Lupus

Monday, April 2, 2012

Lupus and mental illness


Lupus can affect the brain in many ways either by attacking this organ with inflammation, or just by the stress that having such a debilitating illness can cause.  I know many people that suffer with lupus and other mental issues such as depression, anxiety, and bipolar.  It is such a hard illness to deal with emotionally, on so many levels, you never know how you are going to feel from one minute to the next, and just that alone can make anyone feel like they are losing control.  One day you could feel well for you, and then that night have to be rushed to the hospital due to a flare.  This disease is so confusing, it lies to you constantly, by making believe that you are doing fine and then before you know it, you are begging god to help you, and make this illness go away.  It is a feeling that cannot be explained, you have to feel it, to understand it.  With a disease that makes you okay one minute and desperately ill the next, how do you cope with such drastic change physically and emotionally.  The medications can also cause mood changes, prednisone for instance, is a nightmare when dealing with mental issues, and can cause so many on it's own.  SLE can cause many problems with the brain, strokes, depression, memory problems and arguably headaches.  There are many people with lupus that also suffer with bipolar disorder, is there a link?  We don't know, studies suggest that there is not, but that lupus can cause a mental breakdown which mimics bipolar symptoms.  Lupus is still such a mysterious disease and there really is no true answer to many questions that exist about this complex disease. Panic disorders also plague lupus patients and I will also discuss this issue in this post.


Depression (major depression)

Definition

By Mayo Clinic staff Depression is a medical illness that causes a persistent feeling of sadness and loss of interest. Depression can cause physical symptoms, too.
Also called major depression, major depressive disorder and clinical depression, it affects how you feel, think and behave. Depression can lead to a variety of emotional and physical problems. You may have trouble doing normal day-to-day activities, and depression may make you feel as if life isn't worth living.
More than just a bout of the blues, depression isn't a weakness, nor is it something that you can simply "snap out" of. Depression is a chronic illness that usually requires long-term treatment, like diabetes or high blood pressure. But don't get discouraged. Most people with depression feel better with medication, psychological counseling or other treatment.


Symptoms

By Mayo Clinic staff Depression symptoms include:
  • Feelings of sadness or unhappiness
  • Irritability or frustration, even over small matters
  • Loss of interest or pleasure in normal activities
  • Reduced sex drive
  • Insomnia or excessive sleeping
  • Changes in appetite — depression often causes decreased appetite and weight loss, but in some people it causes increased cravings for food and weight gain
  • Agitation or restlessness — for example, pacing, hand-wringing or an inability to sit still
  • Irritability or angry outbursts
  • Slowed thinking, speaking or body movements
  • Indecisiveness, distractibility and decreased concentration
  • Fatigue, tiredness and loss of energy — even small tasks may seem to require a lot of effort
  • Feelings of worthlessness or guilt, fixating on past failures or blaming yourself when things aren't going right
  • Trouble thinking, concentrating, making decisions and remembering things
  • Frequent thoughts of death, dying or suicide
  • Crying spells for no apparent reason
  • Unexplained physical problems, such as back pain or headaches
For some people, depression symptoms are so severe that it's obvious something isn't right. Other people feel generally miserable or unhappy without really knowing why.
Depression affects each person in different ways, so symptoms caused by depression vary from person to person. Inherited traits, age, gender and cultural background all play a role in how depression may affect you.
Depression symptoms in children and teens
Common symptoms of depression can be a little different in children and teens than they are in adults.

  • In younger children, symptoms of depression may include sadness, irritability, hopelessness and worry.
  • Symptoms in adolescents and teens may include anxiety, anger and avoidance of social interaction.
  • Changes in thinking and sleep are common signs of depression in adolescents and adults but are not as common in younger children.
  • In children and teens, depression often occurs along with behavior problems and other mental health conditions, such as anxiety or attention-deficit/hyperactivity disorder (ADHD).
  • Schoolwork may suffer in children who are depressed.
Depression symptoms in older adults
Depression is not a normal part of growing older, and most seniors feel satisfied with their lives. However, depression can and does occur in older adults. Unfortunately, it often goes undiagnosed and untreated. Many adults with depression feel reluctant to seek help when they're feeling down.

  • In older adults, depression may go undiagnosed because symptoms — for example, fatigue, loss of appetite, sleep problems or loss of interest in sex — may seem to be caused by other illnesses.
  • Older adults with depression may have less obvious symptoms. They may feel dissatisfied with life in general, bored, helpless or worthless. They may always want to stay at home, rather than going out to socialize or doing new things.
  • Suicidal thinking or feelings in older adults is a sign of serious depression that should never be taken lightly, especially in men. Of all people with depression, older adult men are at the highest risk of suicide.
When to see a doctor
If you feel depressed, make an appointment to see your doctor as soon as you can. Depression symptoms may not get better on their own — and depression may get worse if it isn't treated. Untreated depression can lead to other mental and physical health problems or problems in other areas of your life. Feelings of depression can also lead to suicide.

If you're reluctant to seek treatment, talk to a friend or loved one, a health care professional, a faith leader, or someone else you trust.
If you have suicidal thoughts
If you or someone you know is having suicidal thoughts, get help right away. Here are some steps you can take:

  • Contact a family member or friend.
  • Seek help from your doctor, a mental health provider or other health care professional.
  • Call a suicide hot line number — in the United States, you can reach the toll-free, 24-hour hot line of the National Suicide Prevention Lifeline at 800-273-8255 to talk to a trained counselor.
  • Contact a minister, spiritual leader or someone in your faith community.
When to get emergency help
If you think you may hurt yourself or attempt suicide, call 911 or your local emergency number immediately. If you have a loved one who has harmed himself or herself, or is seriously considering doing so, make sure someone stays with that person. Take him or her to the hospital or call for emergency help.



Causes

By Mayo Clinic staff It's not known exactly what causes depression. As with many mental illnesses, it appears a variety of factors may be involved. These include:
  • Biological differences. People with depression appear to have physical changes in their brains. The significance of these changes is still uncertain, but may eventually help pinpoint causes.
  • Neurotransmitters. These naturally occurring brain chemicals linked to mood are thought to play a direct role in depression.
  • Hormones. Changes in the body's balance of hormones may be involved in causing or triggering depression. Hormone changes can result from thyroid problems, menopause or a number of other conditions.
  • Inherited traits. Depression is more common in people whose biological family members also have this condition. Researchers are trying to find genes that may be involved in causing depression.
  • Life events. Certain events, such as the death or loss of a loved one, financial problems, and high stress, can trigger depression in some people.
  • Early childhood trauma. Traumatic events during childhood, such as abuse or loss of a parent, may cause permanent changes in the brain that make you more susceptible to depression.
  • Risk factors

    By Mayo Clinic staff Depression often begins in the teens, 20s or 30s, but it can happen at any age. Twice as many women are diagnosed with depression as men, but this may be due in part because women are more likely to seek treatment for depression.
    Although the precise cause of depression isn't known, researchers have identified certain factors that seem to increase the risk of developing or triggering depression, including:
  • Having biological relatives with depression
  • Being a woman
  • Having traumatic experiences as a child
  • Having family members or friends who have been depressed
  • Experiencing stressful life events, such as the death of a loved one
  • Having few friends or other personal relationships
  • Recently having given birth (postpartum depression)
  • Having been depressed previously
  • Having a serious illness, such as cancer, diabetes, heart disease, Alzheimer's or HIV/AIDS
  • Having certain personality traits, such as having low self-esteem and being overly dependent, self-critical or pessimistic
  • Abusing alcohol, nicotine or illicit drugs
  • Taking certain high blood pressure medications, sleeping pills or certain other medications (Talk to your doctor before stopping any medication you think could be affecting your mood.)
  •  

    Complications

    By Mayo Clinic staff Depression is a serious illness that can take a terrible toll on individuals and families. Untreated depression can result in emotional, behavioral and health problems that affect every area of your life. Complications associated with depression can include:
  • Alcohol abuse
  • Substance abuse
  • Anxiety
  • Work or school problems
  • Family conflicts
  • Relationship difficulties
  • Social isolation
  • Suicide
  • Self-mutilation, such as cutting
  • Premature death from other medical conditions
  •  

Definition

By Mayo Clinic staff

Preparing for your appointment

By Mayo Clinic staff You're likely to start by seeing your primary care doctor. However, in some cases when you call to set up an appointment, you may be referred directly to a health provider who specializes in diagnosing and treating mental health conditions (psychologist or psychiatrist).
Because appointments can be brief, and because there's often a lot of ground to cover, it's a good idea to be well prepared for your appointment. Here's some information to help you get ready for your appointment, and know what to expect from your health provider.
What you can do
  • Write down any symptoms you've had, including any that may seem unrelated to the reason for which you scheduled the appointment.
  • Write down key personal information, including any major stresses or recent life changes.
  • Make a list of all medications, vitamins or supplements that you're taking.
  • Take a family member or friend along, if possible. Sometimes it can be difficult to remember all of the information provided to you during an appointment. Someone who accompanies you may remember something that you missed or forgot.
  • Write down questions to ask your health provider.
Your time with your health provider is limited, so preparing a list of questions ahead of time will help you make the most of your time together. List your questions from most important to least important in case time runs out. For problems related to depression, some basic questions to ask your health provider include:
  • Is depression the most likely cause of my symptoms?
  • Other than the most likely cause, what are other possible causes for my symptoms or condition?
  • What kinds of tests will I need?
  • What treatment is likely to work best for me?
  • What are the alternatives to the primary approach that you're suggesting?
  • I have these other health conditions. How can I best manage them together?
  • Are there any restrictions that I need to follow?
  • Should I see a psychiatrist or other mental health provider?
  • Are there any possible side effects or other issues I should be aware of with the medications you're recommending?
  • Is there a generic alternative to the medicine you're prescribing?
  • Are there any brochures or other printed material that I can take home with me? What websites do you recommend visiting?
In addition to the questions that you've prepared to ask your health provider, don't hesitate to ask any additional questions that may occur to you during your appointment.
What to expect from your health provider
Your health provider is likely to ask you a number of questions. Being ready to answer them may reserve time to go over any points you want to spend more time on. Your health provider may ask:

  • When did you or your loved ones first notice your symptoms of depression?
  • How long have you felt depressed? Do you generally always feel down, or does your mood fluctuate?
  • Does your mood ever swing from feeling down to feeling euphoric and full of energy?
  • Do you ever have suicidal thoughts when you're feeling down?
  • How severe are your symptoms? Do they interfere with your daily life or relationships?
  • Do you have any biological relatives with depression or another mood disorder?
  • What other mental or physical health conditions do you have?
  • Do you drink alcohol or use illegal drugs?
  • How much do you sleep at night? Does it change over time?
  • What, if anything, seems to improve your symptoms?
  • What, if anything, appears to worsen your symptoms?
  • Tests and diagnosis

    By Mayo Clinic staff Because depression is common and often goes undiagnosed, some doctors and health care providers may ask questions about your mood and thoughts during routine medical visits. They may even ask you to fill out a brief questionnaire to help check for depression symptoms.
    When doctors suspect someone has depression, they generally ask a number of questions and may do medical and psychological tests. These can help rule out other problems that could be causing your symptoms, pinpoint a diagnosis and also check for any related complications. These exams and tests generally include:
  • Physical exam. This may include measuring your height and weight; checking your vital signs, such as heart rate, blood pressure and temperature; listening to your heart and lungs; and examining your abdomen.
  • Laboratory tests. For example, your doctor may do a blood test called a complete blood count (CBC) or test your thyroid to make sure it's functioning properly.
  • Psychological evaluation. To check for signs of depression, your doctor or mental health provider will talk to you about your thoughts, feelings and behavior patterns. He or she will ask about your symptoms, and whether you've had similar episodes in the past. You'll also discuss any thoughts you may have of suicide or self-harm. Your doctor may have you fill out a written questionnaire to help answer these questions.
Diagnostic criteria for depression
To be diagnosed with major depression, you must meet the symptom criteria spelled out in the Diagnostic and Statistical Manual of Mental Disorders (DSM). This manual is published by the American Psychiatric Association and is used by mental health providers to diagnose mental conditions and by insurance companies to reimburse for treatment.

