needs to know your medical history; family history; information about allergies; other medications, supplements or herbal remedies you take; and other details about your overall health. You or a family member should ask the following questions when a medication is prescribed:

• What is the name of the medication?
• What is the medication supposed to do?
• How and when should I take it?
• How much should I take?
• What should I do if I miss a dose?
• When and how should I stop taking it?
• Will it interact with other medications I take?
• Do I need to avoid any types of food or drink while taking the medication? What should I avoid?
• Should it be taken with or without food?
• Is it safe to drink alcohol while taking this medication?
• What are the side effects? What should I do if I experience them?
• Is the Patient Package Insert for the medication available?

After taking the medication for a short time, tell your doctor how you feel, if you are having side effects, and any concerns you have about the medicine.

Alphabetical List of Medications

This section identifies antipsychotic medications, antidepressant medications, mood stabilizers, anticonvulsant medications, anti-anxiety medications, and ADHD medications. Some medications are marketed under trade names, not all of which can be listed in this publication. The first chart lists the medications by trade name; the second chart lists the medications by generic name. If your medication does not appear in this section, refer to the FDA Web site . Also, ask your doctor or pharmacist for more information about any medication.

Medications Organized by Trade Name

Trade Name	Generic Name	FDA Approved Age
Combination Antipsychotic and Antidepressant Medication
Symbyax (Prozac & Zyprexa)	fluoxetine & olanzapine	18 and older
Antipsychotic Medications
Abilify	aripiprazole	10 and older for bipolar disorder, manic or mixed episodes; 13 to 17 for schizophrenia and bipolar;
Clozaril	clozapine	18 and older
Fanapt	iloperidone	18 and older
fluphenazine (generic only)	fluphenazine	18 and older
Geodon	ziprasidone	18 and older
Haldol	haloperidol	3 and older
Invega	paliperidone	18 and older
Latuda	lurasidone	18 and older
Loxitane	loxapine	18 and older
Moban	molindone	18 and older
Navane	thiothixene	18 and older
Orap (for Tourette's syndrome)	pimozide	12 and older
perphenazine (generic only)	perphenazine	18 and older
Risperdal	risperidone	13 and older for schizophrenia; 10 and older for bipolar mania and mixed episodes; 5 to 16 for irritability associated with autism
Seroquel	quetiapine	13 and older for schizophrenia; 18 and older for bipolar disorder; 10-17 for treatment of manic and mixed episodes of bipolar disorder.
Stelazine	trifluoperazine	18 and older
thioridazine (generic only)	thioridazine	2 and older
Thorazine	chlorpromazine	18 and older
Zyprexia	olanzapine	18 and older; ages 13-17 as second line treatment for manic or mixed episodes of bipolar disorder and schizophrenia.

Trade Name	Generic Name	FDA Approved Age
Antidepressant Medications (also used for anxiety disorders)
Anafranil (tricyclic)	clomipramine	10 and older (for OCD only)
Asendin	amoxapine	18 and older
Aventyl (tricyclic)	nortriptyline	18 and older
Celexa (SSRI)	citalopram	18 and older
Cymbalta (SNRI)	duloxetine	18 and older
Desyrel	trazodone	18 and older
Effexor (SNRI)	venlafaxine	18 and older
Elavil (tricyclic)	amitriptyline	18 and older
Emsam	selegiline	18 and older
Lexapro (SSRI)	escitalopram	18 and older; 12 - 17 (for major depressive disorder)
Ludiomil (tricyclic)	maprotiline	18 and older
Luvox (SSRI)	fluvoxamine	8 and older (for OCD only)
Marplan (MAOI)	isocarboxazid	18 and older
Nardil (MAOI)	phenelzine	18 and older
Norpramin (tricyclic)	desipramine	18 and older
Pamelor (tricyclic)	nortriptyline	18 and older
Parnate (MAOI)	tranylcypromine	18 and older
Paxil (SSRI)	paroxetine	18 and older
Pexeva (SSRI)	paroxetine-mesylate	18 and older
Pristiq	desvenlafaxine (SNRI)	18 and older
Prozac (SSRI)	fluoxetine	8 and older
Remeron	mirtazapine	18 and older
Sarafem (SSRI)	fluoxetine	18 and older for premenstrual dysphoric disorder (PMDD)
Sinequan (tricyclic)	doxepin	12 and older
Surmontil (tricyclic)	trimipramine	18 and older
Tofranil (tricyclic)	imipramine	6 and older (for bedwetting)
Tofranil-PM (tricyclic)	imipramine pamoate	18 and older
Vivactil (tricyclic)	protriptyline	18 and older
Wellbutrin	bupropion	18 and older
Zoloft (SSRI)	sertraline	6 and older (for OCD only)

Trade Name	Generic Name	FDA Approved Age
Mood Stabilizing and Anticonvulsant Medications
Depakote	divalproex sodium (valproic acid)	2 and older (for seizures)
Eskalith	lithium carbonate	12 and older
Lamictal	lamotrigine	18 and older
lithium citrate (generic only)	lithium citrate	12 and older
Lithobid	lithium carbonate	12 and older
Neurontin	gabapentin	18 and older
Tegretol	carbamazepine	any age (for seizures)
Topamax	topiramate	18 and older
Trileptal	oxcarbazepine	4 and older

