Understanding South Africa’s Mental Health Act

The Mental Health Care act no 17 of 2002, which replaced the Mental Health Act of 1973, has brought with it a new set of regulations and new focus. In particular, the Act has a stronger human rights orientation than the previous act, which means that it is more patient-centric with greater respect for the civil liberties of patients. The downside is more checks and balances, which means more paperwork and administration, which, in turn, translates to longer waits for government healthcare services.

According to the new Act, the State has a duty to ensure the provision of mental healthcare services and it must protect the rights and interests of patients. Patients have, amongst others, the following rights:

  • Only tertiary health establishments or psychiatric hospitals may provide tertiary level (intensive) mental health care to patients.
  • Treatment can only be given to patients if they have agreed to it if it has been authorised by the Mental Health Review Board (MHRB), or if a delay in treating a patient may result in their death or injury or the injury of others.
  • Patient’s information may not be revealed to anybody, unless it would be harmful to the patient or other people to withhold it. In this case only the head of the health establishment would be able to disclose the information.
  • Patients may not be unfairly discriminated against because of their mental health status.
  • All mental health patients must be informed of their rights before they are given treatment, unless a delay could result in either death or injury to the patient or death or injury to another person.
  • Healthcare establishments have to provide the appropriate level of care and they may not give psychiatric medication to a patient for more than six months, unless it has been authorised by a registered mental health care practitioner.

The Act requires that mental health care users be treated in the least restrictive manner possible with the least discomfort and inconvenience, and are treated as close to home as possible. However, in practice this is not always the case, treatment is dependent on the beds that are available, which in return is dependent on resources and funding.

Notably, the Act has also introduced a 72-hour assessment period, which takes place at a general hospital prior to further involuntary treatment and the Act has also provided for the establishment of Mental Health Review Boards (MHRB), which is primarily to protect the rights of people with mental illness.  Under the old legislation, South African Police Service (SAPS) members would take a mentally ill person who needed involuntary admission to a magistrate; this is no longer the case. Instead, if a mentally ill person is apprehended by a SAPS member, they must be taken to a health establishment that has assessment facilities for an assessment by a mental health care practitioner. 

In the guidelines, the Act stresses that use of seclusion and physical restraint, should only be used as a matter of last resort.  It also notes that violent patients should only be physically restrained for short periods, while medicine to control the violence is being administered. It also stresses that physical restraint should not be used to punish patients. 

In particular, the Act regulates access to services for categories of mental health care patients: voluntary, assisted, involuntary and emergency.  How they are treated will depend on their status.

Procedures for patients

The procedures are as follows:

Voluntary patients:  the person is competent to make an informed choice and may give consent. This is the preferred admission procedure for all concerned. The person may be admitted to a private or State facility that is registered as a hospital, where they are entitled to appropriate care. They may not receive sleep therapy.

Assisted patients are persons with a mental illness, not capable of consenting to voluntary treatment as a result of their illness, but who do not refuse treatment.

  • In this case, a relative or person close to the patient or mental health practitioner applies in writing for admission and treatment on behalf of the person.  They must have seen the person within the previous seven days of making the application.
  • The person may be admitted to a private or State hospital that is licensed to give electroconvulsive treatment and to admit patients who aren’t able to give consent. Any treatment must be approved by the head of department.
  • The person must be examined by two medical care health practitioners and a physical examination must be conducted. If the practitioner’s findings don’t concur then a third medical practitioner must examine the person.
  • The application will only be approved if the person is believed to be suffering from mental illness or profound disability and they are thought to be incapable of making their own decision about care or treatment.
  • If assisted care is necessary, the person must be admitted within five days.
  • The relevant review board will look into the case within 30 days and decide whether the person should continue treatment at the hospital or be discharged. The patient can appeal within this 30 day period.

An involuntary patient may be admitted without consent. The patient must pose a danger to him or herself and to others or care and treatment rehabilitation is necessary for the financial interests or reputation of the patient.

  • Involuntary treatment may only be considered if a person is suffering from a mental illness in line with accepted psychiatric diagnostic criteria. 
  • An application for involuntary admission must be made to the head of a health establishment by a spouse, next of kin, partner, associate, parent or guardian; they must have substantial contact with the person and have seen them in last seven days. If none of the people are available or willing to make and application. It can be made by a medical professional. Application forms can be obtained at clinics, hospital admission rooms and police stations.
  • A patient can only be admitted to an institution for a period of 24 hours. A mental health care user may be treated involuntarily at a health establishment on an inpatient basis under very specific regulations that serve to protect the users’ rights as much as possible. 
  • If the head of the health establishment approves the application then two mental health care practitioners (MHCP) must do independent assessments of the patients. If their findings don’t correlate then a third MHCP must do an assessment.
  • If involuntary admission is recommended and approved by the head of a health establishment then, within 48 hours the mental health care user must be admitted to a health establishment.
  • The Act then provides for a 72 hour assessment to take place before further involuntary care can take place. The 72 hour period is the maximum that a person can be admitted on an involuntary basis for the purpose of psychiatric examination. Once a person has an involuntary examination and the 72-hour period expires, they cannot undergo a further consecutive 72 hour assessment.
  • If it is decided that the person does need inpatient treatment, a written report must be submitted to the Review Board.
  • If the Review Board grants the request then they submit documents to the High Court.
  • The patient, their spouses, next of kin, parents, associates, partners or guardians, may lodge an appeal within the first 30 days. The Review Board will investigate.

Untreated depression can endanger more than your mental health

You may brush it off as a case of the blues or something that will resolve when your circumstances improve, or you may not want to get help because of the stigma attached, but leaving depression untreated can harm more than just your ability to enjoy life.

Untreated depression has a wide range of effects, some physical, some mental, some relational – many can create long-term or life-threatening problems.

In fact, the World Health Organisation lists depression as the leading cause of disability worldwide, which underlines its seriousness. Worldwide, there has been a 20 percent increase in depression in the past 20 years. Almost 75 percent of people with mental disorders remain untreated in developing countries, a problem shared by South Africa, where mental health is not prioritised.

Although depression symptoms can vary, the most common are persistent sadness, irritability or anxiety, trouble sleeping, a loss of interest in normally enjoyable activities and an inability to carry out daily activities for two weeks or more. Untreated, the symptoms of depression can last for months or even years.

Depression and Suicide

The most dangerous risk of untreated depression is suicide. It is estimated that two thirds of all suicides are caused by depression. In South Africa, there are thought to be at least 23 suicides a day due to depression. One in four teens in South Africa have attempted suicide. If you have suicidal thoughts or intentions, get help immediately. It is not the only way out.

Depression and Substance Abuse

Symptoms rarely go away if they are not treated. This means people with depression often turn to drugs or alcohol to treat their symptoms. This can worsen depression symptoms and increase the chances of getting addicted to the substances. Alcohol, drugs and depression are a dangerous combination, which is why it is so important to get help.

Depression and reckless behaviour

Depression increases the risk of risky behaviour. When people are feel hopeless, angry or down they are less to worry about the consequences of their actions. They are more likely to put themselves in risky situations with potentially dangerous outcomes, for example, driving drunk or unprotected sex.

Depression and impaired cognitive performance 

Untreated depression can make it very difficult to keep to a normal work schedule or to get through tasks at school or work. This is because depression actually impairs cognitive function; it impairs the ability to concentrate as well as memory. For some people, even getting out of bed is can be difficult.

Relationship Problems

Depression can cause relationships to suffer. It can leave people exhausted emotionally, mentally and physically, so it becomes hard to interact positively with friends and family.

Health Concerns 

Depression can become an unhealthy cycle. Because people with depression lose interest in many things, they may find it difficult to take care of themselves in terms of healthy eating and exercise, which ultimately leads to them feeling worse or being vulnerable to other illnesses.

A number of studies have been done on depression and physical health and there is mounting evidence that clinical depression can have a serious effect on physical health, for example:

Depression and Heart Disease: studies show that depression can lead to heart disease, worsen it or make it difficult to recover after complications of heart disease. Depression and stress are closely related and chronic stress put your body in a constant state of emergency which can cause blood vessels to tighten. This can lead to heart disease over time. Poor lifestyle habits that often go along with depression such as poor diet, drinking or smoking are also bad for heart health. 

Depression and Diabetes: The same bad habits can also increase your risk for type 2 diabetes, or make it difficult to manage diabetes. Depression plays a significant role in appetite and nutrition. Some people with depression may overeat and some may lose their appetite altogether. Overeating can lead obesity-related illnesses, such as type 2 diabetes.

Depression and Obesity: There is a higher risk of obesity if you are depressed and if you are obese there is a higher risk of being depressed. This is, in part, because eating is a form of self-medication when feeling depressed. Depression may also cause stress and stress hormones have been shown to promote belly fat.

Depression and immune system: Some studies show that depression may have a negative effect on the immune system, which can make people more vulnerable to infections and diseases and encourage faster tumour growth in cases where people have cancer.

Depression and Mental Decline: Studies have shown that long-term depression can add to the loss of brainpower, especially in elderly people. Brain scans of elderly people show greater shrinkage in certain parts of the brain in people with depression, compared to elderly people without depression.

Depression and Pain: Pain and depression can perpetuate an unhealthy cycle. Depression can make pain harder to treat and pain may make depression worse. For example, if you have chronic depression you are three times more likely to experience migraine headaches. 

Just as there are many negative consequences to leaving depression untreated, there are many benefits of early and appropriate treatment. Early detection and intervention decreases the risk of major depression, promotes remission, helps

prevent relapse and reduces the emotional and physical consequences of the disease. 

 


Bronwyn Harries-Jones is a journalist with 22 years’ experience in the field.  She has freelanced  as both a journalist, advertising copywriter, editor and communications manager for many years, working for publications such as The Sunday Times and consumer magazines, with communication’s clients including Old Mutual, South African Tourism and Verizon. She has a particular passion for mental health research, having suffered from post-natal depression for two years after the birth of her first child.

Mood and Depression Disorder

Depression is more than just “feeling blue” for a period of time. Everyone has days when they feel sad, but depression is a serious medical illness caused by changes in brain chemistry. It affects the way you think, feel and act and can cause difficulty in functioning at work and at home. It is not something that you can “snap out of”.

What is Depression?

Although depression is a serious condition it is also a common one. It affects roughly one in five women and one in ten men at some stage of their lives. It also doesn’t discriminate; depression is found across age groups, educational levels and social backgrounds. Once an episode of depression has occurred there is an increased chance that it can reoccur.

Fortunately depression is very treatable with medication, psychotherapies and other methods and there are many effective strategies for living with depression. It is best to treat depression as soon as possible when symptoms are less severe.