To be diagnosed with major depression, you must have five or more of the following symptoms over a two-week period. At least one of the symptoms must be either a depressed mood or a loss of interest or pleasure. Symptoms can be based on your own feelings or may be based on the observations of someone else. They include:
  • Depressed mood most of the day, nearly every day, such as feeling sad, empty or tearful (in children and adolescents, depressed mood can appear as constant irritability)
  • Diminished interest or feeling no pleasure in all — or almost all — activities most of the day, nearly every day
  • Significant weight loss when not dieting, weight gain, or decrease or increase in appetite nearly every day (in children, failure to gain weight as expected can be a sign of depression)
  • Insomnia or increased desire to sleep nearly every day
  • Either restlessness or slowed behavior that can be observed by others
  • Fatigue or loss of energy nearly every day
  • Feelings of worthlessness, or excessive or inappropriate guilt nearly every day
  • Trouble making decisions, or trouble thinking or concentrating nearly every day
  • Recurrent thoughts of death or suicide, or a suicide attempt
To be considered major depression:
  • Your symptoms aren't due to a mixed episode — simultaneous mania and depression that can occur in bipolar disorder
  • Symptoms must be severe enough to cause noticeable problems in day-to-day activities, such as work, school, social activities or relationships with others
  • Symptoms are not due to the direct effects of something else, such as drug abuse, taking a medication or having a medical condition such as hypothyroidism
  • Symptoms are not caused by grieving, such as temporary sadness after the loss of a loved one
Other conditions that cause depression symptoms
There are several other conditions with symptoms that can include depression. It's important to get an accurate diagnosis so you can get the appropriate treatment for your particular condition. Your doctor or mental health provider's evaluation will help determine if your symptoms of depression are caused by one of the following conditions:

  • Adjustment disorder. An adjustment disorder is a severe emotional reaction to a difficult event in your life. It's a type of stress-related mental illness that may affect your feelings, thoughts and behavior.
  • Bipolar disorder. This type of depression is characterized by mood swings that range from highs to lows. It's sometimes difficult to distinguish between bipolar disorder and depression, but it's important to get an accurate diagnosis so that you can get the proper treatment and medications.
  • Cyclothymia. Cyclothymia (si-klo-THI-me-uh), also called cyclothymic disorder, is a milder form of bipolar disorder.
  • Dysthymia. Dysthymia (dis-THI-me-uh) is a less severe but more chronic form of depression. While it's usually not disabling, dysthymia can prevent you from functioning normally in your daily routine and from living life to its fullest.
  • Postpartum depression. This is a common type of depression that occurs in new mothers. It often occurs between two weeks and six months after delivery.
  • Psychotic depression. This is severe depression accompanied by psychotic symptoms, such as delusions or hallucinations.
  • Seasonal affective disorder. This type of depression is related to changes in seasons and diminished exposure to sunlight.
Make sure you understand what type of depression you have so that you can learn more about your specific situation and its treatments.

Treatments and drugs

By Mayo Clinic staff Numerous depression treatments are available. Medications and psychological counseling (psychotherapy) are very effective for most people.
In some cases, a primary care doctor can prescribe medications to relieve depression symptoms. However, many people need to see a doctor who specializes in diagnosing and treating mental health conditions (psychiatrist). Many people with depression also benefit from seeing a psychologist or other mental health counselor. Usually the most effective treatment for depression is a combination of medication and psychotherapy.
If you have severe depression, a doctor, loved one or guardian may need to guide your care until you're well enough to participate in decision making. You may need a hospital stay, or you may need to participate in an outpatient treatment program until your symptoms improve.
Here's a closer look at your depression treatment options.
Medications
A number of antidepressant medications are available to treat depression. There are several different types of antidepressants. Antidepressants are generally categorized by how they affect the naturally occurring chemicals in your brain to change your mood.

Types of antidepressants include:
  • Selective serotonin reuptake inhibitors (SSRIs). Many doctors start depression treatment by prescribing an SSRI. These medications are safer and generally cause fewer bothersome side effects than do other types of antidepressants. SSRIs include fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), citalopram (Celexa) and escitalopram (Lexapro). The most common side effects include decreased sexual desire and delayed orgasm. Other side effects may go away as your body adjusts to the medication. They can include digestive problems, jitteriness, restlessness, headache and insomnia.
  • Serotonin and norepinephrine reuptake inhibitors (SNRIs). These medications include duloxetine (Cymbalta), venlafaxine (Effexor XR) and desvenlafaxine (Pristiq). Side effects are similar to those caused by SSRIs. These medications can cause increased sweating, dry mouth, fast heart rate and constipation.
  • Norepinephrine and dopamine reuptake inhibitors (NDRIs). Bupropion (Wellbutrin) falls into this category. It's one of the few antidepressants that doesn't cause sexual side effects. At high doses, bupropion may increase your risk of having seizures.
  • Atypical antidepressants. These medications are called atypical because they don't fit neatly into another antidepressant category. They include trazodone (Oleptro) and mirtazapine (Remeron). Both of these antidepressants are sedating and are usually taken in the evening. In some cases, one of these medications is added to other antidepressants to help with sleep. The newest medication in this class of drugs is vilazodone (Viibryd). Vilazodone has a low risk of sexual side effects. The most common side effects associated with vilazodone are diarrhea, nausea, vomiting and insomnia.
  • Tricyclic antidepressants. These antidepressants have been used for years and are generally as effective as newer medications. But because they tend to have more numerous and more-severe side effects, a tricyclic antidepressant generally isn't prescribed unless you've tried an SSRI first without an improvement in your depression. Side effects can include dry mouth, blurred vision, constipation, urinary retention, fast heartbeat and confusion. Tricyclic antidepressants are also known to cause weight gain.
  • Monoamine oxidase inhibitors (MAOIs). MAOIs — such as tranylcypromine (Parnate) and phenelzine (Nardil) — are usually prescribed as a last resort, when other medications haven't worked. That's because MAOIs can have serious harmful side effects. They require a strict diet because of dangerous (or even deadly) interactions with foods, such as certain cheeses, pickles and wines, and some medications including decongestants. Selegiline (Emsam) is a newer MAOI that you stick on your skin as a patch rather than swallowing. It may cause fewer side effects than other MAOIs. These medications can't be combined with SSRIs.
  • Other medication strategies. Your doctor may suggest other medications to treat your depression. These may include stimulants, mood-stabilizing medications, anti-anxiety medications or antipsychotic medications. In some cases, your doctor may recommend combining two or more antidepressants or other medications for better effect. This strategy is known as augmentation.
Finding the right medication
Everyone's different, so finding the right medication or medications for you will likely take some trial and error. This requires patience, as some medications need eight weeks or longer to take full effect and for side effects to ease as your body adjusts. If you have bothersome side effects, don't stop taking an antidepressant without talking to your doctor first. Some antidepressants can cause withdrawal symptoms unless you slowly taper off your dose, and quitting suddenly may cause a sudden worsening of depression. Don't give up until you find an antidepressant or medication that's suitable for you — you're likely to find one that works and that doesn't have intolerable side effects.

If antidepressant treatment doesn't seem to be working, your doctor may recommend a blood test to check for specific genes that affect how your body uses antidepressants. The cytochrome P450 (CYP450) genotyping test is one example of this type of exam. Genetic testing of this kind can help predict how well your body can or can't process (metabolize) a medication. This may help identify which antidepressant might be a good choice for you. These genetic tests may not be widely available, so they're an option only for people who have access to a clinic that offers them.
Antidepressants and pregnancy
If you're pregnant or breast-feeding, some antidepressants may pose an increased health risk to your unborn child or nursing child. Talk to your doctor if you become pregnant or are planning on becoming pregnant.

Antidepressants and increased suicide risk
Although most antidepressants are generally safe, be careful when taking them. The Food and Drug Administration (FDA) now requires that all antidepressant medications carry black box warnings. These are the strictest warnings that the FDA can issue for prescription medications.

The antidepressant warnings note that in some cases, children, adolescents and young adults under 25 may have an increase in suicidal thoughts or behavior when taking antidepressants, especially in the first few weeks after starting an antidepressant or when the dose is changed. Because of this risk, people in these age groups must be closely monitored by loved ones, caregivers and health care providers while taking antidepressants. If you — or someone you know — have suicidal thoughts when taking an antidepressant, immediately contact your doctor or get emergency help.
Again, make sure you understand the risks of the various antidepressants. Working together, you and your doctor can explore options to get your depression symptoms under control.
Psychotherapy
Psychological counseling is another key depression treatment. Psychotherapy is a general term for a way of treating depression by talking about your condition and related issues with a mental health provider. Psychotherapy is also known as therapy, talk therapy, counseling or psychosocial therapy.
Through these talk sessions, you learn about the causes of depression so that you can better understand it. You also learn how to identify and make changes in unhealthy behavior or thoughts, explore relationships and experiences, find better ways to cope and solve problems, and set realistic goals for your life. Psychotherapy can help you regain a sense of happiness and control in your life and help ease depression symptoms such as hopelessness and anger. It may also help you adjust to a crisis or other current difficulty.
There are several types of psychotherapy that are effective for depression. Cognitive behavioral therapy is one of the most commonly used therapies. This type of therapy helps you identify negative beliefs and behaviors and replace them with healthy, positive ones. It's based on the idea that your own thoughts — not other people or situations — determine how you feel or behave. Even if an unwanted situation doesn't change, you can change the way you think and behave in a positive way. Interpersonal therapy and psychodynamic psychotherapy are other types of counseling commonly used to treat depression.
Electroconvulsive therapy (ECT)
In ECT, electrical currents are passed through the brain. This procedure is thought to affect levels of neurotransmitters in your brain. Although many people are leery of ECT and its side effects, it typically offers immediate relief of even severe depression when other treatments don't work. It's unclear how this therapy relieves the signs and symptoms of depression. The most common side effect is confusion, which can last from a few minutes to several hours. Some people also have memory loss, which is usually temporary.

ECT is usually used for people who don't get better with medications and for those at high risk of suicide. ECT may be an option if you have severe depression when you're pregnant and can't take your regular medications. It can also be an effective treatment for older adults who have severe depression and can't take antidepressants for health reasons.
Hospitalization and residential treatment programs
In some people, depression is so severe that a hospital stay is needed. Inpatient hospitalization may be necessary if you aren't able to care for yourself properly or when you're in immediate danger of harming yourself or someone else. Getting psychiatric treatment at a hospital can help keep you calm and safe until your mood improves. Partial hospitalization or day treatment programs also are helpful for some people. These programs provide the support and counseling you need while you get symptoms under control.

Other treatments for depression
If standard depression treatment hasn't been effective, your psychiatrist may consider whether you might benefit from a less commonly used procedure, such as:

  • Vagus nerve stimulation. This treatment uses electrical impulses with a surgically implanted pulse generator to affect mood centers of the brain. This may be an option if you have chronic, treatment-resistant depression.
  • Transcranial magnetic stimulation. These treatments use powerful magnetic fields to alter brain activity. A large electromagnetic coil is held against your scalp near your forehead to produce an electrical current in your brain. Transcranial magnetic stimulation may be an option for those who haven't responded to antidepressants.
  • Lifestyle and home remedies

    By Mayo Clinic staff Depression generally isn't an illness that you can treat on your own. But you can do some things for yourself that will help. In addition to professional treatment, follow these self-care steps:
  • Stick to your treatment plan. Don't skip psychotherapy sessions or appointments, even if you don't feel like going. Even if you're feeling well, resist any temptation to skip your medications. If you stop, depression symptoms may come back, and you could also experience withdrawal-like symptoms.
  • Learn about depression. Education about your condition can empower you and motivate you to stick to your treatment plan.
  • Pay attention to warning signs. Work with your doctor or therapist to learn what might trigger your depression symptoms. Make a plan so that you know what to do if your symptoms get worse. Contact your doctor or therapist if you notice any changes in symptoms or how you feel. Ask family members or friends to help watch for warning signs.
  • Get exercise. Physical activity reduces depression symptoms. Consider walking, jogging, swimming, gardening or taking up another activity you enjoy.
  • Avoid alcohol and illegal drugs. It may seem like alcohol or drugs lessen depression symptoms, but in the long run they generally worsen symptoms and make depression harder to treat. Talk with your doctor or therapist if you need help with alcohol or substance abuse.
  • Get plenty of sleep. Sleeping well is important for both your physical and mental well-being. If you're having trouble sleeping, talk to your doctor about what you can do.
  • Alternative medicine

    By Mayo Clinic staff You may be interested in trying to relieve depression symptoms with complementary or alternative medicine strategies. These include supplements and mind-body techniques. Make certain you understand risks as well as possible benefits before pursuing alternative therapy. Don't forgo conventional medical treatment or psychotherapy for alternative medicine. When it comes to depression, alternative treatments aren't a substitute for medical care.
    Here are some common alternative treatments that are used for depression.
    Herbal remedies and supplements
    A number of herbal remedies and supplements have been used for depression. A few common ones include:

  • St. John's wort. Known scientifically as Hypericum perforatum, this is an herb that's been used for centuries to treat a variety of ills, including depression. It's not approved by the FDA to treat depression in the United States. Rather, it's classified as a dietary supplement. However, it's a popular treatment in Europe for mild or moderate depression. But, it can interfere with other depression medicines, as well as some drugs used to treat people with heart disease, seizures, cancer and organ transplant.
  • SAMe. Pronounced "sammy," this is a synthetic form of a chemical that occurs naturally in the body. The name is short for S-adenosylmethionine. It's not approved by the FDA to treat depression in the United States. Rather, it's classified as a dietary supplement. Side effects are usually minimal, but SAMe can trigger mania in people with bipolar disorder.
  • Omega-3 fatty acids. Eating a diet rich in omega-3s or taking omega-3 supplements may help ease depression, especially when used in addition to standard depression treatments. These healthy fats are found in cold-water fish, flaxseed, flax oil, walnuts and some other foods.
  • Folate. Low levels of folate, a B vitamin, may cause a slowed response to some antidepressants. Taking folate supplements (folic acid) may be helpful when used in addition to antidepressants. Ask your doctor what amount is right for you.
Keep in mind that nutritional and dietary products aren't monitored by the FDA the same way medications are. You can't always be certain of what you're getting and if it's safe. Also, be aware that some herbal and dietary supplements can interfere with prescription medications or cause dangerous interactions. To be safe, talk to your doctors and other health care providers before taking any herbal or dietary supplements.
Mind-body connections
The connection between mind and body has been studied for centuries. Complementary and alternative medicine practitioners believe the mind and body must be in harmony for you to stay healthy.

