Normal Feelings and Emotions versus Psychiatric Illness
There may be some confusion about what is normal and what is psychiatric illness. This is because, in psychiatry, the names of illnesses are the same as normal emotions or feelings. If you go to your family practice doctor and they tell you that you have depression, the first thing you may think is, “doesn’t everyone have times when they are depressed”. The same is true if the doctor told you that you had an anxiety problem. Though some other medical disorders have the same problem in terms of nomenclature, such as having high blood pressure, for the most part, we understand the differences between what is normal and what is a disease. In psychiatry, it is more confusing because most of the population does not understand psychiatric illness.
Everyone has at least four feelings: depression, anxiety, anger and contentment. Feelings are part of our sensory input information that helps us to understand what is going on in our environment. Feelings are like vision, sound, touch, and smell. On occasion, a feeling will occur such as depression, when you do not understand why you feel depressed. This is not a psychiatric illness but a normal response to a change in your life. Your depression is telling you what is missing in your environment that is essential to having a full life.
As spring time moves into April, you may realize that you are more anxious, especially around money. You finally realize that you must do your taxes. Your anxiety gave you information that was critical for an awareness of an important upcoming event. This is not a psychiatric illness but your emotions helping you to focus on what you must do.
Anger is another feeling that is critical to help us set limits with people. Some have been taught as a child that anger is not an acceptable feeling and should be avoided but the reality is that we are all prewired with these feelings and we cannot ignore them but should try to understand them. There is a difference between being angry and communicating your anger to protect yourself from being taken advantage of versus having rage with screaming and overreacting to everything. That would be a psychiatric problem if the raging and anger was frequent and destructive in a relationship, but appropriate anger is not a psychiatric problem.
Depression as a Medical Illness
If over at least a two-week period, you had trouble sleeping, lost your appetite, lost five pounds, started to come in late to work, had decrease sexual desire, and your boss tells you that your work was not of the same quality that you usually perform, you may be in a Major Depressive Episode. This is a psychiatric illness that can occur because of a series of losses in your life or because you are genetically predetermined to have this episode. The criteria to make the diagnosis are that you have at least 5 symptoms out of a list of nine. Other symptoms include diminished ability to think or concentrate, recurrent thoughts of death or suicidal thinking, have agitation or have psychomotor retardation (essentially moving and thinking slow).
If you have two or three Major Depressive Episodes, you may have a Major Depressive Disorder. This is a medical disease like diabetes or hypertension. In the same way as diabetes and hypertension, a Major Depressive Disorder is a life-long illness though it cycles. You may have an episode that lasts a few months then you get better for a few months then it occurs again. The problem though is that the cycling is not predictable, and it can occur any time it wants. 8% of women and 7% of men have a Major Depressive Disorder. Usually, there is a family history, and the average age of onset is between 18 to 25 though you usually begin to have depressive symptoms after puberty. 80% of those with a Major Depressive Disorder also have a Generalized Anxiety Disorder (see below).
Most of the time, a Major Depressive Episode occurs because you have a Major Depressive Disorder. It is rare to have just one episode unless you have experienced a series of major losses in your life such as being fired from your job, getting divorced, having a major medical problem, and your dog dying all in one month. What is important here is that with the Disorder, you must continue to take an antidepressant medication for the rest of your life just as if you had diabetes or hypertension.
Many people with a Major Depressive Disorder will not accept the fact that they have this medical problem. Once they finally accept that they are in an episode, they will rationalize that it is because of how they have been treated or because of events in their life but will not accept that they have a “psychiatric disorder”. This is just human nature. No one wants to believe that there is something wrong with them, especially a psychiatric medical illness. You may believe that accepting this diagnosis means that you are weak and inadequate. Once you can finally accept that you have this medical disease, then you can accept what you will have to do to get the relief that comes with appropriate medical treatment.