Trade Name	Generic Name	FDA Approved Age
Anti-anxiety Medications (All of these anti-anxiety medications are benzodiazepines, except BuSpar)
Ativan	lorazepam	18 and older
BuSpar	buspirone	18 and older
Klonopin	clonazepam	18 and older
Librium	chlordiazepoxide	18 and older
oxazepam (generic only)	oxazepam	18 and older
Tranxene	clorazepate	18 and older
Valium	diazepam	18 and older
Xanax	alprazolam	18 and older

Trade Name	Generic Name	FDA Approved Age
ADHD Medications (All of these ADHD medications are stimulants, except Intuniv and Straterra.)
Adderall	amphetamine	3 and older
Adderall XR	amphetamine (extended release)	6 and older
Concerta	methylphenidate (long acting)	6 and older
Daytrana	methylphenidate patch	6 and older
Desoxyn	methamphetamine	6 and older
Dexedrine	dextroamphetamine	3 and older
Dextrostat	dextroamphetamine	3 and older
Focalin	dexmethylphenidate	6 and older
Focalin XR	dexmethylphenidate (extended release)	6 and older
Intuniv	guanfacine	6 and older
Metadate ER	methylphenidate (extended release)	6 and older
Metadate CD	methylphenidate (extended release)	6 and older
Methylin	methylphenidate (oral solution and chewable tablets)	6 and older
Ritalin	methylphenidate	6 and older
Ritalin SR	methylphenidate (extended release)	6 and older
Ritalin LA	methylphenidate (long-acting)	6 and older
Strattera	atomoxetine	6 and older
Vyvanse	lisdexamfetamine dimesylate	6 and older

Medications Organized by Generic Name

Generic Name	Trade Name	FDA Approved Age
Combination Antipsychotic and Antidepressant Medication
fluoxetine & olanzapine	Symbyax (Prozac & Zyprexa)	18 and older
Antipsychotic Medications
aripiprazole	Abilify	10 and older for bipolar disorder, manic or mixed episodes; 13 to 17 for schizophrenia and bipolar;
chlorpromazine	Thorazine	18 and older
clozapine	Clozaril	18 and older
fluphenazine (generic only)	fluphenazine	18 and older
haloperidol	Haldol	3 and older
iloperidone	Fanapt	18 and older
loxapine	Loxitane	18 and older
lurasidone	Latuda	18 and older
molindone	Moban	18 and older
olanzapine	Zyprexa	18 and older; ages 13-17 as second line treatment for manic or mixed episodes of bipolar disorder and schizophrenia
paliperidone	Invega	18 and older
perphenazine (generic only)	perphenazine	18 and older
pimozide (for Tourette's syndrome)	Orap	12 and older
quetiapine	Seroquel	13 and older for schizophrenia; 18 and older for bipolar disorder; 10-17 for treatment of manic and mixed episodes of bipolar disorder
risperidone	Risperdal	13 and older for schizophrenia; 10 and older for bipolar mania and mixed episodes; 5 to 16 for irritability associated with autism
thioridazine (generic only)	thioridazine	2 and older
thiothixene	Navane	18 and older
trifluoperazine	Stelazine	18 and older
ziprasidone	Geodon	18 and older

Generic Name	Trade Name	FDA Approved Age
Antidepressant Medications (also used for anxiety disorders)
amitriptyline (tricyclic)	Elavil	18 and older
amoxapine	Asendin	18 and older
bupropion	Wellbutrin	18 and older
citalopram (SSRI)	Celexa	18 and older
clomipramine (tricyclic)	Anafranil	10 and older (for OCD only)
desipramine (tricyclic)	Norpramin	18 and older
desvenlafaxine (SNRI)	Pristiq	18 and older
doxepin (tricyclic)	Sinequan	12 and older
duloxetine (SNRI)	Cymbalta	18 and older
escitalopram (SSRI)	Lexapro	18 and older; 12 - 17 (for major depressive disorder)
fluoxetine (SSRI)	Prozac	8 and older
fluoxetine (SSRI)	Sarafem	18 and older for premenstrual dysphoric disorder (PMDD)
fluvoxamine (SSRI)	Luvox	8 and older (for OCD only)
imipramine (tricyclic)	Tofranil	6 and older (for bedwetting)
imipramine pamoate (tricyclic)	Tofranil-PM	18 and older
isocarboxazid (MAOI)	Marplan	18 and older
maprotiline (tricyclic)	Ludiomil	18 and older
mirtazapine	Remeron	18 and older
nortriptyline (tricyclic)	Aventyl, Pamelor	18 and older
paroxetine (SSRI)	Paxil	18 and older
paroxetine mesylate (SSRI)	Pexeva	18 and older
phenelzine (MAOI)	Nardil	18 and older
protriptyline (tricyclic)	Vivactil	18 and older
selegiline	Emsam	18 and older
sertraline (SSRI)	Zoloft	6 and older (for OCD only)
tranylcypromine (MAOI)	Parnate	18 and older
trazodone	Desyrel	18 and older
trimipramine (tricyclic)	Surmontil	18 and older
venlafaxine (SNRI)	Effexor	18 and older