Mind-body techniques that may be tried to ease depression symptoms include:
  • Acupuncture
  • Yoga
  • Meditation
  • Guided imagery
  • Massage therapy
As with dietary supplements, take care in using these techniques. Although they may pose less of a risk, relying solely on these therapies is not enough to treat depression.

Coping and support

By Mayo Clinic staff Coping with depression can be challenging. Talk to your doctor or therapist about improving your coping skills, and try these tips:
  • Simplify your life. Cut back on obligations when possible, and set reasonable goals for yourself. Give yourself permission to do less when you feel down.
  • Consider writing in a journal. Journaling can improve mood by allowing you to express pain, anger, fear or other emotions.
  • Read reputable self-help books and websites. Your doctor or therapist may be able to recommend books to read.
  • Join a support group. Connecting with others facing similar challenges can help you cope. Local support groups for depression are available in many communities, and support groups for depression are also offered online.
  • Don't become isolated. Try to participate in social activities, and get together with family or friends regularly.
  • Take care of yourself. Eat a healthy diet, exercise regularly and get plenty of sleep.
  • Learn ways to relax and manage your stress. Examples include meditation, yoga and tai chi.
  • Structure your time. Plan your day and activities. You may find it helpful to make a list of daily tasks, use sticky notes as reminders or use a planner to stay organized.
  • Don't make important decisions when you're down. Avoid decision making when you're feeling very depressed, since you may not be thinking clearly.
 Bipolar Disorder


Definition
Bipolar disorder — sometimes called manic-depressive disorder — is associated with mood swings that range from the lows of depression to the highs of mania. When you become depressed, you may feel sad or hopeless and lose interest or pleasure in most activities. When your mood shifts in the other direction, you may feel euphoric and full of energy. Mood shifts may occur only a few times a year, or as often as several times a day. In some cases, bipolar disorder causes symptoms of depression and mania at the same time.
Although bipolar disorder is a disruptive, long-term condition, you can keep your moods in check by following a treatment plan. In most cases, bipolar disorder can be controlled with medications and psychological counseling (psychotherapy).

Symptoms

By Mayo Clinic staff Bipolar disorder is divided into several subtypes. Each has a different pattern of symptoms. Types of bipolar disorder include:
  • Bipolar I disorder. Mood swings with bipolar I cause significant difficulty in your job, school or relationships. Manic episodes can be severe and dangerous.
  • Bipolar II disorder. Bipolar II is less severe than bipolar I. You may have an elevated mood, irritability and some changes in your functioning, but generally you can carry on with your normal daily routine. Instead of full-blown mania, you have hypomania — a less severe form of mania. In bipolar II, periods of depression typically last longer than periods of hypomania.
  • Cyclothymic disorder. Cyclothymic disorder, also known as cyclothymia, is a mild form of bipolar disorder. With cyclothymia, hypomania and depression can be disruptive, but the highs and lows are not as severe as they are with other types of bipolar disorder.


Bipolar disorder symptoms reflect a range of moods.Bipolar disorder symptoms reflect a range of moods.
The exact symptoms of bipolar disorder vary from person to person. For some people, depression causes the most problems; for other people, manic symptoms are the main concern. Symptoms of depression and symptoms of mania or hypomania may also occur together. This is known as a mixed episode.
Manic phase of bipolar disorder
Signs and symptoms of the manic or hypomanic phase of bipolar disorder can include:

  • Euphoria
  • Inflated self-esteem
  • Poor judgment
  • Rapid speech
  • Racing thoughts
  • Aggressive behavior
  • Agitation or irritation
  • Increased physical activity
  • Risky behavior
  • Spending sprees or unwise financial choices
  • Increased drive to perform or achieve goals
  • Increased sex drive
  • Decreased need for sleep
  • Easily distracted
  • Careless or dangerous use of drugs or alcohol
  • Frequent absences from work or school
  • Delusions or a break from reality (psychosis)
  • Poor performance at work or school
Depressive phase of bipolar disorder
Signs and symptoms of the depressive phase of bipolar disorder can include:

  • Sadness
  • Hopelessness
  • Suicidal thoughts or behavior
  • Anxiety
  • Guilt
  • Sleep problems
  • Low appetite or increased appetite
  • Fatigue
  • Loss of interest in activities once considered enjoyable
  • Problems concentrating
  • Irritability
  • Chronic pain without a known cause
  • Frequent absences from work or school
  • Poor performance at work or school
Other signs and symptoms of bipolar disorder
Signs and symptoms of bipolar disorder can also include:

  • Seasonal changes in mood. As with seasonal affective disorder (SAD), some people with bipolar disorder have moods that change with the seasons. Some people become manic or hypomanic in the spring or summer and then become depressed in the fall or winter. For other people, this cycle is reversed — they become depressed in the spring or summer and manic or hypomanic in the fall or winter.
  • Rapid cycling bipolar disorder. Some people with bipolar disorder have rapid mood shifts. This is defined as having four or more mood swings within a single year. However, in some people mood shifts occur much more quickly, sometimes within just hours.
  • Psychosis. Severe episodes of either mania or depression may result in psychosis, a detachment from reality. Symptoms of psychosis may include false but strongly held beliefs (delusions) and hearing or seeing things that aren't there (hallucinations).
Symptoms in children and adolescents
Instead of clear-cut depression and mania or hypomania, the most prominent signs of bipolar disorder in children and adolescents can include explosive temper, rapid mood shifts, reckless behavior and aggression. In some cases, these shifts occur within hours or less — for example, a child may have intense periods of giddiness and silliness, long bouts of crying and outbursts of explosive anger all in one day.

When to see a doctor
If you have any symptoms of depression or mania, see your doctor or mental health provider. Bipolar disorder doesn't get better on its own. Getting treatment from a mental health provider with experience in bipolar disorder can help you get your symptoms under control.

Many people with bipolar disorder don't get the treatment they need. Despite the mood extremes, people with bipolar disorder often don't recognize how much their emotional instability disrupts their lives and the lives of their loved ones. And if you're like some people with bipolar disorder, you may enjoy the feelings of euphoria and cycles of being more productive. However, this euphoria is always followed by an emotional crash that can leave you depressed, worn out — and perhaps in financial, legal or relationship trouble.
If you're reluctant to seek treatment, confide in a friend or loved one, a health care professional, a faith leader or someone else you trust. They may be able to help you take the first steps to successful treatment.
If you have suicidal thoughts
Suicidal thoughts and behavior are common among people with bipolar disorder. If you or someone you know is having suicidal thoughts, get help right away. Here are some steps you can take:

  • Contact a family member or friend.
  • Seek help from your doctor, a mental health provider or other health care professional.
  • Call a suicide hot line number — in the United States, you can reach the toll-free, 24-hour hot line of the National Suicide Prevention Lifeline at 800-273-8255 to talk to a trained counselor.
  • Contact a minister, spiritual leader or someone in your faith community.
When to get emergency help
If you think you may hurt yourself or attempt suicide, call 911 or your local emergency number immediately. If you have a loved one who has harmed himself or herself, or is seriously considering doing so, make sure someone stays with that person. Take him or her to the hospital or call for emergency help.





Causes

By Mayo Clinic staff The exact cause of bipolar disorder is unknown, but several factors seem to be involved in causing and triggering bipolar episodes:
  • Biological differences. People with bipolar disorder appear to have physical changes in their brains. The significance of these changes is still uncertain but may eventually help pinpoint causes.
  • Neurotransmitters. An imbalance in naturally occurring brain chemicals called neurotransmitters seems to play a significant role in bipolar disorder and other mood disorders.
  • Hormones. Imbalanced hormones may be involved in causing or triggering bipolar disorder.
  • Inherited traits. Bipolar disorder is more common in people who have a blood relative (such as a sibling or parent) with the condition. Researchers are trying to find genes that may be involved in causing bipolar disorder.
  • Environment. Stress, abuse, significant loss or other traumatic experiences may play a role in bipolar disorder.
  • Risk factors

    By Mayo Clinic staff Factors that may increase the risk of developing bipolar disorder include:
  • Having blood relatives such as a parent or sibling with bipolar disorder
  • Periods of high stress
  • Drug or alcohol abuse
  • Major life changes, such as the death of a loved one
  • Being in your early 20s
Conditions that commonly occur with bipolar disorder
If you have bipolar disorder, you may also have another health condition that's diagnosed before or after your diagnosis of bipolar disorder. Such conditions need to be diagnosed and treated because they may worsen existing bipolar disorder. They include:

  • Anxiety disorders. Examples include post-traumatic stress disorder (PTSD), social phobia and generalized anxiety disorder.
  • Attention-deficit/hyperactivity disorder (ADHD). ADHD has symptoms that overlap with bipolar disorder. For this reason, bipolar disorder can be difficult to differentiate from ADHD. Sometimes one is mistaken for the other. In some cases, a person may be diagnosed with both conditions.
  • Addiction or substance abuse. Many people with bipolar disorder also have alcohol, tobacco or drug problems. Drugs or alcohol may seem to ease symptoms, but they can actually trigger, prolong or worsen depression or mania.
  • Physical health problems. People diagnosed with bipolar disorder are more likely to have certain other health problems, including heart disease, thyroid problems and obesity.
  • Complications

    By Mayo Clinic staff Left untreated, bipolar disorder can result in serious problems that affect every area of your life. These can include:
  • Problems related to substance and alcohol abuse
  • Legal problems
  • Financial problems
  • Relationship troubles
  • Isolation and loneliness
  • Poor work or school performance
  • Frequent absences from work or school
  • Suicide
  •  

    Preparing for your appointment

    By Mayo Clinic staff You're likely to start by seeing your family doctor or a general practitioner. However, in some cases when you call to set up an appointment, you may be referred immediately to a medical doctor who specializes in diagnosing and treating mental health conditions (psychiatrist).
    Because appointments can be brief, and because there's often a lot of ground to cover, it's a good idea to be well prepared for your appointment. Here's some information to help you get ready for your appointment, and know what to expect from your doctor.
    What you can do
  • Write down any symptoms you've had, including any that may seem unrelated to the reason for which you scheduled the appointment.
  • Write down key personal information, including any major stresses or recent life changes.
  • Make a list of all medications, vitamins or supplements that you're taking.
  • Take a family member or friend along, if possible. Sometimes it can be difficult to remember all of the information provided to you during an appointment. Someone who accompanies you may remember something that you missed or forgot.
  • Write down questions to ask your doctor.
Your time with your doctor may be limited, so preparing a list of questions ahead of time will help you make the most of your time together. For problems related to bipolar disorder, some basic questions to ask your doctor include:
  • Do I have bipolar disorder?
  • Are there any other possible causes for my symptoms?
  • What kinds of tests will I need?
  • What treatments are available? Which do you recommend for me?
  • What side effects are possible with that treatment?
  • What are the alternatives to the primary approach that you're suggesting?
  • I have these other health conditions. How can I best manage these conditions together?
  • Should I see a psychiatrist or other mental health provider?
  • Is there a generic alternative to the medicine you're prescribing me?
  • Are there any brochures or other printed material that I can take home with me? What websites do you recommend visiting?
In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask questions during your appointment at any time that you don't understand something.
What to expect from your doctor
Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over any points you want to spend more time on. Your doctor may ask:

  • When did you or your loved ones first begin noticing your symptoms of depression, mania or hypomania?
  • How frequently do your moods change?
  • Do you ever have suicidal thoughts when you're feeling down?
  • How severe are your symptoms? Do they interfere with your daily life or relationships?
  • Do you have any blood relatives with bipolar disorder or another mood disorder?
  • What other mental or physical health conditions do you have?
  • Do you drink alcohol, smoke cigarettes or use street drugs?
  • How much do you sleep at night? Does it change over time?
  • Do you go through periods when you take risks you wouldn't normally take, such as unsafe sex or unwise, spontaneous financial decisions?
  • What, if anything, seems to improve your symptoms?
  • What, if anything, appears to worsen your symptoms?
  •  

    Tests and diagnosis

    By Mayo Clinic staff When doctors suspect someone has bipolar disorder, they typically do a number of tests and exams. These can help rule out other problems, pinpoint a diagnosis and also check for any related complications. These can include:
  • Physical exam. This may involve measuring your height and weight; checking your vital signs, such as heart rate, blood pressure and temperature; listening to your heart and lungs; and examining your abdomen.
  • Lab tests. These may include blood and urine tests. These tests can help identify any physical problems that could be causing your symptoms.
  • Psychological evaluation. A doctor or mental health provider will talk to you about your thoughts, feelings and behavior patterns. You may also fill out a psychological self-assessment or questionnaire. With your permission, family members or close friends may be asked to provide information about your symptoms and possible episodes of mania or depression.
  • Mood charting. To identify exactly what's going on, your doctor may have you keep a daily record of your moods, sleep patterns or other factors that could help with diagnosis and finding the right treatment.
Diagnostic criteria for bipolar disorder
To be diagnosed with bipolar disorder, you must meet the criteria spelled out in the Diagnostic and Statistical Manual of Mental Disorders (DSM). This manual is published by the American Psychiatric Association and is used by mental health providers to diagnose mental conditions and by insurance companies to reimburse for treatment. Diagnostic criteria for bipolar disorder are based on the specific type of bipolar disorder.