The treatment of a Major Depression is medication and psychotherapy. If you are lucky enough to get on an antidepressant that gives you immediate relief, you will still need to do psychotherapy for at least 8 to 12 weeks to understand how the depression has affected your life and self-image. No one realizes that they have a Major Depression, gets on an antidepressant and gets into recovery in three weeks. By the time you realize that you have a problem, usually months to years have gone by and you have taken on the identity of being depressed and feeling inadequate. This will not change because you feel better. Most people will not want to do this and will stay inadequately treated if they do not get involved in psychotherapy.
Psychotherapy is not just a discussion with your best friend, your minister, or your spouse. Psychotherapy is presenting your life history and present situation to a psychotherapist who has been trained to do psychotherapy. This is someone you do not know personally who will help you to find the person you used to be before the Major Depression. The result of the therapy will be much more positive than you can imagine.
Unfortunately, some people with this disorder do not seek treatment early and the depression becomes so severe that they feel hopeless and want to kill themselves. They can also become totally dysfunctional in terms of making decisions, hygiene, and taking care of their home. When this happens, they are dangerous to themselves, are not able to take care of themselves, and need to be admitted to an inpatient psychiatric program for their safety. Usually, the inpatient stay will last about a week during which time they will recover from the more severe stage of their illness. They will need at least another month to stabilize enough to get back into their full routine. This amount of time can be compared to having a heart attack or having severe pneumonia.
During this month, they should be in a Partial Hospitalization Program (PHP) where they will be in groups for therapy, obtain knowledge about their illness through lectures, and have the structure of being with other people going through the same thing as well as making themselves get out of the house and be in a daily routine. The PHP lasts 6 hours a day and, depending on the need, some stay in our recovery residence as well. Most will be in PHP from 2 to 3 weeks then transition to a week or two of Intensive Outpatient Program (IOP) which is the same group, but they stay only 3 hours a day. They are then discharged to outpatient, individual therapy with a psychotherapist and medication management by a psychiatrist.
Another type of a depressive disorder is a Dysthymic Disorder. This is a medical disease consisting of a depressed mood for most of the day, for more days than not, as indicated either by subjective account or observation by others for at least 2 years. They are not suicidal and their ability to think and make decisions is not poor other than they see the world in a pessimistic and negative way. Any changes in their life is looked at as a glass of water that is half empty instead of half full. Medication does not treat this type of depression, but psychotherapy does. The therapist helps the patient to look at life in a more positive way suggesting that the patient’s interpretation of others and events may be seen differently than how they have seen them. A double depression is the combination of a Major Depression with a Dysthymic Disorder.
The Anxiety Disorders
Generalized Anxiety Disorder is a genetic, medical illness that occurs in 9% of men and 7% of females. Individuals with this illness have significant anxiety in every aspect of their life such that it affects their functioning and have had it for at least 6 months. The age of onset of this illness is the same as a Major Depression though it also usually begins just after puberty and can rarely be seen in children. Most people with this illness do not see it as an illness and assume that they just need to “shake it off” or “man-up” so they keep it to themselves because of their shame that they cannot deal with it. Unfortunately, they avoid those places, people, crowds, and jobs that make them more anxious and end up keeping more to themselves not realizing that they have a treatable medical illness.
The treatment is medication and psychotherapy for the same reasons as the depressive disorders. The standard of care is an antidepressant medication even if depression is not there. The complete term for an antidepressant is an antidepressant/antianxiety medication but it is too long of a term to say. It takes at least two weeks for an antidepressant to work to give relief of the anxiety and it may take up to 6 weeks for the medication to reach the maximum benefit for a specific dose (i.e. Prozac 20 mg) of an antidepressant. Treating anxiety disorders is more like treating thyroid disease or other endocrine disorders which takes that long for a medication to start giving relief.
When anxiety becomes severe, those individuals are not able to function and make poor decisions. They may also have a Major Depressive Episode and may have a Major Depressive Disorder. 80% of those with an anxiety disorder also have a depressive disorder. They may need to be hospitalized in an inpatient unit for the same reasons as those with a severe Major Depression. After stabilization they will need to then go to a PHP and/or an IOP program to return to a baseline before returning to their normal routine. There is no quick treatment for this disorder. If the patient tries to return to work too soon, they will relapse causing feelings of hopelessness. Their employer may then question whether they can continue to be employed, and there may be relationship failures leading to divorce and broken friendships.