Generic Name	Trade Name	FDA Approved Age
Mood Stabilizing and Anticonvulsant Medications
carbamazepine	Tegretol	any age (for seizures)
divalproex sodium (valproic acid)	Depakote	2 and older (for seizures)
gabapentin	Neurontin	18 and older
lamotrigine	Lamictal	18 and older
lithium carbonate	Eskalith, Lithobid	12 and older
lithium citrate (generic only)	lithium citrate	12 and older
oxcarbazepine	Trileptal	4 and older
topiramate	Topamax	18 and older

Generic Name	Trade Name	FDA Approved Age
Anti-anxiety Medications (All of these anti-anxiety medications are benzodiazepines, except buspirone.)
alprazolam	Xanax	18 and older
buspirone	BuSpar	18 and older
chlordiazepoxide	Librium	18 and older
clonazepam	Klonopin	18 and older
clorazepate	Tranxene	18 and older
diazepam	Valium	18 and older
lorazepam	Ativan	18 and older
oxazepam (generic only)	oxazepam	18 and older

Generic Name	Trade Name	FDA Approved Age
ADHD Medications (All of these ADHD medications are stimulants, except atomoxetine and guanfacine)
amphetamine	Adderall	3 and older
amphetamine (extended release)	Adderall XR	6 and older
atomoxetine	Strattera	6 and older
dexmethylphenidate	Focalin	6 and older
dexmethylphenidate (extended release)	Focalin XR	6 and older
dextroamphetamine	Dexedrine, Dextrostat	3 and older
guanfacine	Intuniv	6 and older
lisdexamfetamine dimesylate	Vyvanse	6 and older
methamphetamine	Desoxyn	6 and older
methylphenidate	Ritalin	6 and older
methylphenidate (extended release)	Metadate CD, Metadate ER, Ritalin SR	6 and older
methylphenidate (long-acting)	Ritalin LA, Concerta	6 and older
methylphenidate patch	Daytrana	6 and older
methylphenidate (oral solution and chewable tablets)	Methylin	6 and older

Citations

1. Lieberman JA, Stroup TS, McEvoy JP, Swartz MS, Rosenheck RA, Perkins DO, Keefe RS, Davis SM, Davis CE, Lebowitz BD, Severe J, Hsiao JK; Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE). Effectiveness of antipsychotic drugs in patients with chronic schizophrenia. New England Journal of Medicine. 2005 Sep 22;353(12):1209-1223.

2. Rush JA, Trivedi MH, Wisniewski SR, Stewart JW, Nierenberg AA, Thase ME, Ritz L, Biggs MM, Warden D, Luther JF, Shores-Wilson K, Niederehe G, Fava M. Bupropion-SR, sertraline, or venlafaxine-XR after failure of SSRIs for depression. New England Journal of Medicine. 2006 Mar 23; 354(12):1231-1242.

3. Trivedi MH, Fava M, Wisniewski SR, Thase ME, Quitkin F, Warden D, Ritz L, Nierenberg AA, Lebowitz BD, Biggs MM, Luther JF, Shores-Wilson K, Rush JA. Medication augmentation after the failure of SSRIs for depression. New England Journal of Medicine. 2006 Mar 23; 354(12): 1243-1252.

4. Hypericum Depression Trial Study Group. Effect of Hypericum perforatum (St. John's wort) in major depressive disorder: a randomized controlled trial. Journal of the American Medical Association. 2002; 287(14): 1807-1814.

5. Bridge JA, Iyengar S, Salary CB, Barbe RP, Birmaher B, Pincus HA, Ren L, Brent DA. Clinical response and risk for reported suicidal ideation and suicide attempts in pediatric antidepressant treatment, a meta-analysis of randomized controlled trials. Journal of the American Medical Association. 2007; 297(15): 1683-1696.

6. Bowden CL, Calabrese JR, McElroy SL, Gyulai L, Wassef A, Petty F, Pope HG, Jr., Chou JC, Keck PE, Jr., Rhodes LJ, Swann AC, Hirschfeld RM, Wozniak PJ, Group DMS. A randomized, placebo-controlled 12-month trial of divalproex and lithium in treatment of outpatients with bipolar I disorder. Archives of General Psychiatry. 2000 May; 57(5):481-489.

7. Rothschild AJ, Bates KS, Boehringer KL, Syed A. Olanzapine response in psychotic depression. Journal of Clinical Psychiatry. 1999 Feb; 60(2):116-118.

8. Suppes T, Webb A, Paul B, Carmody T, Kraemer H, Rush AJ. Clinical outcome in a randomized 1-year trial of clozapine versus treatment as usual for patients with treatment-resistant illness and a history of mania.American Journal of Psychiatry. 1999 Aug;156(8): 1164-1169.

9. Thase ME, Sachs GS. Bipolar depression: pharmacotherapy and related therapeutic strategies. Biological Psychiatry. 2000 Sep 15;48(6):558-572.