  • Bipolar I disorder. You've had at least one manic or one mixed episode. You may or may not have had a major depressive episode. Because bipolar I varies from person to person, there are more-specific subcategories of diagnosis based on your particular signs and symptoms.
  • Bipolar II disorder. You've had at least one major depressive episode and at least one hypomanic episode (but not a fully manic or mixed episode). With bipolar II, symptoms cause distress or difficulty in some area of your life — such as relationships or work. Bipolar II disorder also has subcategories based on your particular signs and symptoms.
  • Cyclothymic disorder. You've had numerous hypomanic episodes and periods of depression — but you've never had a full manic episode, a major depressive episode or a mixed episode. For a diagnosis of cyclothymic disorder, symptoms last two years or more (one year in children and adolescents). During that time, symptoms never go away for more than two months. Symptoms cause significant distress or difficulty in some area of your life — such as in relationships or at work.
The DSM has very specific criteria for manic, hypomanic, major depressive and mixed episodes.
Criteria for a manic episode
A manic episode is a distinct period of abnormally and persistently elevated, expansive, or irritable mood that lasts at least one week (or less than a week if hospitalization is necessary). During the period of disturbed mood, three or more of the following symptoms must be present (four if the mood is only irritable):

  • Inflated self-esteem or grandiosity
  • Decreased need for sleep (for example, you feel rested after only three hours of sleep)
  • Unusual talkativeness
  • Racing thoughts
  • Distractibility
  • Increased goal-directed activity (either socially, at work or school, or sexually)
  • Doing things that have a high potential for painful consequences — for example, unrestrained buying sprees, sexual indiscretions or foolish business investments
To be considered a manic episode:
  • The mood disturbance must be severe enough to cause noticeable difficulty at work, at school or in usual social activities or relationships; to require hospitalization to prevent harm to yourself or others; or to trigger a break from reality (psychosis).
  • Symptoms do not meet the criteria for a mixed episode (see criteria for mixed episode below).
  • Symptoms are not due to the direct effects of something else such as alcohol or drug use, taking a medication, or a having a medical condition such as hyperthyroidism.
Criteria for a hypomanic episode
A hypomanic episode is a distinct period of elevated, expansive or irritable mood that lasts at least four days, and is different from the usual nondepressed mood. During the period of disturbed mood, three or more of the following symptoms must be present (four if the mood is only irritable):

  • Inflated self-esteem or grandiosity
  • Decreased need for sleep (for example, you feel rested after only three hours of sleep)
  • Unusual talkativeness
  • Racing thoughts
  • Distractibility
  • Increased goal-directed activity (either socially, at work or school, or sexually)
  • Doing things that have a high potential for painful consequences — for example, unrestrained buying sprees, sexual indiscretions or foolish business investments
To be considered a hypomanic episode:
  • The mood disturbance must be severe enough to cause a noticeable and uncharacteristic change in functioning.
  • The episode isn't severe enough to cause significant difficulty at work, at school or in usual social activities or relationships; to require hospitalization; or to trigger a break from reality (psychosis).
  • Symptoms do not meet the criteria for a mixed episode (see criteria for mixed episode below).
  • Symptoms are not due to the direct effects of something else such as alcohol or drug use, taking a medication, or a having a medical condition such as hyperthyroidism.
Criteria for a major depressive episode
To be diagnosed with a major depressive episode, you must have five (or more) of the following symptoms over a two-week period. At least one of the symptoms is either depressed mood or loss of interest or pleasure. Symptoms can be based on your own feelings or on the observations of someone else. They include:

  • Depressed mood most of the day, nearly every day, such as feeling sad, empty or tearful (in children and adolescents, depressed mood can appear as constant irritability)
  • Diminished interest or feeling no pleasure in all — or almost all — activities most of the day, nearly every day
  • Significant weight loss when not dieting, weight gain, or decrease or increase in appetite nearly every day (in children, failure to gain weight as expected can be a sign of depression)
  • Insomnia or increased desire to sleep nearly every day
  • Either restlessness or slowed behavior that can be observed by others
  • Fatigue or loss of energy nearly every day
  • Feelings of worthlessness or excessive or inappropriate guilt nearly every day
  • Diminished ability to think or concentrate, or indecisiveness, nearly every day
  • Recurrent thoughts of death or suicide, or a suicide attempt
To be considered a major depressive episode:
  • Symptoms don't meet the criteria for a mixed episode (see criteria for mixed episode below).
  • Symptoms must be severe enough to cause noticeable difficulty in day-to-day activities, such as work, school, social activities or relationships with others.
  • Symptoms are not due to the direct effects of something else, such as drug abuse, taking a medication or a having a medical condition such as hyperthyroidism.
  • Symptoms are not caused by grieving, such as after the loss of a loved one.
Criteria for mixed episode
  • The criteria are met both for a manic episode and for a major depressive episode nearly every day during at least a one-week period.
  • The mood disturbance must be severe enough to cause noticeable difficulty at work, at school, or in usual social activities or relationships; to require hospitalization to prevent harm to self or others; or to cause a break from reality (psychosis).
  • Symptoms are not due to the direct effects of something else, such as drug abuse, taking a medication or a having a medical condition such as hyperthyroidism.
Diagnosis in children
The same official criteria used to diagnose bipolar disorder in adults are used to diagnose children and adolescents. However, bipolar symptoms in children and adolescents often have different patterns than they do in adults, and may not fit neatly into the categories used for diagnosis. While adults generally tend to have distinct periods of mania and depression, children and adolescents may have erratic, rapid changes in mood, behavior and energy levels.

It's often hard to tell whether these are normal ups and downs, the results of stress or trauma, or signs of a mental health problem other than bipolar disorder. To make it even more difficult, children who have bipolar disorder are frequently also diagnosed with other mental health conditions such as attention-deficit/hyperactivity disorder (ADHD) or behavior problems.
Although bipolar disorder can occur in young children, diagnosis in children preschool age or younger is especially difficult. The current criteria used for diagnosis have not been proved in young children, and a wide range of issues other than bipolar disorder can cause mood and behavior problems at this age.

Treatments and drugs

By Mayo Clinic staff Bipolar disorder requires lifelong treatment, even during periods when you feel better. Treatment is usually guided by a psychiatrist skilled in treating the condition. You may have a treatment team that also includes psychologists, social workers and psychiatric nurses. The primary treatments for bipolar disorder include medications; individual, group or family psychological counseling (psychotherapy); or education and support groups.
  • Hospitalization. Your doctor may have you hospitalized if you are behaving dangerously, you feel suicidal or you become detached from reality (psychotic).
  • Initial treatment. Often, you'll need to begin taking medications to balance your moods right away. Once your symptoms are under control, you'll work with your doctor to find the best long-term treatment.
  • Continued treatment. Maintenance treatment is used to manage bipolar disorder on a long-term basis. People who skip maintenance treatment are at high risk of a relapse of symptoms or having minor mood changes turn into full-blown mania or depression.
  • Substance abuse treatment. If you have problems with alcohol or drugs, you'll also need substance abuse treatment. Otherwise, it can be very difficult to manage bipolar disorder.
Medications
A number of medications are used to treat bipolar disorder. If one doesn't work well for you, there are a number of others to try. Your doctor may suggest combining medications for maximum effect. Medications for bipolar disorder include those that prevent the extreme highs and lows that can occur with bipolar disorder (mood stabilizers) and medications that help with depression or anxiety.

Medications for bipolar disorder include:
  • Lithium. Lithium (Lithobid, others) is effective at stabilizing mood and preventing the extreme highs and lows of certain categories of bipolar disorder and has been used for many years. Periodic blood tests are required, since lithium can cause thyroid and kidney problems. Common side effects include restlessness, dry mouth and digestive issues.
  • Anticonvulsants. These mood-stabilizing medications include valproic acid (Depakene, Stavzor), divalproex (Depakote) and lamotrigine (Lamictal). The medication asenapine (Saphris) may be helpful in treating mixed episodes. Depending on the medication you take, side effects can vary. Common side effects include weight gain, dizziness and drowsiness. Rarely, certain anticonvulsants cause more serious problems, such as skin rashes, blood disorders or liver problems.
  • Antipsychotics. Certain antipsychotic medications, such as aripiprazole (Abilify), olanzapine (Zyprexa), risperidone (Risperdal) and quetiapine (Seroquel), may help people who don't benefit from anticonvulsants. The only antipsychotic that's specifically approved by the U.S. Food and Drug Administration (FDA) for treating bipolar disorder is quetiapine. However, doctors can still prescribe other medications for bipolar disorder. This is known as off-label use. Side effects depend on the medication, but can include weight gain, sleepiness, tremors, blurred vision and rapid heartbeat. Weight gain in children is a significant concern. Antipsychotic use may also affect memory and attention and cause involuntary facial or body movements.
  • Antidepressants. Depending on your symptoms, your doctor may recommend you take an antidepressant. In some people with bipolar disorder, antidepressants can trigger manic episodes, but may be OK if taken along with a mood stabilizer. The most common antidepressant side effects include reduced sexual desire and problems reaching orgasm. Older antidepressants, which include tricyclics and MAO inhibitors, can cause a number of potentially dangerous side effects and require careful monitoring.
  • Symbyax. This medication combines the antidepressant fluoxetine and the antipsychotic olanzapine. It works as a depression treatment and a mood stabilizer. Symbyax is approved by the FDA specifically for the treatment of bipolar disorder. Side effects can include weight gain, drowsiness and increased appetite. This medication may also cause sexual problems similar to those caused by antidepressants.
  • Benzodiazepines. These anti-anxiety medications may help with anxiety and improve sleep. Examples include clonazepam (Klonopin), lorazepam (Ativan), diazepam (Valium), chlordiazepoxide (Librium) and alprazolam (Niravam, Xanax). Benzodiazepines are generally used for relieving anxiety only on a short-term basis. Side effects can include drowsiness, reduced muscle coordination, and problems with balance and memory.
Finding the right medication
Finding the right medication or medications for you will likely take some trial and error. This requires patience, as some medications need weeks to months to take full effect. Generally only one medication is changed at a time so your doctor can identify which medications work to relieve your symptoms with the least bothersome side effects. This can take months or longer, and medications may need to be adjusted as your symptoms change. Side effects improve as you find the right medications and doses that work for you, and your body adjusts to the medications.

Medications and pregnancy
A number of medications for bipolar disorder can be associated with birth defects.

  • Use effective birth control (contraception) to prevent pregnancy. Discuss birth control options with your doctor, as birth control medications may lose effectiveness when taken along with certain bipolar disorder medications.
  • If you plan to become pregnant, meet with your doctor to discuss your treatment options.
  • Discuss breast-feeding with your doctor, as some bipolar medications can pass through breast milk to your infant.
Psychotherapy
Psychotherapy is another vital part of bipolar disorder treatment. Several types of therapy may be helpful. These include:

  • Cognitive behavioral therapy. This is a common form of individual therapy for bipolar disorder. The focus of cognitive behavioral therapy is identifying unhealthy, negative beliefs and behaviors and replacing them with healthy, positive ones. It can help identify what triggers your bipolar episodes. You also learn effective strategies to manage stress and to cope with upsetting situations.
  • Psychoeducation. Counseling to help you learn about bipolar disorder (psychoeducation) can help you and your loved ones understand bipolar disorder. Knowing what's going on can help you get the best support and treatment, and help you and your loved ones recognize warning signs of mood swings.
  • Family therapy. Family therapy involves seeing a psychologist or other mental health provider along with your family members. Family therapy can help identify and reduce stress within your family. It can help your family learn how to communicate better, solve problems and resolve conflicts.
  • Group therapy. Group therapy provides a forum to communicate with and learn from others in a similar situation. It may also help build better relationship skills.
  • Other therapies. Other therapies that have been studied with some evidence of success include early identification and therapy for worsening symptoms (prodrome detection) and therapy to identify and resolve problems with your daily routine and interpersonal relationships (interpersonal and social rhythm therapy). Ask your doctor if any of these options may be appropriate for you.
Transcranial magnetic stimulation
This treatment applies rapid pulses of a magnetic field to the head. It's not clear exactly how this helps, but it appears to have an antidepressant effect. However, not everyone is helped by this therapy, and it's not yet clear who is a good candidate for this type of treatment. More research is needed. The most serious potential side effect is a seizure.