Buspar and benzodiazepines (Xanax, Klonopin, Ativan, Valium) are also used to treat anxiety disorders. The difference between these two medications is that Buspar will start working in a week or two but will cover the anxiety 24/7 so that there are no mood swings in relation to the medication dose. The benzodiazepines give you relief within an hour of taking them, but they do not accumulate so they require a three to four time per day dosing which creates mood swings as they kick in and then wear off. Also, the benzodiazepines usually develop a tolerance, meaning that the benefits of a specific dose of the medication decreases over weeks to months requiring higher doses of the medication. The higher doses can cause more sedation, mental slowing, and slower physical response times which affects driving or operating machinery. If you have an addiction you cannot take a benzodiazepine because it can cause you to relapse on your drug of choice.
Most people with an anxiety disorder do not seek help early because of denial and shame. By the time their life is totally messed up because of the anxiety, they want help immediately which means they want a benzodiazepine. If they depend on a benzodiazepine as their main treatment for the anxiety disorder, it will not cover the scope of the illness and may cause an addiction to the benzodiazepine. Everyone should be on an antidepressant as the core treatment because it covers 24/7.
A panic attack may be a part of an anxiety disorder. This is an involuntary physical and emotional response that can occur without a stimulus event though it usually occurs because of a situation that is causing the patient anxiety and fear. The patient can break out into a sweat, have trouble breathing and have a heaviness in their chest. They feel that something horrible is happening to them medically and are afraid they may be having a heart attack. The attack lasts anywhere from 20 min or longer and once it finally stops, the patient is exhausted and afraid.
A Social Phobia is a medical illness causing anxiety when they are around more than 3 or 4 more people. They are not anxious when they are alone or with one or 2 other people but in a group, they become very uncomfortable, may break out into a sweat or have wet palms, have an increased heart rate, and feel convinced that they will do something that will humiliate themselves such as having a panic attack. These are not just shy people. These individuals avoid groups which can be a real handicap for work, relationships, and avoiding places they would like to be. This medical illness is also treated with an antidepressant and psychotherapy. In most cases, the anxiety can be totally relieved.
Bipolar Disorder
Bipolar Disorder is a group of medical diseases made up of several specific disorders. Bipolar Disorder, Type 1 means that the individual has had at least one manic episode in their lifetime. It makes up about 1% of the population or better explained as around 60,000 individuals in the Atlanta metropolitan area. The patient can also have a Major Depressive Episode which can be severe. The manic episode and the depressive episode cycles in and out without any predictability.
A manic episode is a dramatic change in mood that may include:
- Feeling unusually “high” and optimistic or extremely irritable.
- Unrealistic, grandiose beliefs about one’s abilities or powers.
- Sleeping very little, but feeling extremely energetic (usually going 3 or more days without sleep).
- Talking so rapidly that others can’t keep up.
- Racing thoughts; jumping quickly from one idea to the next.
- Highly distractible, unable to concentrate.
- Impaired judgment and impulsiveness.
- Acting recklessly without thinking about the consequences.
- Delusions and hallucinations (in severe cases).
Usually, this change in mood occurs over several days, lasts several weeks or months, and causes gross dysfunction in the person’s life. They usually do not believe that they are having a problem and will be resistant to any attempts to treat the mania. Many drink a great amount of alcohol and/or use drugs of abuse which may make them calmer initially but usually makes the mania worse. They will eventually cycle out of the mania and they can cycle back into it in a few weeks or months.
Bipolar illness, Type 1 is psychiatry’s most genetic illness. We know the gene on the chromosome that causes this medical illness. If one parent has this disorder, their child has a 10% chance of having the illness. If two parents have the disorder, their child has a 70% chance of having the illness.