10. Sachs G, Nierenberg AA, Calabrese JR, Marangell LB, Wisniewski SR, Gyulai L, Friedman ES, Bowden CL, Fossey MD, Ostacher MJ, Ketter TA, Patel J, Hauser P, Rapport D, Martinez JM, Allen MH, Miklowitz DJ, Otto MW, Dennehy EB, Thase ME. Effectiveness of adjunctive antidepressant treatment for bipolar depression: a double-blind placebo-controlled study. New England Journal of Medicine. Epub 28 Mar 2007; 356(17): 1771-1773.

11. Vainionpaa LK, Rattya J, Knip M, Tapanainen JS, Pakarinen AJ, Lanning P, Tekay A, Myllyla VV, Isojarvi JI. Valproate-induced hyperandrogenism during pubertal maturation in girls with epilepsy. Annals of Neurology. 1999 Apr;45(4):444-450.

12. Joffe H, Cohen LS, Suppes T, McLaughlin WL, Lavori P, Adams JM, Hwang CH, Hall JE, Sachs GS. Valproate is associated with new-onset oligoamenorrhea with hyperandrogenism in women with bipolar disorder. Biological Psychiatry. 2006 Jun 1;59(11):1078-1086.

13. Joffe H, Cohen LS, Suppes T, Hwang CH, Molay F, Adams JM, Sachs GS, Hall JE. Longitudinal follow-up of reproductive and metabolic features of valproate-associated polycystic ovarian syndrome features: A preliminary report. Biological Psychiatry. 2006 Dec 15;60(12):1378-1381.

14. Wilens TC, Faraone, SV, Biederman J, Gunawardene S. Does stimulant therapy of attention-deficit/hyperactivity disorder beget later substance abuse? A meta-analytic review of the literature. Pediatrics. 2003; 111(1):179-185.

15. Swanson J, Greenhill L, Wigal T, Kollins S, Stehli A, Davies M, Chuang S, Vitiello B, Skroballa A, Posner K, Abikoff H, Oatis M, McCracken J, McGough J, Riddle M, Ghouman J, Cunningham C, Wigal S. Stimulant-related reductions in growth rates in the PATS. Journal of the Academy of Child and Adolescent Psychiatry. 2006 Nov; 45(11): 1304-1313.

16. Greenhill L, Kollins S, Abikoff H, McCracken J, Riddle M, Swanson J, McGough J, Wigal S, Wigal T, Vitiello B, Skroballa A, Posner K, Ghuman J, Cunningham C, Davies M, Chuang S, Cooper T. Efficacy and safety of immediate-release methylphenidate treatment for preschoolers with attention-deficit/hyperactivity disorder. Journal of the Academy of Child and Adolescent Psychiatry. 2006 Nov; 45(11):1284-1293.

17. Wigal T, Greenhill L, Chuang S, McGough J, Vitiello B, Skrobala A, Swanson J, Wigal S, Abikoff H, Kollins S, McCracken J, Riddle M, Posner K, Ghuman J, Davies M, Thorp B, Stehli A. Safety and tolerability of methylphenidate in preschool children with attention-deficit/hyperactivity disorder. Journal of the Academy of Child and Adolescent Psychiatry. 2006 Nov; 45(11): 1294-1303.

18. Alwan S, Reefhuis J, Rasmussen S, Olney R, Friedman J for the National Birth Defects Prevention Study. Use of selective serotonin-reuptake inhibitors in pregnancy and the risk of birth defects. New England Journal of Medicine. 2007 Jun 28; 356(26):2684-2692.

19. Louik C, Lin An, Werler M, Hernandez S, Mitchell A. First-trimester use of selective serotonin-reuptake inhibitors and the risk of birth defects. New England Journal of Medicine. 2007 Jun 28; 356(26):2675-2683.

20. Austin M. To treat or not to treat: maternal depression, SSRI use in pregnancy and adverse neonatal effects. Psychological Medicine. 2006 Jul 25; 1-8.

21. Cohen L, Altshuler L, Harlow B, Nonacs R, Newport DJ, Viguera A, Suri R, Burt V, Hendrick AM, Loughead A, Vitonis AF, Stowe Z. Relapse of major depression during pregnancy in women who maintain or discontinue antidepressant treatment. Journal of the American Medical Association. 2006 Feb 1; 295(5): 499-507.

22. U.S. Food and Drug Administration (FDA). FDA Medwatch drug alert on Effexor and SSRIs, 2004 Jun 3. Available at www.fda.gov/medwatch/safety/2004/safety04.htm#effexor.

23. Jain AE, Lacy T. Psychotropic drugs in pregnancy and lactation.Journal of Psychiatric Practice. 2005 May; 11(3): 177-191.

24. Ward RK, Zamorski MA. Benefits and risks of psychiatric medications during pregnancy. American Family Physician. 15 Aug. 2002; 66(4): 629-636.

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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
National Institutes of Health
NIH Publication No. 08-3929
Revised 2008

Reviewed by athealth on February 6, 2014.

by Judith E. Pearson, PhD

What is Hypnosis or Trance?