Electroconvulsive therapy (ECT)
Electroconvulsive therapy can be effective for people who have episodes of severe depression or feel suicidal or people who haven't seen improvements in their symptoms despite other treatment. With ECT, electrical currents are passed through your brain. Researchers don't fully understand how ECT works. But it's thought that the electric shock causes changes in brain chemistry that leads to improvements in your mood. ECT may be an option if you have mania or severe depression when you're pregnant and cannot take your regular medications. ECT can cause temporary memory loss and confusion.
Hospitalization
In some cases, people with bipolar disorder benefit from hospitalization. Getting psychiatric treatment at a hospital can help keep you calm and safe and stabilize your mood, whether you're having a manic episode or a deep depression. Partial hospitalization or day treatment programs also are options to consider. These programs provide the support and counseling you need while you get symptoms under control.

Treatment in children and adolescents
Children and adolescents with bipolar disorder are prescribed the same types of medications as those used in adults. However, there's little research on the safety and effectiveness of bipolar medications in children, so treatment decisions are based on adult research. Treatments are generally decided on a case-by-case basis, depending on exact symptoms, medication side effects and other factors. As with adults, ECT may be an option for adolescents with severe bipolar I symptoms or for whom medications don't work.

Most children diagnosed with bipolar disorder require counseling as part of initial treatment and to keep symptoms from returning. Psychotherapy — along with working with teachers and school counselors — can help children develop coping skills, address learning difficulties and resolve social problems. It can also help strengthen family bonds and communication. Psychotherapy may also be necessary to resolve substance abuse problems, common in older children with bipolar disorder.

Lifestyle and home remedies

By Mayo Clinic staff You'll probably need to make lifestyle changes to stop cycles of behavior that worsen your bipolar disorder, and to make sure you get the support you need from people in your life. Here are some steps to take:
  • Quit drinking or using illegal drugs. One of the biggest concerns with bipolar disorder is the negative consequences of risk-taking behavior and drug or alcohol abuse. Get help if you have trouble quitting on your own.
  • Steer clear of unhealthy relationships. Surround yourself with people who are a positive influence and won't encourage unhealthy behavior or attitudes that can worsen your bipolar disorder.
  • Get regular exercise. Moderate, regular exercise can help steady your mood. Working out releases brain chemicals that make you feel good (endorphins), can help you sleep and has a number of other benefits. Check with your doctor before starting any exercise program, especially if you're taking lithium to make sure exercise won't interfere with your medication.
  • Get plenty of sleep. Sleeping enough is an important part of managing your mood. If you have trouble sleeping, talk to your doctor or mental health provider about what you can do.
  • Alternative medicine

    By Mayo Clinic staff Some alternative treatments may help, but there isn't much research on them. Most of the studies that do exist are on major depression, so it isn't clear how well most of these work for bipolar disorder.
  • Omega-3 fatty acids. These oils may help improve brain function and depression associated with bipolar disorder. Bipolar disorder appears to be less common in areas of the world where people regularly eat fish rich in omega-3s. Omega-3s appear to have a number of health benefits, but more studies are needed to determine just how much they help with bipolar disorder.
  • Magnesium. Several small studies have suggested that magnesium supplements may lessen mania and the rapid cycling of bipolar symptoms. More research is needed to confirm these findings.
  • St. John's wort. This herb may be helpful with depression. However, it can also interact with antidepressants and other medications, and it has the potential to trigger mania in some people.
  • S-adenosyl-L-methionine (SAMe). This amino acid supplement appears to help brain function related to depression. It isn't clear yet whether it's helpful in people with bipolar disorder. As with St. John's wort, SAMe can trigger mania in some people.
  • Herbal combinations. Herbal remedies that combine a number of different herbs, such as those used in traditional Chinese medicine, haven't been well studied. Some appear to help, but the risks and benefits still aren't clear.
  • Acupuncture. This ancient Chinese practice of inserting tiny needles into the skin may relieve depression, but more studies are needed to confirm its benefits. However, it won't hurt for you to try it — acupuncture is safe and can be done along with other bipolar disorder treatments.
  • Yoga. Yoga may help ease depression and mood swings associated with bipolar disorder. It also has a number of other health benefits.
  • Massage therapy. Massage may also help relieve anxiety and stress, which can worsen bipolar symptoms.
Although some alternative medicine treatments can be a good addition to your regular treatment, take some precautions first:
  • Don't stop taking your prescribed medications or skip therapy sessions. Alternative medicine is not a substitute for regular medical care when it comes to treating bipolar disorder.
  • Be honest with your doctors and mental health providers. Tell them exactly which complementary treatments you use or would like to try.
  • Be aware of potential dangers. Just because it's natural doesn't mean it's safe. Before using alternative medicine, be sure you know the risks, including possible interactions with medications.
  •  

    Coping and support

    By Mayo Clinic staff Coping with bipolar disorder can be challenging. Here are some things that can help:
  • Learn about bipolar disorder. Education about your condition can empower you and motivate you to stick to your treatment plan. Likewise, help educate your family and friends about what you're going through.
  • Join a support group. Support groups for people with bipolar disorder can help you connect to others facing similar challenges and share experiences.
  • Stay focused on your goals. Recovery from bipolar disorder can take time. Stay motivated by keeping your recovery goals in mind and reminding yourself that you can work to repair damaged relationships and other problems caused by your mood swings.
  • Find healthy outlets. Explore healthy ways to channel your energy, such as hobbies, exercise and recreational activities.
  • Learn ways to relax and manage stress. Yoga, tai chi, meditation or other relaxation techniques can be helpful.




generalhealth/a/lupus.htm 

Lupus & Bipolar Disorder

Is There a Relationship?

Systemic lupus erythematosus (aka Lupus and SLE) is an autoimmune disorder that can cause chronic disease throughout the human body. The exact mechanism which causes the disease is unknown, but as the immune system turns against its own body, all of the major organs such as the heart, lungs, and kidneys are affected. The musculoskeletal, circulatory, integumentary and nervous systems also develop dysfunction. (A.D.A.M. offers more information about this disease.)
It is the problems caused in the nervous system that lead to the question of a link between lupus and bipolar disorder. Dr. John Hanly (2004) writes, “Involvement of the nervous system by systemic lupus erythematosus is one of the most profound manifestations of the disease and encompasses a wide variety of neurologic and psychiatric features.” Of the array of neurologic features, it is the diffuse symptoms in the central nervous system that most closely resemble bipolar disorder:


  • Anxiety
  • Cognitive Dysfunction
  • Mood Disorder
  • Psychosis
A study of neuropsychiatric syndromes in lupus by Brey et al (2002) found that 40% of their participants struggled with mood disorder and another study found an incidence as high as 57% (Sibbit et al, 2002). However, these symptoms, which parallel those of bipolar disorder and may be treated with the same medications, actually do not indicate a diagnosis of bipolar disorder in and of itself. In other words, there is currently no empirical research to support that bipolar disorder is specifically caused by SLE. These two differing disorders simply have an overlap of symptoms.
Perantie and Brown (2002) write, “The role of the immune system in psychiatric symptoms has been an area of much interest for years … Medical illnesses including HIV infection, systemic lupus erythematosus, and Cushing’s disease are all associated with psychiatric symptoms. In addition, high dosages of prescription corticosteroids (ef, prednisone and dexamethasone) are associated with mood changes, cognitive deficits, and even psychosis. However, the role of the immune system in mediating the psychiatric disturbances with each of these conditions is not clear.”
Posted February 14, 2006


Psychiatric disturbance 
http://www.thelupussite.com/fact5.html 
During severe lupus flares patients can experience a variety of psychiatric disorders varying from mild personality disorders to severe psychotic behaviour. Some lupus patients are wrongly diagnosed as having schizophrenia at the onset of their illness. Interestingly, treatment of the lupus in these patients results in total improvement in the psychiatric features. This is one of the most important observations to come out of lupus research as it provides possible insights into other mental disease. Patients with the antiphospholipid (sticky blood) syndrome suffer memory variants, from subtle ('I couldn't remember what I had gone into the shop for') to severe memory loss. Lupus doctors are now beginning to realise how common and important this aspect of the disease is. Clearly, any patient who feels that this is a major feature of the disease requires full neurologic examination, possibly including MRI, as well as testing for the antiphospholipid syndrome.
Depression
Depression is an important manifestation of lupus - in some it is the presenting sign of the disease. Many patients and, certainly, many doctors wrongly attribute depression in lupus merely to having a chronic illness and all that goes with it. This is not correct. The disease itself causes depression. Depression is an integral part of lupus in some patients - indeed management of the lupus often itself lifts the depression. The management of depression in lupus rests on a combination of treating the underlying lupus itself as well as possibly adding in antidepressant therapy. One of the medical advances in the last decade has been the introduction of newer milder antidepressants with less of the severe side-effects which so hampered older treatments.


Neuropsychiatric systemic lupus erythematosus presenting as bipolar I disorder with catatonic features.

Source

Department of Psychiatry, SUNY Upstate, NY 13210, USA. alaoa@upstate.edu

Abstract

http://www.ncbi.nlm.nih.gov/pubmed/19855042 

BACKGROUND:

The American College of Rheumatology has defined 19 neuropsychiatric syndromes associated with systemic lupus erythematosus (SLE) involving the central, peripheral, and autonomic nervous systems. Neuropsychiatric manifestations of lupus (NPSLE) have been shown to occur in up to 95% of pediatric patients with SLE.

OBJECTIVE:

The authors describe a 15-year-old African American young woman with a family history positive for bipolar I disorder and schizophrenia, who presented with symptoms consistent with an affective disorder.

METHOD:

The patient was diagnosed with Bipolar I disorder with catatonic features and required multiple hospitalizations for mood disturbance. Two years after her initial presentation, the patient was noted to have a malar rash and subsequently underwent a full rheumatologic work-up, which revealed cerebral vasculitis.

RESULTS:

NPSLE was diagnosed and, after treatment with steroids, the patient improved substantially and no longer required further psychiatric medication or therapy.

CONCLUSION:

Given the especially high prevalence of NPSLE in pediatric patients with lupus, it is important for clinicians to recognize that neuropsychiatric symptoms in an adolescent patient may indeed be the initial manifestations of SLE, as opposed to a primary affective disorder.
 

Bipolar Disorder

http://www.orchidrecoverycenter.com/womens-health/bipolar-disorder.html
Bipolar disorder is a form of mental illness characterized by extreme mood changes from mania to depression. It is also known as manic depression. Mood swings are dramatic, and are much different that the normal ups and downs people typically go through.
Bipolar disorder usually develops before the age of 25 and affects people of all ages and backgrounds.   Many people with bipolar disorder are misdiagnosed as suffering from depression. The reason for this is that a person who experiences these extreme mood changes is only likely to seek help when feeling depressed.
When patients are in the “manic” phase, they are energetic, talkative, restless, and euphoric. They experience racing thoughts and a decreased need for sleep. Many people with this disorder will try to cope with mania through drug or alcohol abuse and should seek drug treatment or alcohol rehabilitation if necessary. The “depressive” phase consists of lack of energy, hopelessness, and extreme sadness. Phases of mania or depression can last weeks, months, or years.
Sometimes a mood episode may include symptoms of both mania and depression. This is called a mixed state.
The cause of bipolar disorder hasn’t been identified. It is believed it is caused by a combination of genetic and environmental factors. A person whose parent has bipolar disorder has a 15-25% chance of developing the condition. It is primarily a biological disorder which involves the dysfunction of certain brain chemicals. A mood episode can be triggered by a life event, substance abuse, or hormonal problems.
A doctor can make a diagnosis only after carefully evaluating symptoms, including their length, severity, and frequency. The most identifiable symptom is extreme mood swings. But certain illnesses mimic the symptoms of bipolar disorder, including lupus, HIV, and syphilis. Other anxiety disorders are often present along with bipolar disorder, such generalized anxiety disorder, panic disorder, and post-traumatic stress disorder.   It is estimated that only a third of people suffering from bipolar disorder are properly diagnosed.


Panic attacks and panic disorder

Definition

By Mayo Clinic staff A panic attack is a sudden episode of intense fear that develops for no apparent reason and that triggers severe physical reactions. Panic attacks can be very frightening. When panic attacks occur, you might think you're losing control, having a heart attack or even dying.
You may have only one or two panic attacks in your lifetime. But if you have had several panic attacks and have spent long periods in constant fear of another attack, you may have a chronic condition called panic disorder.
Panic attacks were once dismissed as nerves or stress, but they're now recognized as a real medical condition. Although panic attacks can significantly affect your quality of life, treatment is very effective.