Treatment requires immediate hospitalization because their judgment is so impaired that they can hurt themselves or others by driving too fast, getting in fights, spending large amounts of money on things they cannot afford, having unprotected sex with people they do not know, and the list goes on. Usually, the patient will have to be admitted to a hospital. Each day that the mania is present, their brain swells from inflammation and this damages the neurons (brain cells). The mania and their behavior get worse with each day. The patient is not able to take care of themselves or make appropriate decisions. They are grossly impaired and will require a week or two of inpatient treatment many times against their will.
They will need to be started on a mood stabilizer as the main medication. Depakote is the most used mood stabilizer for a manic episode and lithium is the second most used. Unfortunately, these medications take 5 to 10 days to stabilize the mania so other short acting mood stabilizers will be used several times a day such as Zyprexa, Risperdal, Abilify, Latuda, and several more. Once the acute phase of the illness is stabilized such that they are sleeping 6 to 8 hours a night, it will take another 4 to 6 weeks before their judgment is stable enough to make any major decisions. Unfortunately, they will continue to believe that they are doing good and will be angry that the treatment team believes that more treatment will be necessary in PHP (partial hospitalization program) which happens 5 days a week, from 9am until 3pm. Many patients will need to stay in our recovery residence to prevent them from making poor decisions outside of the hospital such as drinking, spending money, and getting in trouble with the law.
The good news is that once the appropriate mood stabilizer is started and the patient completely recovers, having another manic episode is rare, if they continue to take the medication and do not use alcohol or other drugs of abuse. Unfortunately, most of these patients will not follow these recommendations. Also, there seems to be more mania in these patients up to the age of 50 and more depression after 50 though some do not follow this trend.
Bipolar Type 2 is a medical illness that is more of a bad Major Depression with episodic hypomanic episodes. A hypomanic episode is a period of several weeks when the individual feels more confident, seems to have extra energy, may only sleep 4 to 5 hours a night, will start many projects (but finish none), and can be irritated that others are not moving fast enough, or they believe they are everyone’s friend. After this hypomanic episode will be a severe major depression. These patients can have significant suicidal feelings and may act on them.
The treatment is an antidepressant medication along with a mood stabilizer. Again, alcohol and other drugs of abuse usually make this illness worse. If the patient is suicidal, they must be admitted into an inpatient unit to prevent suicide, otherwise, they may be able to be treated in a PHP program or even as an outpatient. If this is the first episode, PHP would be preferred over just outpatient treatment because you cannot predict how severe the depression will be. Again, there is an acute phase of the illness that requires inpatient treatment and, hopefully, can be stabilized over 10 days to two weeks of medication and psychotherapy, then there is another month during which the chemistry in the brain still is not stable. There is no way to treat this illness quicker.
Bipolar Illness, Mixed State is a mixture of mania and depression at the same time. Stabilizing the mania and the depression at the same time is difficult because the antidepressant can cause mania. Rapid Cycling is another presentation with mood shifts from week to week and sometimes from day to day.
Schizophrenia
Schizophrenia is a medical illness that affects 1% of the population. It is made up of two sets of symptoms; the positive and negative symptoms. The positive symptoms include auditory hallucinations, paranoid delusions, and disorganized thinking and speech. An auditory hallucination is hearing a voice that sounds as clear as if someone were talking to you. This can be a very frightening event because the patient does not know who that person is or where they are. Many times, the voice or voices are angry or degrading. A paranoid delusion is a false belief, but they believe it is true (fixed). It involves the belief that someone is plotting to either harm them physically, steal from them, or to humiliate them. Response to medication to minimize or remove the positive symptoms is much better than with the negative symptoms.
The negative symptoms are harder to understand. Negative symptoms are deficits of normal emotional responses or of other thought processes. They commonly include flat expressions or little emotion, poverty of speech (they do not have much to say), inability to experience pleasure, lack of desire to form relationships, and lack of motivation. Negative symptoms appear to contribute more to poor quality of life, functional ability, and the burden on others than positive symptoms. People with greater negative symptoms often have a history of poor adjustment before the onset of illness, and response to medication is often limited.