There are several forms of depressive disorders:

Major depression: This is the most common form of depression. It is debilitating and interferes with a person’s quality of life. Symptoms must last for more than two weeks. Once a person has had a major depressive episode once, it is likely to reoccur. An estimated 80-90 percent of people respond well to treatment for depression.

Persistent depressive disorder: This is a low mood that lasts as long as two years or more. There may be episodes within this low mood of major depression and then times with less severe symptoms. People can function adequately but not at their best. This type of depression responds well to talk therapy.

Some forms of depression develop as a result of circumstances or are slightly different to the forms above. They are:

Postpartum depression: This occurs in new mothers who feel extreme sadness and even suicidal thoughts after the birth of their babies. It can happen anywhere from weeks to months after childbirth, but usually within a year.

Seasonal Affective Disorder (SAD): 4-6 percent of people in the USA are estimated to have SAD. This is a condition where the symptoms of depression occur during winter, most likely because of the lack of sunlight. Symptoms are usually mild, but they can be severe in some cases. SAD usually lifts in spring. Light therapy may help.

Psychotic depression: This is when a person has depression as well as some sort of psychosis, such as delusions or hallucinations. In effect they lose touch with reality.

Bipolar disorder has periods of major depression that alternate with extreme highs or mania.

Situational depression is depression that is triggered by a stressful life event or trauma. It is three times more common than major depression and generally clears up after the traumatic event has come to an end. If it persists after the event it may become major depression.

Causes

Scientists agree that depression is a brain disorder, caused by changes in brain chemistry, however research indicates that there many other factors that may contribute, these include; genetic vulnerability, faulty mood regulation, some medical conditions or medications and triggers such as stress, or difficult life circumstances.

When it comes to chemical imbalances, it is not a simple equation of one chemical level being too low or high. There are many chemicals and millions of chemical reactions that are responsible for mood and how you see and experience life. This complexity is why different people respond differently to different medications.

Scientists are doing ongoing research into depression and have identified genes that make people more vulnerable to depression, but they don’t have a complete understanding of the illness.

Brain-imaging technologies such as magnetic resonance imaging (MRI) have shown that areas of the brains in people with depression look different from people who don’t have depression. The areas that look different are involved in mood, sleep, thinking, appetite and behaviour.

Signs & Symptoms

Depression symptoms can vary from mild to severe. People with depression do not all have the same symptoms. Signs and symptoms include:

Long-term feeling of sadness or a depressed mood
Feelings of anxiety and “emptiness”
Loss of interest or pleasure in hobbies or activities that were once pleasurable
Feeling irritable or restless
Weight loss or gain, not related to dieting or loss of appetite
Insomnia or sleeping too much
Thoughts of suicide or attempts to commit suicide
Tiredness or loss of energy
Difficulty concentrating, thinking or making decisions
Feelings of worthlessness or guilt
Feelings of hopelessness or pessimism
Unexplained aches or pains, headaches or digestive problems that don’t ease with treatment.

Some medical conditions, for example, thyroid problems can mimic symptoms of depression, so it is important to have a thorough medical assessment to rule out other causes. Of course, many of these symptoms may happen to anyone at a particular time, but clusters of these symptoms indicate depression. For a diagnosis of depression the symptoms should have occurred for two weeks or longer.

Who Is At Risk?

Depression is one of the most common mental disorders. It can affect anyone; however several factors can play a role. Biochemistry, which manifests as differences in levels of certain chemicals in the brain, plays a role. A genetic predisposition can be responsible. Depression can run in families, but it is not always the case. Personality may play a role, such asbeing naturally pessimistic or being prone to stress. Adverse environmental factors such as exposure to violence, neglect, abuse or poverty can make some people more vulnerable to depression.

A depressive episode can happen at any time, but it generally first appears during late adolescence to mid-20s.

Diagnosis

The earlier depression is diagnosed and treatment begins, the more effective it is. Many people with depression do not seek help, which can lead to a greater chance of another episode of depression.

The first step to getting the right treatment is to see a doctor or mental health practitioner. Before you see a doctor it may be helpful to educate yourself on the disorder and how it is diagnosed. Your healthcare provider or doctor will generally take you through a physical examination and then a series of questions which act as a screening tool to identify depression. As certain other illnesses can cause depression, your doctor should rule out these possibilities with tests before taking you through the screening. The doctor should also discuss any history of depression or mental disorders in your family and a history of your symptoms.

Try to be as open and honest as you can with your doctor. You want to get the most accurate diagnosis possible and it will help your doctor to do this.

There are a number of illnesses that can accompany depression such as anxiety, obsessive compulsive disorder, post-traumatic stress disorder or social phobias. Substance abuse, such as abuse of alcohol or drugs can also co-exist with depression. People who have other serious medical illnesses such as HIV/AIDS, diabetes or cancer may also suffer from depression due to dealing with an illness. They may also need to be treated for depression to help them with their illness.

Treatments

There are a number of effective ways to treat depression and these will be fitted to the patient’s needs. Treatments include psychotherapy, medications and lifestyle changes, including improvements in sleeping and eating habits, exercise and stress reduction. Depression is very treatable and the majority of people respond well to treatment.

Medication

Because brain chemicals, called neurotransmitters, are thought to contribute to depression, antidepressants are used to modify brain chemistry. The main neurotransmitters that are regulated are serotonin, norepinephrine and dopamine.

These medications are not sedatives, tranquilizers or stimulants. They are not habit forming.

The medications may produce some improvement in the first week or two if use, however it usually takes about two to three months for the full benefit to be felt. If there is no improvement after several weeks, let your doctor know and they can alter the dose or the medication. Doctors usually recommend that medication should be continued after symptoms have improved. A period of six months or more is recommended.

Popular newer antidepressants

Some of the newest and most popular antidepressants are called selective serotonin reuptake inhibitors (SSRIs). Fluoxetine (Prozac), sertraline (Zoloft), escitalopram (Lexapro), paroxetine (Paxil), and citalopram (Celexa) are some of the most commonly prescribed SSRIs for depression. Most are available in generic versions. Serotonin and norepinephrine reuptake inhibitors (SNRIs) are similar to SSRIs and include venlafaxine (Effexor) and duloxetine (Cymbalta). SSRIs and SNRIs tend to have fewer side effects than older antidepressants, but they sometimes produce headaches, nausea, jitters or insomnia when people first start to take them. These symptoms tend to fade with time. Some people also experience sexual problems with SSRIs or SNRIs, which may be helped by adjusting the dosage or switching to another medication.

One popular antidepressant that works on dopamine is bupropion (Wellbutrin). Bupropion tends to have similar side effects as SSRIs and SNRIs, but it is less likely to cause sexual side effects. However, it can increase a person's risk for seizures.

Tricyclics

Tricyclics are older antidepressants. Tricyclics are powerful, but they are not used as much today because their potential side effects are more serious. They may affect the heart in people with heart conditions. They sometimes cause dizziness, especially in older adults. They also may cause drowsiness, dry mouth, and weight gain. These side effects can usually be corrected by changing the dosage or switching to another medication. However, tricyclics may be especially dangerous if taken in overdose. Tricyclics include imipramine and nortriptyline.

MAOIs

Monoamine oxidase inhibitors (MAOIs) are the oldest class of antidepressant medications. They can be especially effective in cases of "atypical" depression, such as when a person experiences increased appetite and the need for more sleep rather than decreased appetite and sleep. They also may help with anxious feelings or panic and other specific symptoms.

However, people who take MAOIs must avoid certain foods and beverages (including cheese and red wine) that contain a substance called tyramine. Certain medications, including some types of birth control pills, prescription pain relievers, cold and allergy medications, and herbal supplements, also should be avoided while taking an MAOI. These substances can interact with MAOIs to cause dangerous increases in blood pressure. The development of a new MAOI skin patch may help reduce these risks. If you are taking an MAOI, your doctor should give you a complete list of foods, medicines, and substances to avoid.

MAOIs can also react with SSRIs to produce a serious condition called "serotonin syndrome," which can cause confusion, hallucinations, increased sweating, muscle stiffness, seizures, changes in blood pressure or heart rhythm, and other potentially life-threatening conditions. MAOIs should not be taken with SSRIs. How should I take medication?

All antidepressants must be taken for at least 4 to 6 weeks before they have a full effect. You should continue to take the medication, even if you are feeling better, to prevent the depression from returning. Medication should be stopped only under a doctor's supervision. Some medications need to be gradually stopped to give the body time to adjust. Although antidepressants are not habit-forming or addictive, suddenly ending an antidepressant can cause withdrawal symptoms or lead to a relapse of the depression. Some individuals, such as those with chronic or recurrent depression, may need to stay on the medication indefinitely.

In addition, if one medication does not work, you should consider trying another. NIMH-funded research has shown that people who did not get well after taking a first medication increased their chances of beating the depression after they switched to a different medication or added another medication to their existing one. Sometimes stimulants, anti-anxiety medications or other medications are used together with an antidepressant, especially if a person has a co-existing illness. However, neither anti-anxiety medications nor stimulants are effective against depression when taken alone, and both should be taken only under a doctor's close supervision. Report any unusual side effects to a doctor immediately.

FDA warning on antidepressants

SSRI’s are generally safe, however they may have an adverse effect on some people, particularly teenagers and young adults. A study done in 2004 by the US Food and Drug Administration (FDA), conducted a comprehensive review of clinical trials and came to the finding that 4 percent of those taking antidepressants had thoughts of or attempted suicide, compared to 2 percent of those receiving placebos.

This information has led to a “black box” warning on all antidepressants to highlight the increased risk of suicidal thinking, especially in children. Patients of all ages taking antidepressants should be strictly monitored. Your healthcare provider will decide if the potential effects outweigh the risks before prescribing medication.

What about St. John's Wort?

St John’s Wort is a herbal remedy that has been used to hundreds of years. In Europe it is often used to treat mild depression. However, some studies indicate that it may be no more effective than a placebo. It should be taken with caution as it may interfere with certain medications taken for other conditions, such as heart disease. Talk to your doctor before taking any herbal supplement.

Psychotherapy

Psychotherapy or “talk therapy”, helps people with depression to learn ways to deal with the illness. It may be used alone for mild depression, but is usually used in conjunction with medication.There are many types of psychotherapy, but two main types, cognitive behavioural therapy (CBT) and interpersonal therapy (IPT) are particularly effective in treating depression. CBT helps a person to notice distorted thinking and helps them to then modify their behaviours and thinking. IPT helps people to work through relationship issues that contribute to the depression.

Psychotherapy is useful for both the person suffering from depression and their families or loved ones. Group therapy may also be used.

Self-help

There are some things you can do to help ease the symptoms of depression. Amongst them are; regular exercise, getting enough good quality sleep, preferably sleeping at the same time each night. Eating a healthy diet and avoiding alcohol can also help.