Symptoms

By Mayo Clinic staff Panic attack symptoms can make your heart pound and cause you to feel short of breath, dizzy, nauseated and flushed. Because panic attack symptoms can resemble life-threatening conditions, it's important to seek an accurate diagnosis and treatment.
Panic attacks typically include a few or many of these symptoms:
  • A sense of impending doom or death
  • Rapid heart rate
  • Sweating
  • Trembling
  • Shortness of breath
  • Hyperventilation
  • Chills
  • Hot flashes
  • Nausea
  • Abdominal cramping
  • Chest pain
  • Headache
  • Dizziness
  • Faintness
  • Tightness in your throat
  • Trouble swallowing
Panic attacks typically begin suddenly, without warning. They can strike at almost any time — when you're driving the school car pool, at the mall, sound asleep or in the middle of a business meeting. Panic attacks have many variations, but symptoms usually peak within 10 minutes and last about half an hour. You may feel fatigued and worn out after a panic attack subsides.
One of the worst things about panic attacks is the intense fear that you'll have another panic attack. If you have had four or more panic attacks and have spent a month or more in constant fear of another attack, you may have a condition called panic disorder, a type of chronic anxiety disorder.
With panic disorder, you may fear having a panic attack so much that you avoid situations where they may occur. You may even be unable to leave your home (agoraphobia), because no place feels safe.
When to see a doctor
If you have any panic attack symptoms, seek medical help as soon as possible. Panic attacks are hard to manage on your own, and they may get worse without treatment. And because panic attack symptoms can also resemble other serious health problems, such as a heart attack, it's important to get evaluated by your health care provider if you aren't sure what's causing your symptoms.

Causes

By Mayo Clinic staff It's not known what causes panic attacks or panic disorder. Things that may play a role include:
  • Genetics
  • Stress
  • Certain changes in the way parts of your brain function
Some research suggests that your body's natural fight-or-flight response to danger is involved in panic attacks. For example, if a grizzly bear came after you, your body would react instinctively. Your heart rate and breathing would speed up as your body prepared itself for a life-threatening situation. Many of the same reactions occur in a panic attack. But it's not known why a panic attack occurs when there's no obvious danger present.

Risk factors

By Mayo Clinic staff Symptoms of panic disorder often start either in late adolescence or early adulthood and affect more women than men.
Many people have just one or two panic attacks in their lifetimes, and the problem goes away, perhaps when a stressful situation ends.
Factors that may increase the risk of developing panic attacks or panic disorder include:
  • A family history of panic attacks or panic disorder
  • Significant stress
  • The death or serious illness of a loved one
  • Big changes in your life, such as the addition of a baby
  • A history of childhood physical or sexual abuse
  • Undergoing a traumatic event, such as an accident or rape
  • Complications

    By Mayo Clinic staff Left untreated, panic attacks and panic disorder can result in severe complications that affect almost every area of your life. You may be so afraid of having more panic attacks that you live in a constant state of fear, ruining your quality of life.
    Complications that panic attacks may cause or be associated with include:
  • Development of specific phobias, such as fear of driving or leaving your home
  • Avoidance of social situations
  • Problems at work or school
  • Depression
  • Increased risk of suicide or suicidal thoughts
  • Alcohol or substance abuse
  • Financial problems
  •  

    Preparing for your appointment

    By Mayo Clinic staff If you've had signs or symptoms common to a panic attack, make an appointment with your primary care provider. After an initial evaluation, your doctor may refer you to a psychiatrist or psychologist for treatment.
    Here's some information to help you prepare for your appointment, and what to expect from your doctor.
    What you can do in advance
  • Make a list of your symptoms, including when they first occurred and how often you've had them.
  • Write down your key personal information, including traumatic events in your past and any stressful, major events that occurred before your first panic attack.
  • Write down all of your medical information, including other physical or mental health conditions with which you've been diagnosed. Also write down the names of any medications you're taking.
  • Ask a trusted family member or friend to be present for your appointment, if possible. Sometimes it can be difficult to soak up all the information provided to you during an appointment. Someone who accompanies you may remember something that you missed or forgot.
  • Write down questions to ask your doctor.
Questions to ask your doctor at your initial appointment include:
  • What do you believe is causing my symptoms?
  • Is it possible that an underlying medical problem is causing my symptoms?
  • Do I need any diagnostic tests?
  • Should I see a mental health specialist?
  • Is there anything I can do now to help manage my symptoms?
Questions to ask if you are referred to a mental health provider include:
  • Do I have panic attacks or panic disorder?
  • What treatment approach do you recommend in my case?
  • If you're recommending therapy, how frequently will I need therapy sessions, and for how long?
  • Would family or group therapy be helpful in my case?
  • If you're recommending medications, are there any possible side effects?
  • For how long will I need to take medication?
  • Is my condition likely temporary or chronic?
  • How will you monitor whether my treatment is working?
  • What can I do to reduce the risk of my symptoms recurring?
  • Are there any self-care steps I could take to help manage my condition?
  • How much do you expect my symptoms will improve with treatment?
  • Are there any brochures or other printed material that I can take home with me? What Web sites do you recommend visiting?
In addition to the questions that you've prepared in advance, don't hesitate to ask for more information at any time that you don't understand something.
What to expect from your doctor
A doctor or mental health provider who sees you for possible panic attacks or panic disorder may ask:

  • What are your symptoms?
  • When did your symptoms first occur?
  • How long do your attacks last?
  • How often do your attacks occur?
  • How often do you experience fear of another attack?
  • Does anything in particular seem to trigger an attack?
  • Do you avoid the locations or experiences that seem to trigger an attack?
  • How would you say your symptoms are affecting your life, including school, work and personal relationships?
  • Did you experience significant stress or a traumatic event shortly before your first panic attack?
  • Have you experienced significant trauma — such as physical or sexual abuse or military battle — in your lifetime?
  • How would you describe your childhood, including your relationship with your parents?
  • Have any of your close relatives been diagnosed with a mental health problem, including panic attacks or panic disorder?
  • Have you been treated for any other mental health problems?
  • Have you been diagnosed with any medical conditions?
  • Do you use alcohol or recreational drugs? How often?
  • Do you exercise?
  • Do you use caffeine?


Tests and diagnosis

By Mayo Clinic staff To help pinpoint a diagnosis for your symptoms, you'll likely have several exams and tests. Your doctor or other health care provider must determine if you have panic attacks, panic disorder or another condition, such as heart or thyroid problems, that resembles panic symptoms.
Tests and exams you may have include:
  • Physical exam. This may include measuring height and weight; checking vital signs, such as heart rate, blood pressure and temperature; listening to the heart and lungs; and examining the abdomen.
  • Laboratory tests. These may include a complete blood count (CBC) as well as thyroid tests and other blood tests. You may also have tests on your heart, such as an electrocardiogram to help determine how well your heart is functioning.
  • Psychological evaluation. A doctor or mental health provider will talk to you about your symptoms, such as what they feel like, how often they occur, when they occur and how long you've had them. You'll also be asked about stressful situations in your life, fears or concerns you have, relationship problems and other issues affecting your life. You may fill out psychological self-assessments and questionnaires. And you may be asked about substance or alcohol abuse.
Diagnostic criteria for panic disorder
Not everyone who has panic attacks has a full-blown panic disorder. To be diagnosed with panic disorder, you must meet the criteria spelled out in the Diagnostic and Statistical Manual of Mental Disorders (DSM). This manual is published by the American Psychiatric Association and is used by mental health providers to diagnose mental conditions and by insurance companies to reimburse for treatment.

These are the diagnostic criteria for panic disorder:
  • You have frequent, unexpected panic attacks.
  • At least one of your attacks has been followed by one month or more of persistent worry about having another attack; persistent fear of the consequences of an attack, such as losing control, having a heart attack or "going crazy"; or a significant change in your behavior, such as avoiding situations that you think may trigger a panic attack.
  • Your panic attacks aren't caused by substance abuse or another mental health condition, such as social phobia or agoraphobia.
If you have panic attacks but not a full-blown panic disorder, you can still benefit from treatment. If panic attacks aren't treated, they can get worse and develop into panic disorder or phobias.


Treatments and drugs

By Mayo Clinic staff The goal of treatment is to eliminate all of your panic attack symptoms. With effective treatment, most people are eventually able to resume everyday activities.
The main treatment options for panic attacks are medications and psychotherapy. Both are effective. Your doctor likely will recommend starting with just one type of treatment, depending on your preference and whether there are therapists with special training in panic disorders in your area.
Your doctor may recommend a combination of medication and psychotherapy if you:
  • Have severe panic disorder
  • Have panic disorder along with another major mental health diagnosis, such as depression or post-traumatic stress disorder
  • Have already tried one type of treatment and haven't improved
Medications
Medications can help reduce symptoms associated with panic attacks, as well as depression if that's an issue for you. Several types of medication have been shown to be effective in managing symptoms of panic attacks, including:

  • Selective serotonin reuptake inhibitors (SSRIs). Because these antidepressant medications are generally safe and have a low risk of causing serious side effects, SSRIs are typically recommended as the first choice in medication options to treat panic attacks. Drugs in this class that have been approved by the Food and Drug Administration (FDA) for the treatment of panic disorder include fluoxetine (Prozac, Prozac Weekly), paroxetine (Paxil, Paxil CR, Pexeva) and sertraline (Zoloft).
  • Serotonin and norepinephrine reuptake inhibitors (SNRIs). These medications are another class of antidepressants. The SNRI drug called venlafaxine (Effexor XR) is FDA-approved for the treatment of panic disorder.
  • Tricyclic antidepressants (TCAs). While effective, these antidepressants pose a risk of serious side effects, including heart and blood sugar problems. No TCAs are FDA-approved specifically for the treatment of panic disorder.
  • Benzodiazpines. These medications are mild sedatives. They belong to the group of medicines called central nervous system (CNS) depressants. Benzodiazepines may be habit-forming (causing mental or physical dependence), especially when taken for a long time or in high doses. Benzodiazepines that have been FDA-approved for the treatment of panic disorder include alprazolam (Xanax) and clonazepam (Klonopin). If you seek care in an emergency room for signs and symptoms of a panic attack, you may be given a benzodiazepine to help stop the attack.
  • Monoamine oxidase inhibitors (MAOIs). Because these antidepressants can cause life-threatening side effects and require strict dietary restrictions, they're not commonly prescribed. No MAOIs are FDA-approved specifically for the treatment of panic disorder.
If one medication doesn't work well for you, your doctor may recommend switching to another or combining certain medications to boost their effectiveness. Keep in mind that it can take several weeks after first starting a medication to notice an improvement in your symptoms. All medications have a risk of side effects, and some may not be recommended in certain situations, such as pregnancy. Be sure to talk to your doctor about the possible side effects and risks.
Psychotherapy
Psychotherapy, also called counseling or talk therapy, can help you understand panic attacks and panic disorder and how to cope with them. The main type of psychotherapy used to treat panic attacks and panic disorder is cognitive behavioral therapy. Your doctor also may recommend a type of psychotherapy called psychodynamic psychotherapy.

  • Cognitive behavioral therapy. Cognitive behavioral therapy can help you change thinking (cognitive) patterns that trigger your fears and panic attacks. It can also help you change the way you react (behave) to anxious or fearful situations. During therapy sessions, you learn to recognize things that trigger your panic attacks or make them worse, such as specific thoughts or situations. You also learn ways to cope with the anxiety and physical symptoms associated with panic attacks.
    These may include breathing and relaxation techniques. In addition, working carefully with your therapist, you may re-create the symptoms of panic attacks in the safety of his or her office. This is an important step because it can help you learn to control and master the symptoms so that they don't continue to be a source of intense fear. Doing this can also help you overcome fear of certain situations that you may avoid, such as crowded malls or driving.
  • Psychodynamic psychotherapy. Psychodynamic psychotherapy focuses on increasing your awareness of your unconscious thoughts and behaviors. Unlike cognitive behavioral therapy, this approach doesn't intentionally re-create panic symptoms. Instead, your therapist helps you investigate your mind to identify internal emotional conflict that may play a role in your panic and avoidance reactions.
    Based on your findings, your therapist will help you develop healthier ways to respond to conflict. Early study results suggest that psychodynamic psychotherapy focused on panic reactions may be an effective short-term treatment option for panic disorder. More research is needed to fully understand how this type of therapy compares with other treatments for panic disorder.
Your therapist may suggest weekly meetings when you begin psychotherapy. You may start to see improvements in panic attack symptoms within several weeks, and often symptoms go away within several months.
As your symptoms improve, you and your therapist will develop a plan to taper off therapy. You may agree to schedule occasional maintenance visits to help ensure that your panic attacks remain under control.


Alternative medicine

By Mayo Clinic staff Researchers have explored a number of natural remedies as possible treatments for anxiety disorders, including panic disorder. Studies to date have concluded that two alternative therapies, in particular, have potential in the treatment of panic disorder.
  • Relaxation training. Relaxation techniques include deep breathing, yoga, meditation and progressive muscle relaxation, which is accomplished by tensing one muscle at a time, and then completely releasing the tension, until every muscle in the body is relaxed. Studies have found that these techniques may be as effective or nearly as effective as cognitive behavioral therapy for some people with panic disorder.
  • The nutritional supplement inositol. This oral supplement, which influences the action of serotonin, may reduce the frequency and severity of panic attacks.
Talk with your doctor before trying any natural therapies. These products can cause side effects and may interact with other medications. Your doctor can help determine if they are safe for you.
 