Treatment involves medication, life skills training, and at times cognitive psychotherapy. When the patient is not able to take care of themselves, they need to be hospitalized and given the appropriate medication and begin socialization training along with daily structure (i.e. go to bed on time, get up on time, bathe, eat on time). When the patient is in a psychotic episode, the brain swells with inflammation causing damage to the neurons (brain cells). This can give a worse lifetime outcome to the illness as the individual gets older. From recent studies, the first couple of psychotic episodes can cause the most damage to the brain, if they are not stabilized quickly on medication. The medication used is called neuroleptics or antipsychotics. Many of these medications are also mood stabilizers. Every effort is made to find a medication that will help the patient sleep through the night and be alert during the day such that they feel natural.
Sometimes the inpatient stay will be a week and sometimes it may be as much as a month. Once the primary symptoms are improved on medication and the patient is more able to take care of themselves in terms of hygiene, eating, and able to act responsibly, then, they will need a PHP program to help them with life skills training and to provide a daily structure for them to continue to take their medication and to learn appropriate socialization. It will take at least another month of taking the medication in a therapeutic structured program before the patient is able to function more independently with good judgment.
Schizoaffective Disorder is Schizophrenia with a “major affective component” of either mania or depression. The patient has both positive and negative symptoms but also has episodic severe major depression or mania. These symptoms are treated with either an antidepressant or a mood stabilizer.
Post-Traumatic Stress Disorder (PTSD)
This disorder occurs when someone has a traumatic experience that is horrific; that they were not expecting; and their brain is “preset” such that when this event occurs, it triggers off a series of symptoms that grossly affects their ability to function. We also know that repeated witnessing traumatic events such as occurs by EMS operators, police, firefighters, and emergency room personnel can also cause PTSD. Anyone may have an adjustment reaction to a major trauma. This may last a month or two, but most people are able to move on and function. 7 to 12 percent of those exposed to the same trauma are not able to move on because of recurrent thoughts and emotional reactions to anything that reminds them of the trauma and will have PTSD.
There are four sets of symptoms that can occur. Many will have all these symptoms at some time in the progress of their PTSD though some will only have one or two:
- Blunted emotions such that even dangerous situations do not cause a reaction such as walking on the edge of a 10-story building without fear.
- Exaggerated emotional response and hysteria to situations that are not that bad.
- A “Flashback” is when the patient has a feeling that they are reliving the traumatic event though they know that they are not in the traumatic event. This may last for 20 minutes or several hours. They may have a “blackout” of time and not remember the 20 minutes when they were in the flashback. In a more severe flashback the patient believes that they are reliving the traumatic event and are terrified. Dreams of the trauma are also common and may be vivid.
- Negative alterations in cognitions (i.e. loss of memory of the past trauma) and mood (i.e. inability to have positive emotions) associated with the traumatic event.
Dissociations or a dissociative reaction is a disruption of or discontinuity of the normal integration of consciousness, memory, identity, perception, and behavior. A flashback is a dissociation. People seem to go in and out of dissociating and when they come out, they may not remember what they said and did which can be embarrassing and frightening. They do not have any control over this. They are not pretending to get attention.
The treatment of PTSD is not medication. We use medication to help with sleep, severe mood swings, and anxiety/panic but there is not a medication to treat this disease. Cognitive therapy is a type of therapy that is more directive and less insight oriented. DBT cognitive therapy is the best but it can be expensive, and it takes 3 to 4 days a week of different groups and individual therapy. The patient is dysfunctional because of this illness and will have a wide assortment of emotional responses. It takes many months to calm down different symptoms to have a remission of the more intense problems, but it takes several years to get into a recovery. This is potentially a devastating illness, but it is treatable. It will take much patience, family support, therapy, and time.
Personality Disorder
A personality disorder is a type of mental disorder involving a rigid and unhealthy pattern of thinking, functioning, and behaving. A person with a personality disorder has trouble perceiving and relating to situations and people. They can distort what was said and done and misinterpret what was meant. This causes significant problems in relationships, social activities, work, and school. The patient is born with the disorder, but it comes out in adolescence and becomes more severe as a young adult. This is not something that the person learns, nor do they make this up to get attention. One reason that someone cannot seem to get better when they have a Major Depressive Disorder is because they may also have a personality disorder along with the major depression.