Electroconvulsive therapy (ECT) and other brain stimulation therapies:

In cases of severe major depression or bipolar disorder where patients have not responded to medication and/or psychotherapy, ECT may be useful.

ECT used to be known as “shock therapy” and had a bad reputation in the past, but it has improved greatly in recent years and can provide relief where other therapies have failed.

ECT involves a short electrical stimulation to the brain. The patient is put under anaesthesia before the procedure and sleeps through it. The treatment only takes a few minutes and the patient will wake up from the anaesthesia about an hour later. The ECT may have some side effects such as confusion or memory loss, but the side-effects are usually short-lived. Research has shown that one year after ECT, most patients had no adverse effects.

A patient generally receives ECT two to three times a week for a total of six to 12 treatments. Some people may require a maintenance course of ECT for a few months.

There are some newer types of brain stimulation therapies to treat severe depression. These include vagus nerve stimulation (VNS) and repetitive transcranial magnetic stimulation (rTMS). There is current research that they may be of use in treating depression.

Living With

How do women experience depression?

Women, between the ages of 25 and 40 are three of four times more likely to experience depression than men. Women have greater fluctuations in hormones that are associated with depression than men. Hormones directly affect the brain chemicals that control emotions and mood. Women are also at risk of developing postpartum depression after the birth of a child due to the hormonal changes pregnancy and the stresses of caring for a newborn.

During menopause hormone levels also fluctuate and there is a greater risk for developing depression during this time.

Many women get premenstrual syndrome (PMS) and experience symptoms such as breast tenderness, bloating, headaches, anxiety and irritability or a feeling of sadness. These symptoms are usually short-lived. However, for a small number of women PMS may become a severe form of premenstrual syndrome (PMS) called premenstrual dysphoric disorder (PMDD). This type of depression usually needs treatment.

It seems as if the cyclical changes in estrogen, progesterone and other hormones have the ability to disrupt neurotransmitters, such as serotonin, that control mood. Scientists are studying the correlation between hormones and depression.

How do men experience depression?

Men experience depression in a different way to women. Men suffer from the common symptoms of depression such as despondent moods, tiredness, sleep disturbances, problems concentrating, and loss of interest in hobbies, family and work, but they are more likely to also be irritable, aggressive, hostile and agitated. They are also more likely to abuse substances such as alcohol and drugs. More women are likely to attempt suicide, but more men die by suicide

How do older adults experience depression?

Depression can happen at any age and is common in older adults, although it is not a normal part of aging. Often older adults, who are depressed may not recognise the symptoms or may not try to get help for fear of appearing weak.

Depression may appear different in older adults. Many claim to not feel “sad”, instead they experience low levels of motivation, a lack of energy and/or physical problems, such as headaches.

Some symptoms of depression, such as confusion, may look like other illnesses such as Alzheimer’s disease. Sometimes chronic illnesses may cause depressive symptoms, or medications used to treat illnesses can contribute to depressive symptoms. Grief over the loss of a loved one may be difficult to distinguish from depression. Grief is normal, but if it is complicated and lasts for an extremely long time, it may need treatment.

Though it is commonly thought that younger people are prone to suicide, males age 85 or over have the highest suicide rate in the United States.

Like other age groups with depression, older adults with depression improve with treatment.

How do children and teens experience depression?

Roughly five percent of children and teens in the global population suffer from depression.

If a child has attention or learning disorders, anxiety is under stress or has experienced loss is at greater risk for depression. Children who have depression often continue to suffer from the illness in adulthood.

The behaviour of depressed children and teenagers may be different to that of adults. Often the symptoms can mimic some common childhood behaviours, so they may be missed.

Common symptoms of children with depression include frequent sadness often with tearfulness, a lack of interest in the activities they once enjoyed; the child may isolate themselves from friends or display extreme boredom or lack of energy. They may be very sensitive to rejection or failure and often have low self-esteem or guilt. They may be negative and irritable or be openly hostile and aggressive. Children also may try to stay away from school and complain of illnesses such as headaches or stomach-aches. They may talk about wanting to be dead or committing suicide. Depressed teens may abuse alcohol or drugs to feel better.

Depression in teens often co-occurs with other disorders such as anxiety or eating disorders.

Early diagnosis and treatment are important for depressed children. A combination of medication and psychotherapy is successful in treating childhood depression.

How can I help a loved one who is depressed?

When someone you love is depressed your support and encouragement plays an important role in their recovery. Because depression is serious, but treatable, the first step is to encourage them to get treatment.

Other steps you can take include; learning as much as you can about the condition so you can distinguish the symptoms from the person,talk to your loved one about the illness, offer emotional support and understanding, and listen carefully. Offer hope and encouragement. Never ignore comments about suicidal thoughts. Understand that you can’t rescue your loved one or “fix” them. You are not responsible and your loved one has to ultimately be responsible for their own recovery.

Take care of yourself; you may be experiencing a number of difficult emotions related to their depression, which you need to deal with. Form a strong support network for yourself, so that you are not overwhelmed.

How can I help myself if I am depressed?

Know the symptoms, recognise that you need help and then seek help. Early intervention has been shown to help the pace of recovery. Try to keep active and eat healthily. Try to break tasks, which may be overwhelming, down into smaller tasks. Have compassion on yourself. Spend time with people you love who will support and encourage you. Try not to isolate yourself.

Have patience, understand that treatment takes time; you will improve gradually not suddenly.

Continuously educate yourself about depression.

Bipolar Disorder

We all have periods of ups and downs, but in people with bipolar disorder, also known and manic-depressive illness, these mood swings are extreme and intense. The disorder is marked by high periods of mania and low periods of depression. Bipolar disorder isn’t a rare diagnosis, it is thought that about 2.5% of the population suffers from this illness. People with bipolar disorder may have trouble managing everyday life tasks, at school or work, or maintaining relationships. Although it is a lifelong condition, bipolar disorder can be managed effectively with a good treatment plan.

Causes

The exact causes of bipolar disorder are not known, however scientists think that the interaction of genetic, neurochemical and environmental factors play a role in the start and progression of bipolar disorder. From a neurochemical standpoint, it is thought to be a dysfunction of certain neurotransmitters or brain chemicals, the major ones being serotonin, dopamine and noradrenaline. For example, there's evidence that episodes of mania may occur when levels of noradrenaline are too high, and episodes of depression may be the result of noradrenaline levels becoming too low.

Bipolar disordermay lie dormant and be triggered by a stressor such as a stressful life event, alcohol or drug abuse or hormonal problems. Medications such as antidepressants or appetite suppressants, excessive caffeine or drugs can also trigger a manic episode in people who are vulnerable to bipolar disorder.

Bipolar disorder also appears to be linked to genetics. The risk of bipolar disorder goes up if close family members have the disorder, however,no single gene is responsible for bipolar disorder and more research needs to be done on the genetics.

Brain structure and functioning

Some brain-imaging tools such as MRI and positron emission tomography (PET), have been used to study the brains of people with bipolar disorder to see if they differ from healthy people.

One MRI study found that the brain’s prefrontal cortex, which controls functions such as problem solving and decision making, in people with bipolar disorder is usually smaller and does not function as well as healthy adults. This suggests that there may be abnormal development of the brain structure in adolescent years and may help doctors pinpoint who is at risk of bipolar disorder.

However, scientists still don’t fully understand how the different regions of the brain connect and influence each other, so they are still working on learning more about this before they can understand which treatment will work most effectively.

Signs & Symptoms

Bipolar disorder can look different in different people, but is usually characterised by extreme mood swings that can vary in their severity and frequency. The intense emotional states occur in periods called “mood episodes”. They can range from extreme highs (mania) to extreme lows (depression).The symptoms vary widely in their pattern, severity, and frequency. Episodes of depression and mania often last for weeks or even months. Sometimes the episode has symptoms of both mania and depression, this is known as a mixed state, for example, feeling both agitated and hopeless at the same time. Generally, there is a time of feeling normal between depressive and manic episodes, but some people experience “rapid cycling” which is where they repeatedly go from a high to low phase quickly without having a "normal" period in between. This needs to be treated urgently.

Mania and hypomania:

These are two different types of mania, mania and hypomania. They have the same symptoms, but hypomania is not as severe as mania and may not affect relationships and job performance. However, the person affected will notice that there is a change in their mood. In the manic phase, it is common to experience three or more of the following symptoms:

Abnormally upbeat, jumpy or wired
Heightened energy, creativity and activity or restlessness and irritability
Unrealistic, grandiose beliefs about one’s abilities or powers
Euphoria, feeling overjoyed or elated
Sleeping very little, but still having lots of energy
Unusual talkativeness and rapid speech
Racing thoughts
Distractibility and inability to concentrate
Not eating
Impaired judgement, impulsiveness and acting recklessly, for example,going on spending sprees, taking sexual risks or making foolishinvestments
In severe cases, delusions and hallucinations, for example, believing that you are famous or have super powers.
Depression

During a major depressive episode symptoms are severe enough to affect normal functioning. An episode typically includes a number of these symptoms:

Feeling deep sadness, hopelessnessor emptiness
Feeling irritable
Loss of energy or fatigue
Restlessness or slowed behaviour
Lack ofpleasure and interest in activities one once enjoyed
Appetite or weight changes
Sleep problems: insomnia or sleeping too much
Difficulty concentrating or remembering things
Feelings of worthlessness or inappropriate guilt
Feeling pessimistic about everything
Suicidal thoughts

Who Is At Risk?

Bipolar disorder can occur at any age, but it is typically develops in the late teens or early adult years. Having a first a first degree relative such as a parent or a sibling with bipolar disorder increases a person’s risk of developing the illness, but it doesn’t necessarily mean that other family members will develop the disorder. If one parent has bipolar disorder, there's a 10% chance that their child will develop the illness.If both parents have bipolar disorder, the likelihood of their child developing bipolar disorder rises to 40%.

Diagnosis

There are four basic types of bipolar disorders. Doctors diagnose bipolar disorder using guidelines from the Diagnostic and Statistical Manual of Mental Disorders (DSM).Each type of bipolar disorder is defined by the length and frequency and the patterns of the episodes.  The basic types of bipolar disorder are:

  • Bipolar I disorder. This involves periods of extreme mood episodes from mania to depression. At least one manic episode must have occurred. In some cases, mania may even trigger psychosis, which is a break from reality.
  • Bipolar II disorder.  This disorder involves minor forms of mood elevation that alternate with severe depression. The highs in Bipolar II, which are called hypomanias, are not as high as those in Bipolar I. Bipolar II is not a milder form of Bipolar I, but a separate disorder.
  • Cyclothymic disorder. This is a milder form of bipolar, with a number of hypomanic episodes and less severe depression than major depression. These episodes must have been taking place for at least two years.
  • Rapid Cycling: Bipolar disorder with rapid cycling is when a person has four or more episodes of major depression, mania, hypomania or mixed states in a year. It can happen in any type of bipolar disorder and can be a temporary condition for some people. Rapid cycling seems to happen more in people who have their first bipolar episode at a younger age.