Hypnosis is a method of communication that induces a trance or a trance-like state. Hypnosis can be conducted by one individual addressing another, or it may be conducted with the self (self-hypnosis). Trance is a naturally occurring state in which one's attention is narrowly focused and relatively free of distractions. The attention may be focused either internally (on thoughts---internal self-talk or images or both) or externally (on a task, a book, or a movie, for example). The focus of attention is so narrow that other stimuli in the environment are ignored or blocked out of conscious awareness for a time. Examples of trance states are daydreaming and some forms of meditation.

As an adjunct to psychotherapy, hypnosis can help clients enter a relaxed, comfortable, trance state for obtaining specific therapeutic outcomes. With clinical hypnosis, the therapist can make suggestions designed to help the client formulate specific internal processes (feelings, memories, images and internal self-talk) that will lead to mutually-agreed-upon outcomes.

Hypnotic suggestions can influence behavior when the listener is

(a) relaxed, receptive and open to the suggestions
(b) experiences visual, auditory, and/or kinesthetic representations of the suggestions
(c) anticipates and envisions that these suggestions will result in future outcomes.

These three criteria are facilitated through the use of "hypnotic language patterns." Hypnotic language patterns include: guided visualization, stories, guided memories, analogies, ambiguous words or phrases, repetition, and statements about association, meaning, and cause-effect.

Myths and Misconceptions about Hypnosis

Hypnosis is not mind control or brainwashing. People change their minds and actions throughout their lives. When such changes occur as a result of exposure to specific information, it is because this information has been presented through persuasion and influence. A hypnotherapist uses communicative methods of persuasion and influence; so do people who advertise and market goods and services; so do teachers, politicians, lawyers, entertainers, parents, and ministers.

During trance, you are not immobilized. You know exactly where you are the entire time. You can adjust your position, scratch, sneeze, or cough. You can open your eyes and bring yourself out of trance at any time you wish. During trance, you can still hear sounds around you, like a phone ringing. You can alert yourself and respond to any situation that needs your immediate attention. You remain oriented as to person, place, and time. You can even hold a conversation in trance.

Trance is not sleep, although some people get so relaxed in trance that they may fall asleep. This is no problem because some part of the mind continues to listen to the voice of the hypnotherapist. In trance, sleeping subjects can still follow instructions such as moving a finger, taking a deep breath, or awakening themselves when they are told to do so.

There is no "right" way to experience trance. One person may experience it as a deep, heavy restful feeling, while another may experience it as a light, floating sensation. Some people hear every word spoken by the therapist, while others allow their minds to drift to other thoughts. Some experience vivid imagery, while others do not. Some people remember the suggestions they hear, and some do not. Every person's experience of hypnosis is unique.

Hypnosis cannot cause anyone to do something against their will or that contradicts their values. First, a hypnotherapist is ethically required to make only those suggestions that support agreed-upon outcomes. Second, clients are not receptive to suggestions that go against their morals or values---because receptivity is one of the ingredients of success in hypnosis.

Remember: hypnosis cannot solve every problem. Even with hypnosis, it may still be necessary for you to do some conscientious planning and research about the types of changes you want to achieve. You must still take action to get results. Hypnosis is not a cure-all. Hypnosis can be effective in many cases, but there are no guarantees that hypnosis will work for you.

Risks and Precautions

Hypnosis carries very few risks. Hypnosis may be contraindicated for individuals with certain medical problems, or who are actively abusing drugs or alcohol, or who are delusional or hallucinatory. Hypnosis should not be used for physical problems, such as pain, unless the client has first consulted a physician to determine underlying physical causes.

Formal hypnotic methods are not recommended for small children, because children lack the necessary attention span. More interactive treatment methods can be used, however, such as art therapy, play therapy, storytelling, and guided visualization, during which helpful suggestions can be made to the child.

Hypnosis is often requested for the purpose of uncovering childhood memories. Hypnosis may or may not work in this regard. When memories do surface, the client may have a "false memory" and there is no guarantee that such memories are accurate or based on reality. Such memories may be uncomfortable and distressing, but not always.

Sometimes after trancework, the client may feel somewhat disoriented. The therapist and the client can work together to make sure the client is fully alert and energized sufficiently to leave the therapist's office and continue the day's activity. In very rare cases, after a hypnotic session, and client may experience mildly disturbing thoughts or feelings. If this happens, the client should call the therapist immediately for a follow-up session.

Ericksonian Hypnosis

The kind of hypnotherapy most frequently practiced in psychotherapy today is "Ericksonian Hypnosis," named after the late Milton H. Erickson, M.D. From the 1930's to the 1980's Dr. Erickson was very influential in bringing the use of clinical hypnosis into the fields of medicine and psychotherapy. He taught and practiced a kind of hypnosis that was gentle, permissive, and respectful of the client. He established the National Association for Clinical Hypnosis and published the first professional journals and monographs on the therapeutic uses of hypnosis. The Ericksonian Foundation continues his work. Hundreds of books and articles have been written about Dr. Erickson and his methods. Dr. Erickson has been regarded as the leading hypnotherapist in the world.