There are many personality disorders from Dependent to Narcissistic Personality Disorder but one type of Personality Disorder that is pervasive and causes great dysfunction is a Borderline Personality Disorder. This is a long-term pattern of abnormal behavior characterized by unstable relationships with other people, unstable sense of self, and unstable emotions. There is often an extreme fear of abandonment and rejection, frequent dangerous behavior, a feeling of emptiness, and self-harm. Three times as many women have this disorder than men. In general, these patients present with dramatic emotional reactions out of proportion to the event. They may become very angry because they feel someone has taken something away from them in the relationship or because they feel put down or degraded in some way. They may become very depressed because they interpret interactions with others as if they were ignored or devalued leading the patient to feel they must be worthless which leads them to self-mutilate by cutting or burning themselves or to attempt suicide. The following are a few statistics:
- 1-3% of the population.
- 8-18% of psychiatric outpatients.
- 20-25% of psychiatric inpatients.
- 56% of Emergency Department admits for suicide.
- 18% of all Suicides in the United States.
- 8% risk of suicide.
The treatment is psychotherapy. Medication does not treat this illness though it can help with mood swings, sleep, depression, and anxiety. Therapy works but it takes a couple of years. The patient may need to be admitted inpatient when they are suicidal or be in a PHP program to provide the structure and support that is needed to stabilize the more severe symptoms before they can do outpatient therapy with a therapist. Ideally, cognitive therapy, particularly DBT (Dialectical Behavioral Therapy) is preferred but the main point is for there to be a strong relationship with a therapist that the patient can work with and trust.
The other Personality Disorders include Avoidant, Dependent, Narcissistic, Paranoid, Histrionic, Schizoid, Obsessive-Compulsive, Schizotypal and Antisocial Personality. They are also treatable if the patient wants to change.
Other Mental Disorders
Attention Deficit Hyperactivity Disorder (ADHD), Anorexia, Bulimia, Asperger Syndrome, addiction, and Dementia are all serious medical disorders that will not be covered here because of time. We at Ridgeview Institute treat these disorders but information about these disorders will need to be obtained from another source.
Medication
Medication is a major component of the treatment of most psychiatric illnesses. There is a difference between a medication that is used to treat an illness and a drug that is abused. In the same way that you would have to take an antibiotic if you had pneumonia, you must take psychiatric medication to treat a psychiatric medical disease. Finding the right medication and the right dose of the medication is based on the experience of the psychiatrist treating the specific symptoms of the illness. For example, a depression with no motivation to do even the basic things in life, sleeping 10 to 12 hours a day, and being unable to concentrate and make decisions may need Wellbutrin which helps the brain to increase dopamine. There is no blood test that will tell us which antidepressant to use.
The biggest issue with medication is “compliance” which means taking the medication as prescribed. Studies have been done and, believe it or not, only 30% of people take their medication as prescribed, if they take it at all. Nobody wants to have a psychiatric illness. We will rationalize, minimize, or deny we have a problem. Not taking the medication is part of this way of thinking.
The second issue concerning medication is the fear that any pharmaceutical will cause damage to our body. Many people believe that these medications damage our livers. Others are afraid that these medications will cause us to be “unnaturally” happy and serene such that we will not deal with life’s problems. Others believe that these medications all lead to being addicted. Any concern must be addressed with the doctor. Most of the time, none of these things occur. Psychiatrists want you to be on a medication without side effects; feel alert during the day; sleep at night; and get relief from your psychiatric problems.
The third issue is to find the right medication for each person. Everyone has a different genetic makeup and can have a different response to the same medication. Some people have a “paradoxical” response to a medication which means having an opposite response than what is expected. For example, 2% of the population will have more depression on an antidepressant medication. They will know this within the first 2 to 4 weeks of being on the medication. When this happens, the medication should be stopped. This is the same as the medication Benadryl. Most adults will have some sedation but about 3 to 5% of the population will be activated and cannot sleep when they take Benadryl.