Currently, bipolar disorder can’t be identified through lab tests or scans. An experienced doctor or mental health professional, such as a psychiatrist, must discuss signs and symptoms and do a mental health evaluation of the person experiencing bipolar symptoms, in order to make a diagnosis.

In order to help a doctor make an accurate diagnosis, it is useful to write down your symptoms, particularly those which reflect depression or mania. Also note sleep patterns, energy patterns, thinking and behaviour. A family history is also very helpful. 

If you suspect that you may have bipolar disorder, it is important to see help as soon as possible as bipolar disorder can worsen if left undiagnosed and untreated. It often has an adverse effect on relationships and work which can lead to problems in these areas if undiagnosed. Substance abuse is also common in people with bipolar disorder, which could become an issue and needs to be addressed.

Treatments

A combination of medication and counselling is generally used to treat bipolar disorder. For people who have very severe symptoms, don’t respond to, or can’t take the medication, other treatments such electroconvulsive therapy (ECT) may be used.

Medications

Some medications address both mania and depression, but at times it is necessary to treat the mania and depression symptoms separately with different medications. Some medications are used to keep moods steady. Generally, antidepressants are not used alone, as they can cause mania. Often with the correct medications, mood symptoms disappear, but even if they do not, they should become more manageable.

For those suffering from mania, the first step is usually treatment with an anti-manic mood stabilizer and sometimes an antipsychotic drug or benzodiazepine to quickly control the symptoms.

Mood stabilizers treat manias or depressions without causing symptoms to cause the opposite effect. These often have to be taken for many years. Examples include lithium and certain anticonvulsant drugs such as carbamazepine (Tegretol), lamotrigine (Lamictal) or valproate (Depakote).  Atypical antipsychotics used to treat mania include aripiprazole (Abilify), asenapine (Saphris), cariprazine (Vryalar), olanzapine (Zyprexa), quetiapine (Seroquel), risperidone (Risperdal), and ziprasidone (Geodon) .

For those who are in a manic state, hospitalisation may be necessary to help control reckless or risky behaviour and to make sure that medication is taken. 

Not everyone responds to medications in the same way, so you may need to work closely with your doctor to find the ones that work best for you. You may need to try several different medications and monitor the side effects and symptoms closely.

Valproic acid may increase levels of testosterone (a male hormone) in teenage girls. This can lead to polycystic ovary syndrome (PCOS) in women who begin taking the medication before age 20. It may also lead to suicidal thoughts. Young girls and women taking valproic acid should be monitored carefully by a doctor.

What are the side effects of mood stabilisers?

Lithium can cause side effects such as:

Restlessness
Dry mouth
Bloating or indigestion
Acne
Unusual discomfort to cold temperatures
Joint or muscle pain
Brittle nails or hair.

When taking lithium, your doctor should check the levels of lithium in your blood regularly, and will monitor your kidney and thyroid function as well. Lithium treatment may cause low thyroid levels in some people. Low thyroid function, called hypothyroidism, has been associated with rapid cycling in some people with bipolar disorder, especially women.

Because too much or too little thyroid hormone can lead to mood and energy changes, it is important that your doctor check your thyroid levels carefully. You may need to take thyroid medication, in addition to medications for bipolar disorder, to keep thyroid levels balanced.

Common side effects of other mood stabilising medications include:

Drowsiness
Dizziness
Headache
Diarrhea
Constipation
Heartburn
Mood swings
Stuffed or runny nose, or other cold-like symptoms.

These medications may also be linked with rare, but serious side effects. Talk with your doctor or a pharmacist to make sure you understand signs of serious side effects for the medications you're taking. If extremely bothersome or unusual side effects occur, tell your doctor as soon as possible.

Atypical antipsychotics are sometimes used to treat symptoms of bipolar disorder. Often, these medications are taken with other medications, such as antidepressants. Atypical antipsychotics include:

Olanzapine (Zyprexa), which when given with an antidepressant medication, may help relieve symptoms of severe mania or psychosis. Olanzapine can be taken as a pill or a shot. The shot is often used for urgent treatment of agitation associated with a manic or mixed episode. Olanzapine can be used as maintenance treatment as well, even when psychotic symptoms are not currently present. Aripiprazole (Abilify), which is used to treat manic or mixed episodes. Aripiprazole is also used for maintenance treatment. Like olanzapine, aripiprazole can be taken as a pill or a shot. The shot is often used for urgent treatment of severe symptoms. Quetiapine (Seroquel), risperidone (Risperdal) and ziprasidone (Geodon) also are prescribed to relieve the symptoms of manic episodes.What are the side effects of atypical antipsychotics?

If you are taking antipsychotics, you should not drive until you have adjusted to your 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 your metabolism. This may increase your risk of getting diabetes and high cholesterol. Your doctor should monitor your weight, glucose levels and lipid levels regularly while you are taking these medications.

In rare cases, long-term use of atypical antipsychotic drugs may lead to a condition called tardive dyskinesia (TD). The condition causes uncontrollable muscle movements, frequently around the mouth. TD can range from mild to severe. Some people with TD recover partially or fully after they stop taking the drug, but others do not. Antidepressants are sometimes used to treat symptoms of depression in bipolar disorder. Fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), and bupropion (Wellbutrin) are examples of antidepressants that may be prescribed to treat symptoms of bipolar depression.

However, taking only an antidepressant can increase your risk of switching to mania or hypomania, or of developing rapid-cycling symptoms. To prevent this switch, doctors usually require you to take a mood-stabilizing medication at the same time as an antidepressant.

What are the side effects of antidepressants?

Antidepressants can cause:

Headache
Nausea (feeling sick to your stomach)
Agitation (feeling jittery)
Sexual problems, which can affect both men and women. These include reduced sex drive and problems having and enjoying sex.

Report any concerns about side effects to your doctor right away. You may need a change in the dose or a different medication. You should not stop taking a medication without talking to your doctor first. Suddenly stopping a medication may lead to "rebound" or worsening of bipolar disorder symptoms. Other uncomfortable or potentially dangerous withdrawal effects are also possible.

Some antidepressants are more likely to cause certain side effects than other types. Your doctor or pharmacist can answer questions about these medications. Any unusual reactions or side effects should be reported to a doctor immediately.

Should women who are pregnant or may become pregnant take medication for bipolar disorder? Women with bipolar disorder who are pregnant or may become pregnant face special challenges. Mood-stabilising medications can harm a developing fetus or nursing infant. But stopping medications, either suddenly or gradually, greatly increases the risk that bipolar symptoms will recur during pregnancy. Lithium is generally the preferred mood-stabilising medication for pregnant women with bipolar disorder. However, lithium can lead to heart problems in the fetus. In addition, women need to know that most bipolar medications are passed on through breast milk. The FDA has also issued warnings about the potential risks associated with the use of antipsychotic medications during pregnancy. If you are pregnant or nursing, talk to your doctor about the benefits and risks of all available treatments.

FDA Warning on Antidepressants

Antidepressants are safe and popular, but some studies have suggested that they may have unintentional effects on some people, especially in adolescents and young adults. The FDA warning 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 behaviour, or any unusual changes in behaviour such as trouble sleeping, agitation, or withdrawal from normal social situations. For the latest information, see the FDA website .

Psychotherapy

Psychotherapy can help people find ways to deal with bipolar disorder and the effect it has on their lives. It can help the person to cope with difficult feelings, manage stress, rebuild relationships and provide support and guidance.

Some psychotherapy treatments used at Papillon to treat bipolar disorder include:

Cognitive therapy: this therapy involves learning to identify and change harmful or negative patterns of thinking.

Interpersonal and Social Rhythm therapy: this helps people with bipolar disorder manage their daily routines and relationships.

Family-focused therapy: helps family members learn coping strategies to help themselves and their loved ones. It also assists in improving communication in families.

Psychoeducation: teaches people how to recognise warning signs so they can get help and treatment before they have a serious episode. Research has shown that psychoeducation leads to fewer relapses and hospitalisation rates and a faster recovery rate.

Other treatments

Electroconvulsive therapy (ECT) is primarily used to treat the depressive phase of bipolar disorder, but it can also be used for the manic phase.

It uses a short electric current which is passed through the scalp while the patient is under anaesthetic. This causes a small seizure which in turn causes changes in the brain chemistry and “reboots” the brain. Although there are some negative associations with ECT and misuse in the past, it has greatly improved and is considered very effective for treating bipolar episodes. It is generally only used when other methods have been ineffective. It has also been shown to be effective in preventing future episodes. A side effect can be memory loss, but it is typically only loss of memory around the time of the therapy session. Other side effects such as confusion and nausea are only temporary. It is considered safe enough to use on pregnant women and elderly people, but it may pose risks for people with certain medical issues. It needs to be done by a trained doctor.

Herbal supplements:

Not much research has been done on herbal or natural supplements and bipolar disorder. St John’s wort is a herb that is sometimes marketed as a natural antidepressant, but it may cause mania in people with bipolar disorder.

Ongoing research

Scientists are working to better understand bipolar disorder. The NIMH is heading up the Research Domain Criteria (RDoC) Project, which is working to widen our understanding of brain circuitry that relates to behavioural and cognitive functioning. It is hoping to open the door to new preventive interventions, improve current medications and develop new treatments for bipolar disorder.

A particular focus is to find faster-acting medications. Some progress has been made in this sphere already. Ketamine has been shown to reduce symptoms of depression in less than an hour. This is a type of anaesthetic medicine and has serious side effects, so it cannot be used, but scientists are trying to find medications that act in the same way, without the side effects.

Living With

Bipolar disorder affects about 60 million people worldwide. If you have bipolar disorder you are not alone. Beyond your medical treatment, there are many things you can do to maintain your balance and develop coping skills. Among them are educating yourself as much as possible on the disorder, surrounding yourself with a support system and leading a healthy lifestyle.

To help yourself:

Be involved in your treatment: Learn everything you can about bipolar disorder, know the symptoms so that you can recognise them in yourself. Work with your doctor or therapist on your treatment. Don’t be afraid to ask questions or give input. Make healthy choices for yourself. Take your medication.

Monitor your symptoms and moods: Keep a close track of your moods. Know your triggers, such as stress, arguments with family, financial difficulties. Keep a mood chart so you don’t forget to monitor yourself in the business of life.

If you spot warning signs, you need to have something to draw on to get your back on track. Something like a wellness toolbox, which is a list of coping skills, may help. You will know which coping skills work for you, but consider tools like, talking to someone supportive, making sure you get enough sleep, cut back on commitments or activities, go to a support group, call your doctor, exercise, do something creative, make sure your diet is healthy and cut out stimulants.