Applications of Hypnotherapy

Hypnosis has many applications in therapeutic settings. Among them are:

• Building Confidence
• Relaxation During Childbirth
• Treating Phobias, Fears and Anxiety
• Sleep Disorders and Disturbances
• Interpersonal Problems
• Depression
• Sexual Difficulties
• Psychosomatic Complaints
• Post Trauma Relief
• Pain Management
• Stress Management
• Habit Control
• Academic Performance
• Athletic Performance
• Help with Life Transitions
• Preparation for Medical/Dental Procedures
• Blocks to Motivation and Creativity
• Treatment of Grief and Loss

Credentialing of Hypnotherapists

A hypnotherapist is a licensed or certified mental health professional who has obtained specialized, post graduate training and certification in the use of clinical hypnosis within the context of counseling, psychotherapy, or other medical specialty.

About the author:

Judy Pearson, PhD is a licensed professional counselor and has a private practice in Springfield, Virginia. Her phone number is 703-764-0753. She is certified in clinical hypnosis and neuro-linguistic programming. She offers individual counseling and therapy for adults in the following areas: stress and depression, fear of public speaking, sexual problems, pain management, health concerns, survivor issues, phobias and anxiety, low self-esteem, habit control, sleep disorders and relationship issues. She works to eliminate blocks to motivation, creativity, and self-confidence.

Page last modified or reviewed by athealth.com on February 1, 2014

Club drugs are a pharmacologically heterogeneous group of psychoactive drugs that tend to be abused by teens and young adults at bars, nightclubs, concerts, and parties. Gamma hydroxybutyrate (GHB), Rohypnol, ketamine, as well as MDMA (ecstasy) and methamphetamine (which are featured in separate InfoFacts) are some of the drugs included in this group.

• GHB (Xyrem) is a central nervous system (CNS) depressant that was approved by the Food and Drug Administration (FDA) in 2002 for use in the treatment of narcolepsy (a sleep disorder). This approval came with severe restrictions, including its use only for the treatment of narcolepsy, and the requirement for a patient registry monitored by the FDA. GHB is also a metabolite of the inhibitory neurotransmitter gamma-aminobutyric acid (GABA). It exists naturally in the brain, but at much lower concentrations than those found when GHB is abused.
• Rohypnol (flunitrazepam) use began gaining popularity in the United States in the early 1990s. It is a benzodiazepine (chemically similar to sedative-hypnotic drugs such as Valium or Xanax), but it is not approved for medical use in this country, and its importation is banned.
• Ketamine is a dissociative anesthetic, mostly used in veterinary practice.

How Are Club Drugs Abused?

GHB and Rohypnol are available in odorless, colorless, and tasteless forms that are frequently combined with alcohol and other beverages. Both drugs have been used to commit sexual assaults (also known as “date rape,” “drug rape,” “acquaintance rape,” or “drug-assisted” assault) due to their ability to sedate and incapacitate unsuspecting victims, preventing them from resisting sexual assault.

GHB is usually ingested orally, either in liquid or powder form, while Rohypnol is typically taken orally in pill form. Recent reports, however, have shown that Rohypnol is being ground up and snorted.

Both GHB and Rohypnol are also abused for their intoxicating effects, similar to other CNS depressants.

GHB also has anabolic effects (it stimulates protein synthesis) and has been used by bodybuilders to aid in fat reduction and muscle building.

Ketamine is usually snorted or injected intramuscularly.

How Do Club Drugs Affect the Brain?

GHB acts on at least two sites in the brain: the GABAB receptor and a specific GHB binding site. At high doses, GHB’s sedative effects may result in sleep, coma, or death.

Rohypnol, like other benzodiazepines, acts at the GABAA receptor. It can produce anterograde amnesia, in which individuals may not remember events they experienced while under the influence of the drug.

Ketamine is a dissociative anesthetic, so called because it distorts perceptions of sight and sound and produces feelings of detachment from the environment and self. Ketamine acts on a type of glutamate receptor (NMDA receptor) to produce its effects, which are similar to those of the drug PCP., Low-dose intoxication results in impaired attention, learning ability, and memory. At higher doses, ketamine can cause dreamlike states and hallucinations; and at higher doses still, ketamine can cause delirium and amnesia.

Addictive Potential

Repeated use of GHB may lead to withdrawal effects, including insomnia, anxiety, tremors, and sweating. Severe withdrawal reactions have been reported among patients presenting from an overdose of GHB or related compounds, especially if other drugs or alcohol are involved.

Like other benzodiazepines, chronic use of Rohypnol can produce tolerance, physical dependence, and addiction.

There have been reports of people binging on ketamine, a behavior that is similar to that seen in some cocaine- or amphetamine-dependent individuals. Ketamine users can develop signs of tolerance and cravings for the drug.

What Other Adverse Effects Do Club Drugs Have on Health?

Uncertainties about the sources, chemicals, and possible contaminants used to manufacture many club drugs make it extremely difficult to determine toxicity and associated medical consequences. Nonetheless, we do know that:

Coma and seizures can occur following use of GHB. Combined use with other drugs such as alcohol can result in nausea and breathing difficulties. GHB and two of its precursors, gamma butyrolactone (GBL) and 1,4 butanediol (BD), have been involved in poisonings, overdoses, date rapes, and deaths.

Rohypnol may be lethal when mixed with alcohol and/or other CNS depressants.

Ketamine, in high doses, can cause impaired motor function, high blood pressure, and potentially fatal respiratory problems.