Lupus Facts III

Headaches and Other Neurological Symptoms

http://www.oocities.org/hotsprings/spa/9534/facts3p.html
Compared to the general population, twice as many individuals with SLE experience migraine-type headaches on a regular basis. Many patients began experiencing these headaches in childhood or adolescence, along with "growing pains", frequent sore throats, and easily-sprained joints. It is important to note that growing is not painful. When a child suffers from recurring pain which is put off as "growing pains", there IS a cause. While it may not be lupus, just keep in mind that growing doesn't hurt or all children would be in constant pain.
Like migraines, Lupus headaches are sensitive to light, sound, and motion, can last anywhere from 12 to 72 hours, and are often accompanied by vomiting, blue lips, and vertigo. Migraine and lupus headaches are much more severe than the average tension or sinus headache, resulting from the dilation of cerebral blood vessels, but the cause is unknown. Such headaches are particularly common in patients with the Anticoagulant Syndrome and Raynaud's Phenomenom. The instability in the dilating and constricting of blood vessels may result from a defect in local autonomic nervous system control. The one major difference which sets Lupus headaches apart from non-lupus migraines is their responsiveness to steroids. While taking Prednisone, lupus patients report a dramatic decrease or even elimination of headaches.
Headaches are but one of the many neurological manifestations found in SLE. Central Nervous System (CNS) involvment may stop at headaches and fogged memory, or it can escalate to psychosis, seizures, and comma. These cases are far less common and most experience problems somewhere in the mid-range.
      * Altered Behavior (including psychosis, organic brain syndrome, seizures, depression, and confusion) are changes noticable to friends and family and are caused by lupus directly affecting the central nervous system in what is called "CNS Vasculitis", or can be a reaction to certain medications.
      * Cognitive Dysfunctions are much more common in lupus patients, which are usually subtle and often noticed only by the patient. Such problems as not thinking clearly, impaired memory, and poor concentration are classified under this catagory and usually derive from a blood flow abnormality.

Such reports from undiagnosed lupus patients as headaches, difficutly concentrating, depression, anxiety attacks, "nervousness", and insomnia only increases the chances of being given anti-depressant medications and referred for psychological treatment. In addition, hormonal changes and emotional stress activate the immune system, triggering a flare of the disease. Therefore, the week preceding menstration, in which the female body under-goes hormonal changes, as well as emotionally-upsetting occurances in the patient's life can bring about actual physiological illnesses, which are often minimized as mere PMS or an inability to cope with stress. However, these are very real, neurological symptoms of SLE.
One of the most over-looked symptoms in SLE is anxiety attacks -- or, "panic attacks", often coupled with Agoriphobia and Claustrophobia. It is interesting to note that a great many reported cases indicated problems especially while driving or riding in vehicles, as well as occurances in public places. These individuals commonly experience light-headedness and vertigo. Differing from dizziness, vertigo is not limited to a "spinning" sensation, but includes any type of moving sensation, such as floating, falling, horizontal movement, or vibrating sensations. Panic attacks are a sudden, unrealistic sense of impending doom which occurs for no appearent reason. The body's natural "fight or flight" response is triggered, in which extra adrenalin is released for combating threatening situations. The heart pounds, pulse races, thoughts speed dramatically, and the person usually experiences nausea and/or diarrhea, brought on by a sense of immediate danger, though no danger is present. The two prevalent thoughts which occur in every victim's mind are, "I am dying or going crazy." These episodes seem to come on without provocation, though the patient generally finds some occurance in their life which they blame for these episodes, thus labeling them as "post-traumatic stress disorder". In the cases where SLE is found, these attacks are actually manifestations of Autonomic Nervous System involvement, and are similar to simple seizures, rather than psychological instablity.


Both, the Central Nervous System and the Peripheral Nervous System can be affected by SLE.

  • CENTRAL NERVOUS SYSTEM: (CNS) Includes the brain and spinal cord.
    TIAs or Multiple Sclerosis?

    TIA (Transient Ischemic Attack) is a "pre-cursor" to a stroke. These are warning signs of a blood clot and that a full stroke is quite possible. In lupus patients, this is usually due to the Anticoagulant Syndrome. Symptoms include headaches, dizziness, confusion, numbness, tingling, blurred or sudden loss of vision, loss of bladder and bowel control (which can either be incontinence or retention), poor coordination, difficulty walking, and a "dropped" arm or foot (loss of use).
    These are also the symptoms of MS (Multiple Sclerosis). Brain imaging and spinal fluid evaluations usually help differentiate the two.
    Multiple Sclerosis and Myasthenia Gravis are autoimmune disorders of the central nervous system and both have an increased incidence among lupus patients. Myasthenia gravis causes rapid muscle pain and weakness with repetitive tasks.
  • PERIPHERAL NERVOUS SYSTEM: (PNS) Those nerves not included in the brain and spinal cord --
          * Sensory Nerves: controlling body sensations, such as the sense of touch and feeling in the skin. Abnormalities include any altered sensations, such as hot and cold sensations on a certain area of the skin (without actual change in body temperature), tingling, pins and needles, vibratory sensations, and loss of feeling on the skin. Other strange sensations, including various forms of vertigo, are problems of the CNS.       * Motor Nerves: controlling muscle strength and movement.
    (see Peripheral Neuropathy below)

          * Autonomic Nerves: regulates adrenalin release, the tone of local blood vessels, and muscular contractions. These nerves control our "fight or flight" responses to stress, including sweating, bladder and bowel functions, slow or rapid breathing and heart rate, feelings of hot and cold, and burning sensations. "Panic" or "Anxiety" Attacks, as described earlier in this section, are caused in Lupus patients by impaired autonomic nerves. Inadequately studied in SLE, these problems cause more emotional distress to the patient than any other symptoms of the disease.


  • NEURITIS: is the "inflammation" of a nerve, often causing excruciating, sharp or burning pain. The pain comes and goes with movement of or touch to the affected area. A condition is said to be "neuritis" when nerve inflammation exists without actual nerve damage. Treatment for neuritis is steroids, which resolves the problem. Recurring episodes lead to permanent nerve damage which is no longer responsive to steroid treatment. (Nerve damage is called "Neuropathy")
  • NEURALGIA: is the term used to label the "pain" from a damaged nerve. In lupus patients, the pain tends to be chronic and severe, sharp and hard to bear. It is a "shooting" pain which travels along the pathway of the affected nerve. It usually only lasts a few seconds, but several attacks may occur in quick succession, or repeatedly over a course of time. Depending upon the location and severity, treatments include pain medications, drugs that change nerve conduction (such as anti-convulsants), and surgery.
  • PERIPHERAL NEUROPATHY: is "damage" to a peripheral nerve, characterized by a tingling sensation which tends to slowly spread from the extremities to the trunk. Numbness may also occur in the same fashion. Often, the skin becomes very sensitive to touch accompanied by neuralgic pain. Sometimes there is a gradual weakening of muscle power. You may experience a complete numbness or a lack of sensation in the skin. Local nerve palsies can also result, where the use of a hand, arm, foot, or leg is lost or severely impaired (called "dropped" which also occurs in Multiple Sclerosis) There is no direct treatment for peripheral neuropathy, but when it is caused by an underlying disorder, such as SLE, more aggressive lupus treatments usually slow or halt the progression of the neuropathy.       * It is interesting to note that many lupus patients experience flares of disease activity when exposed to certain chemicals (such as the propellents in aerosol sprays, strong perfume odors, and househould cleaning products). Likewise, peripheral neuropathy can sometimes be traced to exposure to certain chemicals, especially arsenic, mercury, lead, and insecticides. While it is doubtful that we have come in contact with any of the first three toxins mentioned, we all have been exposed to insecticides. { Return to "Motor Nerves" above. } 

    Psychiatric and psychosocial disorders in patients with systemic lupus erythematosus: a longitudinal study of active and inactive stages of the disease.

    http://www.ncbi.nlm.nih.gov/pubmed/11035432 

    Source

    Department of Psychiatry and Clinical Psychology, Department of Medicine, IDIBAPS (Institut d' Investigacions, Biomédiques August Pi i Sunyer), Hospital Clinic, School of Medicine, University of Barcelona, Barcelona, Spain.

    Abstract

    The objective was to analyze psychiatric disorders and psychosocial dysfunction in patients with systemic lupus erythematosus (SLE), studied longitudinally during active and subsequent inactive stage of their disease. During a 6 month period of study, we selected 20 consecutive patients with SLE who presented with a SLE flare. All patients fulfilled the 1982 revised criteria of the American College of Rheumatology for the classification of SLE. When patients entered the study, we performed psychiatric (CIS, RDC, STAI, HD, BDI, GHQ and MMS) psychosocial (GAS and VAS-P) scores assessment. One year later, we repeated the psychiatric and psychosocial assessment when patients showed inactive disease. The 20 patients evaluated were women, with a mean age of 34 y (SE 14.4, range 20-57). According to CIS evaluation, we diagnosed 8 (40%) psychiatric cases in the acute episode of SLE. The RDC diagnosis showed generalized anxiety in 5 patients, panic disorders in 2 patients and generalized anxiety plus depressive symptoms in one patient. One year later, when patients did not show disease activity, we diagnosed 2 (10%) psychiatric cases (P<0.05). When SLE patients were clinically inactive, they showed lower levels of psychological distress (GHQ scale, 1.8 vs 5.6, P<0.001), with a lower grade of anxiety measured by both HA (3.2 vs 8.2, P<0.01) and STAI-S (7.95 vs 20.90, P<0.001) scales. We also found a lower score in pain perception (VAS-P) (2.80 vs 4.25, P<0. 01) and higher occupational activity (VAS-P) (83.9 vs 66.2, P<0.01) and general functioning (GAS) (93.75 vs 83.50, P<0.05) during the inactive stage. No significant differences were found when we compared cognitive impairment, grade of depression and physical disability between inactive and active stages. We conclude that in SLE patients, psychiatric and psychosocial disorders during acute episodes are usually mild and seem to be related to the psychological impact of disease activity on patients. This type of psychiatric pathology is similar to that which would be expected in other groups coping with a stressful event, indicating that our patients did not react in a way specifically determined by their systemic disease.
    Prevalence of mood and anxiety disorders in women with systemic lupus erythematosus
    Elizabeth A. Bachen, Ph.D., Margaret A. Chesney, Ph.D., and Lindsey A. Criswell, M.D., M.P.H.
    Department of Psychology, Mills College; University of Maryland School of Medicine; The Rosalind Russell Medical Research Center for Arthritis, Department of Medicine, University of California, San Francisco
    Address correspondence and reprint requests to Elizabeth A. Bachen, Ph.D., Department of Psychology, Mills College, Oakland, CA 94613 Tel: (510) 430-2141 Fax: (510) 430-2271 ; bachen@mills.edu

    Objective
    To examine the lifetime prevalence of mood and anxiety disorders in patients with SLE. Demographic and disease-related variables were examined for association with lifetime major depressive disorder and the presence of any mood or anxiety disorder.

    Methods
    Three-hundred and twenty-six Caucasian women with SLE completed the Composite International Diagnostic Interview (CIDI) and the Systemic Lupus Activity Questionnaire (SLAQ), a self-report measure of disease activity in SLE. The binomial test was used to compare the prevalence of psychiatric diagnoses in SLE patients to a population sample of Caucasian women.

    Results
    Sixty-five percent of participants received a lifetime mood or anxiety diagnosis. Major depressive disorder (47%), specific phobia (24%), panic disorder (16%), obsessive-compulsive disorder (9%), and bipolar I disorder (6%) were more common among the SLE patients compared to Caucasian women (p = 0.00009 for specific phobia, all other p values = 0.00001). Although most patients with histories of mood disorders reported their psychiatric symptoms to a medical provider, a substantial number of patients with anxiety disorders did not. Self-reported disease activity was associated with a lifetime history of major depression (p = 0.001) and presence of a mood or anxiety disorder (p = 0.001), after controlling for demographic and clinical characteristics.