Relapses do occur, so have an emergency plan in place too; write down a list of doctor’s numbers, the medication you are on and treatment preferences.

Remember that it takes time, symptoms tend to improve gradually.

Don’t isolate yourself: Keep in regular communication with your therapist and people who support you. Have regular contact with family and friends. Join a bipolar support group, spending time with people who know what you are going through can be very therapeautic. Join new community activities too, such as a church or charity work or classes and courses on something you are interested in.

Have a daily routine: Build structure into your life, eat healthily, exercise, make sure you sleep for at least eight hours a night. Try to go to bed and wake up at the same time each day and try to reduce stress in your life, using relaxation methods and making sure you schedule leisure time.

Friends and relatives:

If you are a friend, relative or caregiver of someone with bipolar disorder, it can be stressful and disruptive and you may need support or coping skills too.

You can help your friend or relative by:

Getting help for them. If you suspect someone has bipolar disorder you need to help him or her to get the right treatment. You may need to take them to the right doctor for a diagnosis and be there to encourage them to stick with the treatment.

Educate yourself about bipolar disorder, know the symptoms and as much as you can about the disorder, so that you are equipped to help.

Be understanding and sympathetic. Let the person know that you are there for them and will support them. Listen carefully; show that you understand their triggers. Keep in contact with the person, arrange times to see them and take them out. Be encouraging about their treatment and chances of recovery.

Be patient. Getting well is a long process and may have setbacks. Don’t expect a quick recovery.

Dealing with a person with bipolar disorder can be challenging. Family members or caregivers often struggle with a range of emotions from fear to anger as well as the daily struggles to deal with the symptoms. The strain can cause damaged relationships and exhaustion.

There are ways to cope:

Accept the illness: Understand that it isn’t anyone’s fault, but also that things will never be exactly the same again. Have realistic expectations. Don’t take the things the person may say or do personally.

Accept your loved ones limits as well as your own limits. People with bipolar disorder cannot control their moods in the same way as other people, you need to understand this. At the same time you are not responsible for your loved one’s recovery, that lies in their hands.

Establish routines for both your loved one and yourself, this will ease stress. Have regular meal times and bed times.

Reduce your own stress: Do this by having a support network, or belonging to a support group. Set boundaries; be realistic about the amount of care you can give without burning out. Keep sight of your own goals and interests too. If it becomes too much for you, ask for help.

Schizophrenia Disorder

Schizophrenia is a chronic, severe and disabling brain disorder that has affected people throughout history. People with the disorder may hear voices other people don't hear. They may believe other people are reading their minds, controlling their thoughts, or plotting to harm them. This can terrify people with the illness and make them withdrawn or extremely agitated.

What Is Schizophrenia?

Schizophrenia is a chronic, severe and disabling brain disorder that has affected people throughout history. People with the disorder may hear voices other people don't hear. They may believe other people are reading their minds, controlling their thoughts, or plotting to harm them. This can terrify people with the illness and make them withdrawn or extremely agitated.

People with schizophrenia may not make sense when they talk. They may sit for hours without moving or talking. Sometimes people with schizophrenia seem perfectly fine until they talk about what they are really thinking. Families and society are affected by schizophrenia too. Many people with schizophrenia have difficulty holding a job or caring for themselves, so they rely on others for help.

Treatment helps relieve many symptoms of schizophrenia, but most people who have the disorder cope with symptoms throughout their lives. However, many people with schizophrenia can lead rewarding and meaningful lives in their communities. Researchers are developing more effective medications and using new research tools to understand the causes of schizophrenia. In the years to come, this work may help prevent and better treat the illness.

Causes

Experts think schizophrenia is caused by several factors, genes and environment. Scientists have long known that schizophrenia runs in families. The illness occurs in one percent of the general population, but it occurs in 10 percent of people who have a first-degree relative with the disorder, such as a parent, brother or sister. People who have second-degree relatives (aunts, uncles, grandparents, or cousins) with the disease also develop schizophrenia more often than the general population. The risk is highest for an identical twin of a person with schizophrenia. He or she has a 40 to 65 percent chance of developing the disorder. We inherit our genes from both parents. Scientists believe several genes are associated with an increased risk of schizophrenia, but that no gene causes the disease by itself. In fact, recent research has found that people with schizophrenia tend to have higher rates of rare genetic mutations. These genetic differences involve hundreds of different genes and probably disrupt brain development.

Other recent studies suggest that schizophrenia may result in part when a certain gene that is key to making important brain chemicals malfunctions. This problem may affect the part of the brain involved in developing higher functioning skills. Research into this gene is ongoing, so it is not yet possible to use the genetic information to predict who will develop the disease.

Despite this, tests that scan a person's genes can be bought without a prescription or a health professional's advice. Ads for the tests suggest that with a saliva sample, a company can determine if a client is at risk for developing specific diseases, including schizophrenia. However, scientists don't yet know all of the gene variations that contribute to schizophrenia. Those that are known raise the risk only by very small amounts. Therefore, these "genome scans" are unlikely to provide a complete picture of a person's risk for developing a mental disorder like schizophrenia.

In addition, it probably takes more than genes to cause the disorder. Scientists think interactions between genes and the environment are necessary for schizophrenia to develop. Many environmental factors may be involved, such as exposure to viruses or malnutrition before birth, problems during birth, and other not yet known psychosocial factors. Different brain chemistry and structure. Scientists think that an imbalance in the complex, interrelated chemical reactions of the brain involving the neurotransmitters dopamine and glutamate, and possibly others, plays a role in schizophrenia. Neurotransmitters are substances that allow brain cells to communicate with each other. Scientists are learning more about brain chemistry and its link to schizophrenia.

Also, in small ways the brains of people with schizophrenia look different than those of healthy people. For example, fluid-filled cavities at the center of the brain, called ventricles, are larger in some people with schizophrenia. The brains of people with the illness also tend to have less gray matter, and some areas of the brain may have less or more activity.

Studies of brain tissue after death also have revealed differences in the brains of people with schizophrenia. Scientists found small changes in the distribution or characteristics of brain cells that likely occurred before birth. Some experts think problems during brain development before birth may lead to faulty connections. The problem may not show up in a person until puberty. The brain undergoes major changes during puberty, and these changes could trigger psychotic symptoms. Scientists have learned a lot about schizophrenia, but more research is needed to help explain how it develops.

Signs & Symptoms

The symptoms of schizophrenia fall into three broad categories: positive symptoms, negative symptoms, and cognitive symptoms.

Positive symptoms

Positive symptoms are psychotic behaviors not seen in healthy people. People with positive symptoms often "lose touch" with reality. These symptoms can come and go. Sometimes they are severe and at other times hardly noticeable, depending on whether the individual is receiving treatment. They include the following:

Hallucinations are things a person sees, hears, smells, or feels that no one else can see, hear, smell, or feel. "Voices" are the most common type of hallucination in schizophrenia. Many people with the disorder hear voices. The voices may talk to the person about his or her behavior, order the person to do things, or warn the person of danger. Sometimes the voices talk to each other. People with schizophrenia may hear voices for a long time before family and friends notice the problem.

Other types of hallucinations include seeing people or objects that are not there, smelling odors that no one else detects, and feeling things like invisible fingers touching their bodies when no one is near. Delusions are false beliefs that are not part of the person's culture and do not change. The person believes delusions, even after other people prove that the beliefs are not true or logical. People with schizophrenia can have delusions that seem bizarre, such as believing that neighbours can control their behaviour with magnetic waves. They may also believe that people on television are directing special messages to them, or that radio stations are broadcasting their thoughts aloud to others. Sometimes they believe they are someone else, such as a famous historical figure. They may have paranoid delusions and believe that others are trying to harm them, such as by cheating, harassing, poisoning, spying on, or plotting against them or the people they care about. These beliefs are called "delusions of persecution."

Thought disorders are unusual or dysfunctional ways of thinking. One form of thought disorder is called "disorganised thinking." This is when a person has trouble organising his or her thoughts or connecting them logically. They may talk in a garbled way that is hard to understand. Another form is called "thought blocking." This is when a person stops speaking abruptly in the middle of a thought. When asked why he or she stopped talking, the person may say that it felt as if the thought had been taken out of his or her head. Finally, a person with a thought disorder might make up meaningless words, or "neologisms."

Movement disorders may appear as agitated body movements. A person with a movement disorder may repeat certain motions over and over. In the other extreme, a person may become catatonic. Catatonia is a state in which a person does not move and does not respond to others. Catatonia is rare today, but it was more common when treatment for schizophrenia was not available.

Negative symptoms

Negative symptoms are associated with disruptions to normal emotions and behaviors. These symptoms are harder to recognise as part of the disorder and can be mistaken for depression or other conditions. These symptoms include the following:

"Flat affect" (a person's face does not move or he or she talks in a dull or monotonous voice)
Lack of pleasure in everyday life
Lack of ability to begin and sustain planned activities
Speaking little, even when forced to interact.
People with negative symptoms need help with everyday tasks. They often neglect basic personal hygiene. This may make them seem lazy or unwilling to help themselves, but the problems are symptoms caused by the schizophrenia.Cognitive symptoms

Cognitive symptoms are subtle. Like negative symptoms, cognitive symptoms may be difficult to recognize as part of the disorder. Often, they are detected only when other tests are performed. Cognitive symptoms include the following:

Poor "executive functioning" (the ability to understand information and use it to make decisions)
Trouble focusing or paying attention
Problems with "working memory" (the ability to use information immediately after learning it).

Cognitive symptoms often make it hard to lead a normal life and earn a living. They can cause great emotional distress.

Who Is At Risk?

Schizophrenia affects men and women equally. It occurs at similar rates in all ethnic groups around the world. Symptoms such as hallucinations and delusions usually start between ages 16 and 30. Men tend to experience symptoms a little earlier than women. Most of the time, people do not get schizophrenia after age 45. Schizophrenia rarely occurs in children, but awareness of childhood-onset schizophrenia is increasing.

It can be difficult to diagnose schizophrenia in teens. This is because the first signs can include a change of friends, a drop in grades, sleep problems, and irritability—behaviors that are common among teens. A combination of factors can predict schizophrenia in up to 80% of youth who are at high risk of developing the illness. These factors include isolating oneself and withdrawing from others, an increase in unusual thoughts and suspicions, and a family history of psychosis. In young people who develop the disease, this stage of the disorder is called the "prodromal" period.

Treatments

Because the causes of schizophrenia are still unknown, treatments focus on eliminating the symptoms of the disease. Treatments include antipsychotic medications and various psychosocial treatments.