What Treatment Options Exist?

There is very little information available in the scientific literature about treatment for persons who abuse or are dependent upon club drugs.

There are no GHB detection tests for use in emergency rooms, and as many clinicians are unfamiliar with the drug, many GHB incidents likely go undetected. According to case reports, however, patients who abuse GHB appear to present both a mixed picture of severe problems upon admission and a good response to treatment, which often involves residential services.3

Treatment for Rohypnol follows accepted protocols for any benzodiazepine, which may consist of a 3- to 5-day inpatient detoxification program with 24-hour intensive medical monitoring and management of withdrawal symptoms, since withdrawal from benzodiazepines can be life-threatening.3

Patients with a ketamine overdose are managed through supportive care for acute symptoms, with special attention to cardiac and respiratory functions.

How Widespread Is Club Drug Abuse?

Monitoring the Future (MTF) Survey*

MTF has reported consistently low levels of abuse of these club drugs since they were added to the survey. For GHB and ketamine, this occurred in 2000; for Rohypnol, 1996. According to results of the 2009 MTF survey, 0.7 percent of 8th-grade and 1.1 percent of 12th-grade students reported past-year** use of GHB, a statistically significant decrease from peak-year use of 1.2 percent in 2000 for 8th-graders and 2.0 percent for 12th-graders in 2004. GHB use among 10th-grade students was reported at 1.0 percent, an increase from 2008 (0.5 percent), and statistically unchanged from peak use of 1.4 percent in 2002 and 2003.

Past-year use of ketamine was reported by 1.0 percent of 8th-graders, 1.3 percent of 10th-graders, and 1.7 percent of 12th-graders in 2009. These percentages also represent significant decreases from peak years: 2000 for 8th-graders (at 1.6 percent) and 2002 for 10th- and 12th-graders (at 2.2 and 2.6 percent, respectively).

For Rohypnol, 0.4 percent of 8th- and 10th-graders, and 1.0 percent of 12th-graders reported past-year use, also down from peak use in 1996 for 8th-graders (1.0 percent), 1997 for 10th-graders (1.3 percent), and 2002 and 2004 for 12th-graders (1.6 percent).

Other Information Sources

For more information about club drugs, visit www.clubdrugs.gov, www.teens.drugabuse.gov, and www.backtoschool.drugabuse.gov; or call NIDA at 877-643-2644. For street terms searchable by drug name, street term, cost and quantities, drug trade, and drug use, visit http://www.whitehousedrugpolicy.gov/streetterms/default.asp.

Data Sources

* These data are from the 2009 Monitoring the Future survey, funded by the National Institute on Drug Abuse, National Institutes of Health, Department of Health and Human Services, and conducted annually by the University of Michigan’s Institute for Social Research. The survey has tracked 12th-graders’ illicit drug use and related attitudes since 1975; in 1991, 8th- and 10th-graders were added to the study.

** “Lifetime” refers to use at least once during a respondent’s lifetime. “Past year” refers to use at least once during the year preceding an individual’s response to the survey. “Past month” refers to use at least once during the 30 days preceding an individual’s response to the survey.

References

1 Anis NA, Berry SC, Burton NR, Lodge D. The dissociative anaesthetics, datamine and phencyclidine, selectively reduce excitation of central mammalian neurons by N-methyl-aspartate. Br J Pharmacol 79(2): 565–575, 1983.

2 Kapur S, Seeman P. NMDA receptor antagonists ketamine and PCP have direct effects on dopamine D2 and serotonin 5-HT2 receptors – Implications for models of schizophrenia. Molecular Psychiatry 7: 837–844, 2002.

3 Maxwell JC, Spence RT. Profiles of club drug users in treatment. Subst Use Misuse 40(9–10):1409–1426, 2005.

4 Jansen KL, Darracot-Cankovic R. The nonmedical use of ketamine, part two: A review of problem use and dependence. J Psychoactive Drugs 33(2):151–158, 2001.

5 Smith KM, Larive LL, Romanelli F. Club Drugs: Methylenedioxymethamphetamine, flunitrazepam, ketamine hydrochloride, and ?–hydroxybutyrate. Am J Health-Syst Pharm 59(11):1067–1076, 2002.

National Institute on Drug Abuse
Revised 7/10

Page last modified or reviewed by athealth.com on February 1, 2014

by Kathleen M. Carroll, PhD
Yale University

CONTENTS

Foreword

Cognitive-Behavioral Therapy: An Overview

• Why CBT?
• Components of CBT
  • Functional Analysis
  • Skills Training
  • Critical Tasks
• Parameters of CBT
  • Format
  • Length
  • Setting
  • Patients
  • Compatibility With Adjunctive Treatments
• Active Ingredients of CBT
  • Essential and Unique Interventions
  • Recommended But Not Unique Interventions
  • Acceptable Interventions
  • Interventions Not Part of CBT
• CBT Compared to Other Treatments
  • Similar Approaches
    • Cognitive Therapy
    • Community Reinforcement Approach
    • Motivational Enhancement Therapy
  • Dissimilar Approaches
    • Twelve-Step Facilitation
    • Interpersonal Psychotherapy