Antidepressants are a class of medication that is the standard of care for the treatment of a Major Depression and the anxiety disorders. Again, our nomenclature is misleading suggesting that you must be depressed to be on an antidepressant. This is not true. These medications are not addictive. They must build up in you over a period of weeks for them to work. If you miss a day of taking the medication, you will have recurrence of depressive or anxiety symptoms and this will cause mood swings.
Antidepressants work in the brain by increasing certain neurotransmitters. Neurotransmitters are chemicals produced in the brain that act as a chemical bridge between two neurons (brain cells) so that information from one cell can get to another cell. Each neuron has a specific purpose such as an eye neuron and a foot neuron. For the foot to know not to step on a sharp object, the eye neurons must tell the foot neurons where to step. We know that one cause of the depressive and anxiety disorders is a lack of enough neurotransmitters because of the individual’s genetic makeup.
Antidepressants are holistic medications. This means the medication does not give you more neurotransmitters, but they help your brain to get back into a state of normality by using the neurotransmitters that you already have. The main neurotransmitters are serotonin, norepinephrine, dopamine, and GABA. 70% of people with a depressive disorder are genetically programmed to not have enough serotonin which is the cause of the major depression. Prozac is a serotonin antidepressant that can help your brain increase the active serotonin such that the depression gets better. The other 30% of those with a major depression may need an antidepressant that increases the other neurotransmitters. Some people will need to be on two antidepressants to cover all the neurotransmitters that are low.
In the treatment of a major depression, an antidepressant will begin working within 3 days to 2 weeks though it takes the medication a month to reach its maximum benefit at a specific dose. In the treatment of an anxiety disorder, an antidepressant will begin working after about 2 to 3 weeks of starting the medication. The obsessive-compulsive anxiety disorders may require 4 to 6 weeks for the antidepressant to start working. Obviously, this is a real problem when someone is dysfunctional with their anxiety.
Benzodiazepines are a group of medications used to treat anxiety. Used by themselves, they are an inadequate way to treat an anxiety disorder. They can be addicting. They need to be taken several times a day. They develop a tolerance meaning that over time, the dose must be increased to give the same anxiety relief. We use these medications either as an initial treatment until the antidepressant can begin to work or we may use them on an as needed addition to the overall treatment. If the patient has an addiction to other substances such as alcohol or opioids, they cannot take a benzodiazepine because it will trigger a relapse on their addiction.
The Mood Stabilizers are a class of medications used to treat Bipolar Disorder and anyone who is having significant mood swings that is not controlled by other medications. Depakote is the most prescribed mood stabilizer for Bipolar Disorder, Type 1 followed by lithium. It takes about 4 to 5 days for these two medications to reach a therapeutic blood level. All the newer antipsychotic medications are also mood stabilizers including Zyprexa, Seroquel, Risperdal, Geodon, Latuda, and Saphris. These medications do not have to build up in the blood and can start working at the time that they are prescribed but for Bipolar illness they do not cover the symptoms as completely as Depakote and lithium.
Summary
The psychiatric medical illnesses are no different than any other medical illness. In fact, they compare to diabetes, hypertension, and heart disease in terms of how they are lifelong illnesses. We can manage these illnesses, but we cannot cure them. With appropriate medication, psychotherapy, and living a healthy lifestyle, there is no reason why these individuals cannot have as full and enjoyable a life as those people who have other medical problems. This requires understanding the facts about these diseases and following through with the right treatment.
There are three stages of treatment. The acute stage, when the patient is not able to take care of themselves or are suicidal, requires inpatient treatment. The subacute stage (PHP/IOP) is when the patient may not be ready to make major decisions or return to work. The patient needs the structure of the day or evening program; the expertise of therapists that can monitor their progress almost daily; and time for the medication to work. The outpatient stage is when the patient is seeing an individual therapist and having medication management by a psychiatrist.