Antipsychotic medications

Antipsychotic medications have been available since the mid-1950's. The older types are called conventional or "typical" antipsychotics. Some of the more commonly used typical medications include:

Chlorpromazine (Thorazine)
Haloperidol (Haldol)
Perphenazine (Etrafon, Trilafon)
Fluphenazine (Prolixin).

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

One of these medications, clozapine (Clozaril) is an effective medication that treats psychotic symptoms, hallucinations, and breaks with reality. 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. 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. But clozapine is potentially helpful for people who do not respond to other antipsychotic medications.

Other atypical antipsychotics were also developed. None cause agranulocytosis. Examples include:

Risperidone (Risperdal)
Olanzapine (Zyprexa)
Quetiapine (Seroquel)
Ziprasidone (Geodon)
Aripiprazole (Abilify)
Paliperidone (Invega).

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. 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.

TD happens to fewer people who take the 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 in pill or liquid form. Some anti-psychotics 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, as well as the right 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 typical antipsychotic perphenazine (Trilafon) 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. More information about CATIE is on the NIMH website.

Psychosocial treatments

Psychosocial treatments can help people with schizophrenia who are already stabilized on antipsychotic medication. Psychosocial treatments help these patients deal with the everyday challenges of the illness, such as difficulty with communication, self-care, work, and forming and keeping relationships. Learning and using coping mechanisms to address these problems allow people with schizophrenia to socialise and attend school and work. Patients who receive regular psychosocial treatment also are more likely to keep taking their medication, and they are less likely to have relapses or be hospitalised. A therapist can help patients better understand and adjust to living with schizophrenia. The therapist can provide education about the disorder, common symptoms or problems patients may experience, and the importance of staying on medications. For more information on psychosocial treatments, see the psychotherapies section on the NIMH website.

Illness management skills. People with schizophrenia can take an active role in managing their own illness. Once patients learn basic facts about schizophrenia and its treatment, they can make informed decisions about their care. If they know how to watch for the early warning signs of relapse and make a plan to respond, patients can learn to prevent relapses. Patients can also use coping skills to deal with persistent symptoms. Integrated treatment for co-occurring substance abuse. Substance abuse is the most common co-occurring disorder in people with schizophrenia. But ordinary substance abuse treatment programs usually do not address this population's special needs. When schizophrenia treatment programs and drug treatment programs are used together, patients get better results.

Rehabilitation. At Papillon we have a multidisciplinary team ready to help with rehabilitation: Our programme emphasises social and vocational training to help people with schizophrenia function better in their communities. Because schizophrenia usually develops in people during the critical career-forming years of life (ages 18 to 35), and because the disease makes normal thinking and functioning difficult, most patients do not receive training in the skills needed for a job.

Our programme includes job counselling and training, money management counselling, help in learning to use public transportation, and opportunities to practice communication skills. We have a seventy percent success rate, because we include both job training and specific therapy designed to improve cognitive or thinking skills. Programmes like this help patients hold jobs, remember important details, and improve their functioning. Family education. It is important that family members know as much as possible about the disease. With the help of one our therapist’s, family members can learn coping strategies and problem-solving skills. In this way the family can help make sure their loved one sticks with treatment and stays on his or her medication. Families should learn where to find outpatient and family services.

Cognitive behavioural therapy. Cognitive behavioural therapy (CBT) is a type of psychotherapy that focuses on thinking and behaviour. CBT helps patients with symptoms that do not go away even when they take medication. The therapist teaches people with schizophrenia how to test the reality of their thoughts and perceptions, how to "not listen" to their voices, and how to manage their symptoms overall. CBT can help reduce the severity of symptoms and reduce the risk of relapse.

Self-help groups. Self-help groups for people with schizophrenia and their families are becoming more common. Professional therapists usually are not involved, but group members support and comfort each other. People in self-help groups know that others are facing the same problems, which can help everyone feel less isolated. The networking that takes place in self-help groups can also prompt families to work together to advocate for research and more hospital and community treatment programmes. Also, groups may be able to draw public attention to the discrimination many people with mental illnesses face. We work with SADAG in this regard.

Living With

How can you help a person with schizophrenia?

People with schizophrenia often resist treatment. They may not think they need help because they believe their delusions or hallucinations are real. In these cases, family and friends may need to take action to keep their loved one safe. It can be difficult to force a person with a mental disorder into treatment or hospitalization. But when a person becomes dangerous to himself or herself, or to others, family members or friends may have to call the police to take their loved one to the hospital. At Papillon we assist with this endeavour known as "sectioning" – this is a free service we offer.

Treatment at the hospital. In the emergency room, a mental health professional will assess the patient and determine whether a voluntary or involuntary admission is needed. For a person to be admitted involuntarily, the law states that the professional must witness psychotic behavior and hear the person voice delusional thoughts. Family and friends can provide needed information to help a mental health professional make a decision. After a loved one leaves the hospital. Family and friends can help their loved ones get treatment and take their medication once they go home. If patients stop taking their medication or stop going to follow-up appointments, their symptoms likely will return. Sometimes symptoms become severe for people who stop their medication and treatment. This is dangerous, since they may become unable to care for themselves. Some people end up on the street or in jail, where they rarely receive the kind of help they need.

Family and friends can also help patients set realistic goals and learn to function in the world. Each step toward these goals should be small and taken one at a time. The patient will need support during this time. When people with a mental illness are pressured and criticised, they usually do not get well. Often, their symptoms may get worse. Telling them when they are doing something right is the best way to help them move forward.It can be difficult to know how to respond to someone with schizophrenia who makes strange or clearly false statements. Remember that these beliefs or hallucinations seem very real to the person. It is not helpful to say they are wrong or imaginary. But going along with the delusions is not helpful, either. Instead, calmly say that you see things differently. Tell them that you acknowledge that everyone has the right to see things his or her own way. In addition, it is important to understand that schizophrenia is a biological illness. Being respectful, supportive, and kind without tolerating dangerous or inappropriate behavior is the best way to approach people with this disorder.

Are people with schizophrenia violent?

People with schizophrenia are not usually violent. In fact, most violent crimes are not committed by people with schizophrenia. However, some symptoms are associated with violence, such as delusions of persecution. Substance abuse may also increase the chance a person will become violent. If a person with schizophrenia becomes violent, the violence is usually directed at family members and tends to take place at home. The risk of violence among people with schizophrenia is small. But people with the illness attempt suicide much more often than others. About 10 percent (especially young adult males) die by suicide. It is hard to predict which people with schizophrenia are prone to suicide. If you know someone who talks about or attempts suicide, help him or her find professional help right away.

What about substance abuse?

Some people who abuse drugs show symptoms similar to those of schizophrenia. Therefore, people with schizophrenia may be mistaken for people who are affected by drugs. Most researchers do not believe that substance abuse causes schizophrenia. However, people who have schizophrenia are much more likely to have a substance or alcohol abuse problem than the general population.

Substance abuse can make treatment for schizophrenia less effective. Some drugs, like marijuana and stimulants such as amphetamines or cocaine, may make symptoms worse. In fact, research has found increasing evidence of a link between marijuana and schizophrenia symptoms. In addition, people who abuse drugs are less likely to follow their treatment plan.

Schizophrenia and smoking

Addiction to nicotine is the most common form of substance abuse in people with schizophrenia. They are addicted to nicotine at three times the rate of the general population (75 to 90 percent vs. 25 to 30 percent).The relationship between smoking and schizophrenia is complex. People with schizophrenia seem to be driven to smoke, and researchers are exploring whether there is a biological basis for this need. In addition to its known health hazards, several studies have found that smoking may make antipsychotic drugs less effective. Quitting smoking may be very difficult for people with schizophrenia because nicotine withdrawal may cause their psychotic symptoms to get worse for a while. Quitting strategies that include nicotine replacement methods may be easier for patients to handle. Doctors who treat people with schizophrenia should watch their patients' response to antipsychotic medication carefully if the patient decides to start or stop smoking.

Dual Diagnosis Disorder

Dual Diagnosis is a combination of any mental disorder and addiction. For example, a mood disorder such as depression and a problem with substance abuse, like drug or alcohol abuse.

What is Dual Diagnosis Disorder?

A person with a dual diagnosis has two separate illnesses and each needs its own treatment plan. Dual Diagnosis is a relatively new concept, which emerged just over 20 years ago. It is sometimes not well understood by the medical establishment, even though as many as half of those with drug or alcohol addiction also have some form of mental illness. Often dual problems, if not treated in an integrated manner can lead to a high incidence of relapse. For example, if the addiction is treated, but not the underlying psychiatric disorder at the same time, it can complicate the process and a relapse may occur. Or, if the two problems are treated by different doctors, they may not have comprehensive picture of the person’s health.

Causes

A Dual Diagnosis situation might develop in response to some kind of genetic issue. In other words people often use drugs to deal with the symptoms of their illness, they “self-medicate”. For example, someone with anxiety may drink to calm themselves. The situation may also develop when damage caused by addiction comes into contact with a genetic abnormality that could lead to mental illness. The National Institute on Drug Abuse in the USA, suggests that people with a genetic vulnerability to schizophrenia might see that disorder surface when they use marijuana, it might otherwise never appear if they didn’t use drugs.

Signs & Symptoms

Signs and symptoms can vary from case to case, but there are some general warning signs that something is not right with you or with a loved one.

Mental health professsionals recommend looking for the following signs that a disorder may be present:

Not being able to remember a time, before the abuse of drugs and alcohol, when you were satisfied with life. Drugs make you feel normal. 
The use of drugs or alcohol to overcome anxiety or stress, or the use of drugs and alcohol to counter the side effects of medications for mental illness.
A traumatic experience in your past. These can trigger both substance abuse and mental illness. 
A family history of mental illness or addiction. Both of these disorders can have a strong genetic component. 
Struggling to keep down a job or to keep up with studies
Trying to quit a drug or alcohol makes you angry, violent or suicidal.
Experiencing withdrawal symptoms after trying to quit a harmful substance or cutting down the dose.

The only way to know that Dual Diagnosis exists is to be evaluated by a mental health professional with specialised training in Dual Diagnosis. Getting help is the first step in the recovery process.

Who Is At Risk?

According to a report in the Journal of the American Medical Association half of people with severe mental health disorders struggle with substance abuse too. Genetic markers, exposure to traumatic events and exposure to medications which cause addiction can all add to the risk of dual diagnosis.


Having a dual diagnosis can have a knock-on effect often creating other problems such as conflict in relationships, financial problems, inability to hold down a job, risky behaviour, isolation, legal problems or an unstable home environment.

Diagnosis

Diagnosing a comorbid situation is often difficult as the symptoms of the one can contribute to the cause of the other. The simultaneous nature of the illness and the fact that each illness is complex can make a diagnosis complicated.

Determining which illness came first, can also be problematic. Often a period of detoxification can make it easier to diagnose.