Basic Principles of CBT

• Learned Behavior
  • Modeling
  • Operant Conditioning
  • Classical Conditioning
• Functional Analysis
  • Deficiencies and Obstacles
  • Skills and Strengths
  • Determinants of Cocaine Use
  • Relevant Domains
  • Assessment Tools
• Skills Training
  • Learning Strategies Aimed at Cessation of Cocaine Use
  • Generalizable Skills
  • Basic Skills First
  • Match Material to Patient Needs
  • Use Repetition
  • Practice Mastering Skills
    • Give a Clear Rationale
    • Get a Commitment
    • Anticipate Obstacles
    • Monitor Closely
    • Use the Data
    • Explore Resistance
    • Praise Approximations

The Structure and Format of Sessions

• 20/20/20 Rule
• First Third of Session
  • Assess Patient Status
    • Urine Tests
    • Problem Solving
  • Listen for Current Concerns
  • Discuss the Practice Exercise
• Second Third of Session
  • Introduce the Topic
  • Relate Topic to Current Concerns
  • Explore Reactions
• Final Third of Session
  • Assign a Practice Exercise
  • Anticipate High-Risk Situations
• Topics

Integrating CBT and Medication

Session 1: Introduction to Treatment and CBT

• Session Goals
• Key Interventions
  • History and Relationship Building
  • Enhance Motivation
  • Negotiate Treatment Goals
  • Present the CBT Model
  • Establish Treatment Ground Rules
  • Introduce Functional Analysis
• Practice Exercise

Topic 1: Coping With Craving

• Session Goals
• Key Interventions
  • Understanding Craving
  • Describing Craving
  • Identifying Triggers
  • Avoiding Cues
  • Coping With Craving
    • Distraction
    • Talking About Craving
    • Going With the Craving
    • Recalling Negative Consequences
    • Using Self-Talk
• Practice Exercises

Topic 2: Shoring Up Motivation and Commitment to Stop

• Session Goals
• Key Interventions
  • Clarify Goals
  • Address Ambivalence About Abstinence
  • Identifying and Coping With Thoughts About Cocaine
    • Recognize
    • Avoid
    • Cope
• Practice Exercises

Topic 3: Refusal Skills/Assertiveness

• Session Goals
• Key Interventions
  • Assess Cocaine Availability
  • Handling Suppliers
  • Cocaine Refusal Skills
    • Within-Session Role-Play
    • Passive, Aggressive, and Assertive Responding
  • Remind Patients of Termination
• Practice Exercises

Topic 4: Seemingly Irrelevant Decisions

• Session Goals
• Key Interventions
  • Understand Seemingly Irrelevant Decisions
  • Identify Personal Examples
  • Practice Safe Decision-making
• Practice Exercise

Topic 5: An All-Purpose Coping Plan

• Session Goals
• Key Interventions
  • Anticipate High-Risk Situations
  • Develop a Coping Plan
• Practice Exercise

Topic 6: Problemsolving

• Session Goals
• Key Interventions
  • Introduce the Basic Steps
  • Practice Problem-solving Skills
• Practice Exercise

Topic 7: Case Management

• Session Goals
• Key Interventions
  • Problem Identification
  • Goal Setting
  • Resource Identification
  • Specifying a Plan
  • Monitoring Progress
• Practice Exercise

Topic 8: HIV Risk Reduction

• Session Goals
• Key Interventions
  • Assess Risk
  • Build Motivation to Change
  • Set Goals
  • Problem-solve Barriers
  • Provide Specific Guidelines
• Practice Exercise

Significant Other Session

• Session Goals
• Key Interventions
  • Plan Ahead
  • Provide Information/Set Goals
  • Identify Strategies
• Practice Exercise

Final Session: Termination

• Session Goals

Appendix A: Therapist Selection, Training, and Supervision

• Therapist Training
  • Didactic Seminar
  • Supervised Training Cases
  • Rating of Therapists
    • Therapist Checklist
    • Rating Scale
  • Certification of Therapists
• Ongoing Supervision
  • Guidelines
  • Common Problems Encountered in Supervision
    • Balance
    • Speeding Through Material
    • Overwhelming the Patient
    • Unclear Strategies
    • No Specific Examples
    • Downplaying Practice Exercises
    • Abandoning the Manual With Difficult Patients

Appendix B: Clinical Research Supporting CBT

• CBT and Interpersonal Therapy
• CBT and Clinical Management
  • CBT and Depressive Symptoms
  • CBT and Alexithymia
  • One-Year Follow-up
• CBT and Alcoholic Cocaine Abusers

References

Acknowledgements

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Disclaimer
The opinions expressed herein are the views of the author and do not necessarily reflect the official policy or position of the National Institute on Drug Abuse or any other part of the U.S. Department of Health and Human Services.

Public Domain Notice
All material appearing in this report except the forms (Exhibit 9, Exhibit 13 and Exhibit 14) is in the public domain and may be reproduced without permission from the National Institute on Drug Abuse or the author. Citation of the source is appreciated.

National Institute on Drug Abuse
NIH Publication Number 98-4308
Printed April 1998

Page last modified or reviewed by athealth on February 1, 2014