Comorbidities are often difficult to diagnose because the symptoms of one can often contribute to or cause the other. For example, those with depression often may experience more intense side effects as a result of alcohol use. Some drugs like psychedelics may instigate certain symptoms of psychosis or schizophrenia in individuals. So, the nature of these complex and simultaneous illnesses can complicate an accurate diagnosis.

What can help with an accurate diagnosis is determining which illness came first. That can be hard to do sometimes as it requires a person to abstain from drugs or alcohol for a period of time. Once detoxification is complete, clinicians can then look at the symptoms that remain and address them.

Assessing and treating a comorbid condition can be especially difficult due to the co-occurring nature of the disorders. One can often proliferate the other or, in some cases, both the substance abuse and the mental illness can occur separately from one another. Determining which illness is primary to the other can be problematic and troublesome. After a period of detoxification, physicians may have a better chance of diagnosing a patient with one of the above types of substance-related comorbidities. Many substance use disorders have symptoms that will rapidly decline after use discontinues, making a proper diagnosis more feasible.

So what then? After substance use stops, how to physicians know how to diagnose a mental health disorder? For that, a variety of illness-specific models have been established to help doctors, psychiatrists, and physicians better determine what disorders are present within an individual.

Perhaps one of the most widely used interview models for clinical assessment is the PRISM-IV. The PRISM-IV stands for Psychiatric Research Interview for Substance and Mental Disorders, and is a structured set of questions that help the interviewer assess mental illness and its relation to substance abuse. With a structured set of interview questions and measures for illness severity, an interviewer can better identify one or more of many mental illnesses. Over 10 major mental health disorders are targeted in this questionnaire including personality disorders, PTSD, obsessive-compulsive disorder (OCD), panic disorder, social phobias, specific phobias, major depression, manic depression and schizophrenia. Typically, questions relating to substance use precede those relating to mental illness so as to best serve as a benchmark for possible mental health disorders, and to understand how the two relate in an individual.

Other assessment models include the Young Mania Rating Scale (YMRS) for manic disorders and bipolar disorder, the Inventory of Depressive Symptoms (IDS), the Montgomery Asberg Depression Rating Scale (MADRS), the Structured Clinical Interview for DSM-IV for Axis II personality disorders (SCID-II), and the Angst Hypomania Check List (AHCL) that assesses hyperactivity and hypomania (useful for bipolar disorder evaluation).

These targeted assessments, along with detoxification, can dramatically help a physician determine what mental illness or illnesses remain comorbid with a substance use problem. While a 100 percent accurate diagnosis may be difficult all the time, achieving the best diagnosis possible is the goal.

Treatments

The best treatment for dual diagnosis is integrated intervention, when a person receives care for both their diagnosed mental illness and substance abuse. The idea that “I cannot treat your depression because you are also drinking” is outdated—current thinking requires both issues be addressed.

You and your treatment provider should understand the ways each condition affects the other and how your treatment can be most effective. Treatment planning will not be the same for everyone, but here are the common methods used as part of the treatment plan:

Detoxification. The first major hurdle that people with dual diagnosis will have to pass is detoxification. Inpatient detoxification is generally more effective than outpatient for initial sobriety and safety. During inpatient detoxification, trained medical staff monitor a person 24/7 for up to seven days. The staff may administer tapering amounts of the substance or its medical alternative to wean a person off and lessen the effects of withdrawal.

Inpatient Rehabilitation. A person experiencing a mental illness and dangerous/dependent patterns of substance use may benefit from an inpatient rehabilitation center where they can receive medical and mental health care 24/7. These treatment centers provide therapy, support, medication and health services to treat the substance use disorder and its underlying causes. 

Supportive Housing, like group homes or sober houses, are residential treatment centers that may help people who are newly sober or trying to avoid relapse. These centers provide some support and independence. Sober homes have been criticized for offering varying levels of quality care because licensed professionals do not typically run them. Do your research when selecting a treatment setting.

Psychotherapy is usually a large part of an effective dual diagnosis treatment plan. In particular, cognitive behavioral therapy (CBT) helps people with dual diagnosis learn how to cope and change ineffective patterns of thinking, which may increase the risk of substance use.

Medications are useful for treating mental illnesses. Certain medications can also help people experiencing substance use disorders ease withdrawal symptoms during the detoxification process and promote recovery.

Self-Help and Support Groups. Dealing with a dual diagnosis can feel challenging and isolating. Support groups allow members to share frustrations, celebrate successes, find referrals for specialists, find the best community resources and swap recovery tips. They also provide a space for forming healthy friendships filled with encouragement to stay clean. Here are some groups NAMI likes:

  • Double Trouble in Recovery is a 12-step fellowship for people managing both a mental illness and substance abuse.
  • Alcoholics Anonymous and Narcotics Anonymous are 12-step groups for people recovering from alcohol or drug addiction. Be sure to find a group that understands the role of mental health treatment in recovery.
  • Smart Recovery is a sobriety support group for people with a variety of addictions that is not based in faith.

Searching for the right mental health professional or program look for  therapists that have specialised training in Dual Diagnosis and well as the ability to be able to provide services for both illnesses in a single centre or place. It is also important to have an individualised treatment with both one-on-one and group counselling sessions.

The best treatment for co-occurring disorders is an integrated approach, where both the substance abuse problem and the mental disorder are treated simultaneously.

Recovery depends on treating both the addiction and the mental health problem. Whether your mental health or substance abuse problem came first, recovery depends on treating both disorders. There is hope. Recovering from co-occurring disorders takes time, commitment and courage. It may take months or even years but people with substance abuse and mental health problems can and do get better. Combined treatment is best. Your best chance of recovery is through integrated treatment for both the substance abuse problem and the mental health problem. This means getting combined mental health and addiction treatment from the same treatment provider or team.

Relapses are part of the recovery process. Don’t get too discouraged if you relapse. Slips and setbacks happen, but, with hard work, most people can recover from their relapses and move on with recovery. Peer support can help. You may benefit from joining a self-help support group like Alcoholics Anonymous or Narcotics Anonymous. They give you a chance to lean on others who know what you’re going through and learn from their experiences.

Living With

Why is it important to treat both the mood disorder and the alcohol/drug use? When neither illness is treated, one illness can make the other worse. When only one illness is treated, treatment is less likely to be effective. When both illnesses are treated, the chances for a full and lasting recovery are greatly improved, and it is easier to return to a full and productive life. Why is it important to stay clean and sober when getting treatment? Mixing alcohol or drugs with medication can have serious and dangerous effects. Many medications, including over-the-counter medications, interact with alcohol or drugs in harmful ways. It is also unlikely that you will benefit from talk therapy if you are under the influence.

What should I expect from treatment?

You may need to go to more than one doctor and attend more than one support group. All of your treatment providers should be aware that you have a dual diagnosis. Treatment for your mood disorder may include counselling or psychotherapy, medication and DBSA support groups where you can share your experience living with depression or bipolar disorder. Treatment for your alcohol and/or drug use may include some type of recovery group. If you are drinking or using every day, you and your doctor may decide that you need to check into a hospital or treatment center so you can be treated for physical withdrawal symptoms. After treating the withdrawal, you will need to treat the addiction. This may include a residential or outpatient alcohol/drug treatment center, a 12-step group or another group that focuses on living without substances. In these groups, you will learn how others stopped drinking or using, how to cope with cravings and urges to drink or use, and how to live comfortably without the use of alcohol or drugs.

Talk therapy (psychotherapy) can help you learn to cope with symptoms of depression and/or mania, and change the patterns of thinking that may be making them worse. Therapy can also help you look at your drinking/using habits and work on staying clean and sober. You may get therapy from a psychiatrist, a psychologist, a social worker, a therapist, a counsellor, a nurse or another health professional.

Medication to help with symptoms of depression and mania may be prescribed by a physician or psychiatrist. You and your doctor will work together to find the right medication(s) for you. Different people have different responses to medication, and many people need to try several before they find the best one(s). Though it may not be easy, be patient when starting new medications and wait for them to work. Don’t lose hope. Some can take four to eight weeks before you feel their full effects.

Keep your own records of treatment—how you feel each day, what medications and dosages you take and how they affect you, and any alcohol or drug use.

Medications that affect the brain may also affect other systems of the body, and cause side effects such as dry mouth, constipation, sleepiness, blurred vision, weight gain, weight loss, dizziness or sexual problems. You might feel the side effects before you feel the helpful effects of your medication. Many times, these side effects will go away in a few weeks. If they don’t go away immediately, don’t be discouraged. There are ways to reduce or get rid of them.

Change the time you take your medication to help with sleepiness or sleeplessness.

Take it with food to help with nausea.

Your doctor may change your dosage or prescribe another medication.

Tell your doctor about any side effects you are having. You and your doctor should work together to make decisions about medication.

Never stop taking your medication or change your dosage without talking to your doctor first.

Am I still clean and sober if I take medication?

Absolutely. Taking medication as prescribed by a doctor is not the same as using alcohol or street drugs to feel better. Medications affect the same brain chemicals that alcohol and street drugs do. But medication balances the levels of these chemicals instead of making them rise and fall. Medications help keep your brain chemicals, and your moods, more predictable and stable. They can help you to be yourself.

Medications do not impair your judgment. They do not give you a false sense of courage. They do not cause you to crave another pill soon after you’ve taken the first. They are not mixed or “cut” with other dangerous chemicals. They have been tested and found to be safe and effective.

The goal of medication treatment is to help you become stable and healthy. Medications manage your symptoms, rather than masking them. They help you take control and work toward positive changes in your life. Your doctor also monitors your medications, and if you have any problems, s/he can help you decide what changes need to be made. Some drug and alcohol recovery groups may believe that you can’t be clean and sober if you take medications prescribed by a doctor. This belief is just plain wrong. Medication for your mood disorder is no different than medication for another illness such as asthma, high blood pressure or diabetes. If your recovery group challenges your use of medication, it is probably best for you to become part of another group that understands the concept of dual diagnosis. The good news is there are many different recovery groups to choose from. Don’t give up hope. If you keep looking, you will find other people who are dually diagnosed and receive treatment for both illnesses.

Borderline Personality Disorder

Borderline Personality Disorder (BPD) is a mental illness that manifests as ongoing patters of difficulty with self-regulation. People with BPD often feel that everything is unstable in their lives, from their moods to relationships, thinking, behaviour and self-image.

What is Borderline Personality Disorder?

Borderline Personality Disorder (BPD) is a mental illness that manifests as ongoing patters of difficulty with self-regulation. People with BPD often feel that everything is unstable in their lives, from their moods to relationships, thinking, behaviour and self-image.

BPD usually begins in adolescence or early adulthood and affects relationships due to an inabilityto manage emotions. The lack of internal stability can make it a frightening way to live.

BPD was listed as a diagnosable illness for the first time in 1980 in the Diagnostic and Statistical Manual for Mental Disorders, Third Edition (DSM-III). The name came stemmed from a perception of BPD as on the ‘borderline’ between psychosis and neurosis, and although it doesn’t describe the condition very accurately, it has stuck.

BPD is often misdiagnosed or connected to other mental illnesses such as bipolar disorder or depression and can sometimes get lost in the treatment of these illnesses.

People who have BPD tend to suffer from:

Problems with regulating, thoughts, feelings and actions

Difficulty maintaining relationships

Explosive anger

Impulsive and sometimes reckless behaviour

There is hope - BPD is treatable with consistent therapy, self-awareness, and support. Specialised treatments and coping skills can help break dysfunctional patterns of thinking, feeling and behaving and restore emotional balance.

Causes

It appears that no one single cause or risk factor is responsible for causing the disorder. Although research into BDP is still at a very early stage, most researchers agree that BPD is commonly caused by an interaction of a combination factors:

Biological factors such as a genetic predisposition to developing the disorder. Studies of twins with BPD suggest that the illness is strongly inherited. Genetic abnormalities appear to affect the proper functioning of brain pathways that regulate the behavioural functions of information processing and impulse control and cognitive activity such as perception and reasoning

Environmental factors: For example, difficult or traumatic experiences while growing up, such as death of a parent, chronic fear or distress, family instability, abuse or neglect. Environmental factors increase the risk, but the disorder can develop without them in some cases.

Signs & Symptoms

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition ((Referred to as DSM-V), defines nine specific diagnostic criteria for BPD. To be diagnosed with BPD, patients must have five of the following criteria:

Impulsive, self-destructive behaviours. This includes engaging in harmful or sensation-seeking behaviours, for example driving recklessly, binge eating, impulsive spending, reckless driving, risky sex or overdoing drugs and alcohol.

A pattern of unstable relationships: Tending to have relationships that are intense and quickly over. Relationships tend to veer from idealisation to intense dislike, with nothing in-between.

Fear of abandonment: People with BPD are often terrified of being abandoned or left alone. This leads to jealousy and clinginess in relationships.

Unclear or unstable sense of self. People with BPD have a self-image that is unstable. Sometimes they feel good about themselves, but at other times hate themselves. They often don’t have a clear idea of who they are and what they want, which can lead to changes in religion, jobs, values, opinions, feelings and goals.

Self-harm: Attempts to hurt oneself, such as cutting or burning and suicidal behaviour is common in people with BPD.
Intense emotional swings: Changeable emotions or moods are common with BPD. Emotions can fluctuate between happiness and despair in minutes. The mood swings are intense, but are short and tend to pass quickly.

Severe and long-term feelings of emptiness or boredom: Feeling like there is a void inside that is uncomfortable and needs to be filled. People with BPD often fill this ‘hole’ with drugs, food or sex.

Explosive anger: People with BPD often struggle with intense anger, lose their tempers quickly and have trouble controlling themselves once they are in a temper. This anger may be directed inwards and they may feel angry with themselves.

Suspicious thoughts and feeling out of touch with reality. People with BPD often struggle with paranoia and doubts about other people’s motives. They may experience dissociation (feeling spaced out or outside your own body) when they are stressed.

Who Is At Risk?

According to recent statistics, over 4 million people in the United States alone have BPD. Far more women are likely to be diagnosed with BPD with men, but this may be due to the fact that it is underdiagnosed in men. People may be at greater risk of developing BPD if they had a family member with BPD, felt emotionally vulnerable as a child or were emotionally abused or if they were raised in an impulsive household.

Diagnosis

Cases of BPD are often missed or misdiagnosed, which can delay or prevent recovery. It is frequently misdiagnosed as bipolar disorder because of mood instability, but there are fundamental differences between the two conditions. In the case of bipolar disorder, mood changes exist for weeks, but with BPD, mood changes are short-lived.

Only a qualified mental health professional such as a psychiatrist, psychologist, clinical social worker or psychiatric nurse can diagnose BPD. Diagnosis is usually only made after a medical exam to rule out other causes of symptoms, as well as a comprehensive assessment of symptoms and presentation, often based on the DSM classification system. The professional may also consult family, friends and caregivers to increase understanding of symptoms. The mental health practitioner will decide on the best course of treatment for the patient.

The diagnosis will normally only be made in adults as signs and symptoms of BPD may go away as children get older and more mature.

BPD often co-occurs with other disorders such as substance abuse, depression, bipolar disorder, eating disorder and anxiety disorders.

Treatments

People with BPD can recover. Research increasingly shows that some treatments for BPD are effective and many people with BPD experience a lessening of symptoms and substantially improved quality of life after treatment.

Treatments typically involve a combination of psychotherapy, medication and social support. At Papillon, BPD is treated primarily with psychotherapy. In some cases, medication may be prescribed in conjunction with other treatments to manage specific symptoms, such as anxiety. In cases where a person is under the care of more than one professional it is imperative for the professionals to work as a team on the treatment plan. As the treatment plan may take time, it is also important for friends and family to be patient and supportive during treatment.

Some of the treatments options available to a person with BPD are covered in more detail below.

Psychotherapy

Psychotherapy is the central treatment for BPD. Several different psychotherapy approaches appear be successful. Ongoing studies into BPD treatments are providing increasing insight into which psychotherapy approaches are optimal.

The primary therapies used to treat BPD are;Cognitive Behavioural Therapy (CBT), Dialectical Behaviour Therapy (DBT) and Schema-Focused therapy and a skilled therapist will be familiar with them. Many psychotherapists will also adapt therapy to suit the patients’ needs, or mix techniques from different therapies.

Therapy can either be in a group or one-on-one session. Group sessions may teach people with BPD how to improve interaction with other people and how to express themselves constructively. Families of people with BPD can also benefit from therapy to develop skills and better support a person with BPD.

A breakdown of common therapy treatments follows:

Cognitive Behavioural Therapy (CBT): CBT can help people with BPD reduce symptoms by helping them change the way they think about or interpret situations and change the actions they take in response. CBT may help reduce a range of mood and anxiety symptoms and reduce the number of suicidal or self-harming behaviours.

Dialectical Behaviour Therapy (DBT): DBT integrates CBT with the concept of mindfulness, which is learning to be focus and be aware of what is happening moment-to-moment. DBT also teaches techniques to control intense emotions, tolerate stress, reduce self-destructive behaviours, and improve relationships.

Schema-Focused Therapy: Schemas are self-defeating, core themes or patterns that people keep repeating throughout their lives. This therapy combines elements of CBT with other types of psychotherapy to ‘reframe’ the way people see themselves.

It is important for a person with BPD to find a therapist they feel safe with and commit to therapy. Recovery is a slow process, the core symptoms of mood swings, anger and impulsiveness tend to be the ones that require the most attention. Additionally, people whose symptoms improve may still face issues with co-occurring disorders such as anxiety and depression. However, every time a person with BPD practices a new coping response or self-soothing technique it helps to create new neural pathways in the brain and will with time and regular practice change the way the person with BPD thinks, feels and acts. Research shows that once a level of functioning is reached, only a small minority fall back, while the majority of people tend to maintain the level they have reached, unless faced with considerable stressors.

Medications

There are no drugs specifically licenced to treat BPD. The use of medications in BPD is primarily to treat a co-occurring disorder such as depression or anxiety and manage the symptoms of that disorder. Health providers may use anti-depressants, anti-psychotics and mood stabilizers, to treat these co-occurring disorders. People diagnosed with BPD should be aware of all the facts and talk to the prescribing doctor about possible side-effects, to make an informed decision.

Other Treatments

Omega-3 fatty acids have been used to some extent and have been the subject of some research which primarily found that Omega-3 fatty acids may have moderating effects on aggression and impulsivity.

Some lifestyle modifications can be useful in recovering from BPD such as maintaining a regular sleeping and eating schedule, regular exercise, avoiding alcohol and drugs and enlisting the support of friends and family.

SA’s Mental Health Status

The MHIC adds that one of the greatest obstacles to preventing mental illness, and improving services and treatment, is ignorance. Psychiatric Disability Awareness month aims to focus the attention on mental illness and thereby to reduce ignorance. (Source: Ilse Pauw, Health24)

Mental Illness is Common

According to a comprehensive study done on mental illness in South Africa, The South African Stress and Health (SASH) study, 30.3% of adults will have suffered some form of mental disorder in their lifetime. In the twelve-month period measured in the study, one in six adults suffered from common mental disorders, and a quarter of these, suffered serious mental disorders; this represents one in four out of every hundred South Africans.

Statistics released by the Department of Health correlate this, they estimate that one in five South Africans are significantly affected by a mental disorder and show that between 1% and 3% of the South African population are likely to suffer from a mental health problem severe enough to require hospitalisation. Almost 20% of high school students a year, think about fatally harming themselves.

According to the Mental Health Information Centre (MHIC) mental disorders have a negative impact on society both from a social and economic standpoint. Just the economic cost of alcohol abuse is estimated to be R5 billion a year, through health and medical expenses as well as lost productivity and violence. It estimates that the costs of other mental disorders are just as high as those for substance abuse, particularly when they are diagnosed late. There is also the human cost, for example; marital and family breakdown and individual suffering.

Globally, the World Health Organisation (WHO) estimates that more than 450 million people across the globe suffer from mental illness.

Disability

Common mental disorders lead to considerable losses in health and functioning in rich and poor communities alike, and the prevalence of these mental disorders is increasing, particularly in low and middle-income countries. Unipolar major depression ranks as the leading cause of disability in the world and manic-depressive illness, alcohol abuse, anxiety disorders and schizophrenia fall into the top ten causes of disability world-wide.

350 million people suffer from depression worldwide and the numbers are on the increase. The number of people living with depression has increased by 18,4 % from 2005 to 2015. Depression is also a major contributor to the average of 800 000 suicide deaths a year. Anxiety disorders affect 3,4% of the world’s population.

Over the past few decades new and innovative treatments for mental disorders have emerged from ongoing research on the basic biology of mental disorders. Many illnesses are very treatable, especially with early diagnoses and intervention. In particular, early diagnosis can prevent the illness getting worse or lasting a long time. Tragically, many people do not receive treatment.

Why treatment isn't offered

Why is proven and affordable care for mental disorders not provided? Some of the barriers to treatment include; a public lack of awareness of symptoms and the necessity for treatment, the stigma attached to seeking help, lack of referral by primary care providers to mental health resources, lack of insurance for medications, inadequate numbers of hospital beds for mental illness and low priority given to mental health.

Some important myths and facts about mental illness and recovery:

It is a myth that children don’t experience mental health problems. Half of all mental health disorders show first signs before a person turns 14 years old, and three quarters of mental health disorders begin before age 24, which makes the young particularly vulnerable.