    Conclusion
    Several mood and anxiety disorders are more common in women with SLE compared to the general population, and disease activity may contribute to this higher risk. Brief self-report questionnaires may help providers identify patients with these conditions, particularly when patients are reluctant to disclose their symptoms.
    Systemic lupus erythematosus (SLE) is a chronic, relapsing autoimmune disorder that is most prevalent in women and involves multiple organ systems (1). Due to the potentially debilitating nature of the disease and relatively early onset for many women, SLE can pose multiple challenges and disrupt life goals throughout adulthood. Previous studies have found higher levels of psychiatric disturbance in patients with SLE, particularly depression or distress (210). The reported prevalence of depressive symptomatology in SLE varies widely across studies, from 17 to 71% (11). This variation is likely due to divergent criteria used to define distress or psychiatric disturbance, differences in sample characteristics, the assessment tools used, and small sample sizes. Some studies, but not all, have found that greater disease activity, SLE severity or longer disease duration increases vulnerability for clinical depression in SLE (412).
    Although most research has focused on depressed mood or clinical unipolar depression in SLE, others suggest that symptoms of anxiety may be equally important in this population. In an Icelandic study of 62 SLE patients, diagnoses of agoraphobia with and without panic, specific phobia and social phobia were more prevalent in SLE patients than the general population (13). Segui et al. (6) reported that among 20 female SLE patients, 40% met criteria for a psychiatric disorder, with generalized anxiety disorder and panic disorder being the most common diagnoses. Higher levels of social introversion (10) and obsessive-compulsive disorder have also been reported in patients with SLE (14), compared to healthy controls or population rates. Because population prevalence rates of some anxiety and depressive disorders are low, employing larger sample sizes to examine rates of these disorders in SLE is advantageous (15).
    In the United States, epidemiological studies indicate that comorbidity of psychiatric disorders is common, with more than half of all lifetime disorders occurring in 14% of the population who have a history of three or more comorbid disorders and only 21% of lifetime disorders occurring in respondents with a history of just one disorder (15). These findings suggest that while a history of psychiatric disorders is common (affecting nearly 50%), the major burden of such disorders is concentrated in a highly comorbid group (15). No studies to date have examined the comorbidity of psychiatric disorders among patients with SLE.
    In addition to high rates of psychiatric comorbidity, U.S. studies also find an underutilization of professional services for emotional problems (1516). Fewer than 40% of respondents with any lifetime psychiatric disorder receive professional treatment (15). Physicians provide the most care for psychiatric problems in the U.S. and primary care physicians are responsible for almost all referrals to mental health specialists (1718). Because rheumatology patients may visit their rheumatologists as often or more often than primary care providers (19), rheumatologists can also play an important role in identifying and facilitating the treatment of psychiatric problems. Recently, Sleath et al. (20) found that only 19% of depressed patients with rheumatoid arthritis discussed depression with their rheumatologists during medical visits, and that patients initiated the discussion each time.
    The purpose of this study is to investigate lifetime prevalence rates of anxiety and depressive disorders in patients with SLE. It extends previous work by simultaneously assessing multiple lifetime anxiety and mood disorders in a large sample of SLE patients, using a reliable and validated structured clinical interview, and diagnostic criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV, 21). In addition, we determine rates of comorbidity for lifetime disorders and the prevalence of symptom reporting to medical providers in the sample. Finally, demographic and clinical characteristics of SLE, including duration of disease, recent self-reported disease activity, history of renal involvement (as an indicator of SLE severity), and current prednisone use are examined as potential correlates of lifetime major depression and presence of a psychiatric disorder.

    PATIENTS AND METHODS

    Cohort
    Participants were 326 Caucasian women living in diverse geographical regions in the U.S. and enrolled in a study examining genetic risk factors for SLE at the University of California at San Francisco (UCSF Lupus Genetics Project) (22). For the current study, 616 women participants in the genetics project who were Caucasian and confirmed as having SLE by medical chart review (23), were contacted by mail and invited to participate in a study investigating health and well-being in women with SLE. Three-hundred and eighty-five women (62.5%) returned a postcard expressing interest, and we were able to reach 371 of them by telephone. Of those reached, 326 participated (88% of 371; 53% of 616). Reasons for nonparticipation among those who returned a postcard included health problems (5), too busy (6), moved (4), changed mind or didn't return consent forms (21), no longer diagnosed with SLE (3), or other (6). The 326 participants were recruited from UCSF-affiliated rheumatology offices (13%), community rheumatology offices (11%), and community-based sources, such as support groups and conferences (28%), and newsletters, Web site, and other forms of publicity (48%). Participants did not differ from non-participants (n =290) in terms of age (47.9+/−11.3 vs. 47.7+/−13.2 years, respectively), age at SLE diagnosis (32.5+/−12.2 vs. 34.1+/−13.0 years, respectively), or history of renal involvement (25.5% vs. 20.8%, respectively), all p's >.05.

    Data collection
    During a telephone interview, participants completed the Composite International Diagnostic Interview (CIDI), a structured diagnostic interview for the assessment of psychiatric disorders, which provides, by means of computer algorithms, lifetime diagnoses according to DSM-IV criteria (15). The CIDI is the most widely used interview in epidemiological studies of mental disorders and was used in the National Comorbidity Survey (NCS-1) (15) and National Comorbidity Survey Replication (NCS-R) (24) to determine the prevalence of lifetime psychiatric diagnoses in the U.S. The CIDI has good reliability and validity for diagnosing mood and anxiety disorders (25). The demographic, anxiety and depressive modules of the CIDI were administered, and included questions about the age of onset and recency of psychiatric disorders. Interviews were conducted by one of the authors (EB), who is trained as a clinical psychologist and received designated training to conduct the CIDI. In addition to computerized scoring of diagnoses, we also used criteria described by Means-Christensen et al. (26), which allows for a more sensitive assessment of panic disorder when other comorbid anxiety disorders are present. Finally, no symptom was counted toward a psychiatric diagnosis if it was attributed by either the respondent or clinician to physiological effects of injury, illness, medication, drugs, or alcohol.
    Following the CIDI, participants were interviewed about current psychotropic and SLE medications. Participants were mailed questionnaires that included the Systemic Lupus Activity Questionnaire (SLAQ) to assess self-reported lupus activity in the last 3 months (27). An analog to the Systemic Lupus Activity Measure (SLAM), the SLAQ includes 24 questions related to disease activity in SLE. Items are weighted and aggregated in a manner analogous to the scoring system used in the SLAM, and scores range from 0 to 44, with higher scores indicating greater disease activity (27). The SLAQ is highly correlated with physicians' ratings of disease activity (2728) and other health indices, including the SF-12 Physical Component Summary and SF-36 Physical Functioning subscale (29). Renal involvement for each participant was determined through medical chart review. Subjects meeting the ACR renal criterion (30) or who had lupus nephritis on renal biopsy were classified as having a history of renal involvement. History of renal involvement was chosen as an indicator of disease severity because the kidney is one of the most commonly involved organs in SLE and nephritis is a major determinant of disease morbidity and mortality in SLE (31). The study was approved by the Institutional Review Boards at UCSF and Mills College.

    Statistical analysis
    The binomial test [(GraphPad Software (32)] was used to compare the prevalence of mood and anxiety disorders in the sample with prevalence estimates in Caucasian females in the United States. Comparison rates were taken from the NCS-R because the NCS-R provides recent prevalence data from a large nationally representative sample of adults and, like the current study, employed the CIDI as its diagnostic instrument and based diagnoses on DSM-IV criteria (24,3334). Logistic regression was used to study demographic and disease-related variables associated with the prevalence of lifetime major depressive disorder and any mood or anxiety diagnosis. Sociodemographic covariates included age, education, income, marital and employment status. Additional covariates included duration of SLE, renal involvement, current prednisone use, and recent disease activity. Statistical significance was evaluated at the 0.05 level of significance.

    Three-hundred and one (92.3%) participants returned their questionnaires following the phone interview (CIDI). Participants who failed to return questionnaires (n=25) did not differ from those who did, in terms of age or prevalence of psychiatric diagnoses. Therefore, participants who did not return questionnaires were included in the prevalence assessment of psychiatric diagnoses.
    Demographic and clinical characteristics of the sample are shown in Table 1. Subjects were diagnosed with SLE an average of 15 years prior to study participation. At the time of the interview, 46% reported using psychotropic medications, the most common of which were antidepressants (41%). The mean SLAQ score for the sample was 14.0+/−7.6 and ranged from 0 to 35, reflecting a wide range of self-reported disease activity in SLE. Twenty-six percent of the sample had a history of renal involvement, which is consistent with other Caucasian SLE cohorts (35).
    Table 1
    Table 1
    Demographic and clinical characteristics of 326 SLE study subjects.

    Psychiatric diagnoses
    Fifteen participants were excluded from the prevalence estimates because their symptoms were attributed to the physiological effects of injury, illness, medications or drugs1, thus yielding conservative estimates. Similarly, 22 subjects reported persistently elevated or irritable mood due to medications or medical causes and were not included in the rates of bipolar disorder.
    Two-hundred and eleven of the 326 participants (65%) met criteria for at least one of the following lifetime depressive or anxiety disorders: Major depressive disorder (MDD) (47%), specific phobia (24%), social phobia (16%), obsessive-compulsive disorder (OCD) (9%), panic disorder (8%), bipolar I disorder (formerly manic-depressive disorder, 6%), generalized anxiety disorder (GAD) (4%), dysthymic disorder (3%), and agoraphobia without panic disorder (1%). A further review of panic disorder indicated that 35 participants met criteria for panic disorder, but did not receive the diagnosis due to a pre-existing comorbid anxiety disorder that is often accompanied by panic attacks. Using the revised scoring criteria described by Means-Christensen et al. (26) that addresses this issue, 26 of the 35 participants were reclassified as having a panic disorder because they answered “yes” to having frequent panic attacks in situations unrelated to their comorbid anxiety disorder (e.g., in a patient with social phobia, panic attacks also occurred in non-social situations). This resulted in a 2-fold increase (from 8 to 16%) of panic disorder.
    The binomial test was used to compare prevalence rates of psychiatric disorders in the SLE sample with Caucasian women in the U.S., using prevalence rates obtained from the NCS-R (34).2 As shown in Table 2, prevalence rates for the SLE sample did not change appreciably after adjusting for age using the NCS-R age distribution. Thus, observed (unadjusted) prevalence rates were used for analysis. MDD, bipolar I disorder, panic disorder, specific phobia, and OCD were significantly more common among the SLE subjects, (p = 0.00009 for specific phobia; all other p values = 0.00001). In contrast, GAD and dysthymic disorder were less common in the SLE sample (p = 0.00001 and p = 0.05, respectively), and there was no difference in the prevalence of social phobia and agoraphobia without panic disorder between SLE patients and Caucasian women in the NCS-R.
    Table 2
    Table 2
    Prevalence and Confidence Intervals of DSM-IV psychiatric disorders among 326 Caucasian women with SLE and population estimates for Caucasian women in the United States.
    Rates of psychiatric comorbidity were also assessed in the sample. Of the 211 participants with a lifetime history of psychiatric disorders, 29% had one disorder, 19% had two comorbid disorders, and 17% had three or more comorbid disorders. Thus, about one-third of participants with a psychiatric disorder met criteria for at least two lifetime psychiatric disorders.
    Over 90% of participants who met criteria for MDD or bipolar 1 disorder reported symptoms of depression to a medical care provider. Eighty-five percent of the patients with GAD informed their providers of their anxiety symptoms. However, only 72% of patients with panic disorder, 50% of patients with either dysthymia or agoraphobia without panic disorder, 40% of patients with social anxiety disorder, and 34% of patients with OCD reported their symptoms to a provider.
    To explore the timing of psychiatric disorders relative to SLE, the age of onset of each psychiatric disorder was compared to the age at which SLE was diagnosed. Table 3 shows the percentage of participants who reported the onset of a psychiatric disorder after the diagnosis of SLE, and the mean number of years between a diagnosis of SLE and the onset of a psychiatric disorder in this group. As shown in Table 3, the majority of patients experienced their first onset of psychiatric disorders prior to being diagnosed with SLE. However, a substantial proportion of participants also had first episodes of psychiatric disorders following SLE diagnosis. This was particularly true for MDD, panic disorder, agoraphobia, and bipolar 1 disorder, where 40 to 50% of participants with these disorders reported an onset after SLE diagnosis. Because many participants reported that their SLE symptoms preceded a SLE diagnosis by one or more years (mean = 5 years), we also examined the percentage who reported the onset of a psychiatric disorder after SLE symptom onset. As shown in Table 3, an even higher percentage of psychiatric disorders began after the onset of SLE symptoms.
    Table 3
    Table 3
    Relationship between onset of lifetime DSM-IV psychiatric disorder and diagnosis of SLE.

    Correlates of lifetime major depression and any mood or anxiety disorder
    Demographic characteristics (age, marital status, income, education, working outside the home) and characteristics of SLE (duration of SLE, self-reported disease activity (SLAQ), history of renal involvement, and current use of prednisone) were examined for association with lifetime MDD and the presence of any mood or anxiety disorder. As shown in Table 4, greater disease activity was associated with a higher odds of MDD and any psychiatric disorder after controlling for all other variables in the model (for MDD, OR 1.10, 95% CI 1.05–1.14, p = 0.001; for any disorder, OR 1.15, 95% CI 1.09–1.20, p = 0.001). For every one-unit increase in SLAQ scores, there was a corresponding 9% increase in the likelihood of lifetime MDD and a 14% increase in the likelihood of any mood or anxiety disorder. Household income below $50,000 was also associated with a higher odds of any psychiatric disorder after controlling for the remaining clinical and demographic characteristics (OR 2.01, 95% CI 1.03–3.91, p = 0.04). Finally, because the SLAQ includes symptoms that overlap with MDD (depression, fatigue, and forgetfulness), we repeated the regression analyses using a modified SLAQ score that eliminated these items. In each analysis, disease activity remained a significant predictor of MDD (OR 1.10, 95% CI 1.06–1.16, p = 0.001) and any disorder (OR 1.16, 95% CI 1.10–1.23 p = 0.001), after controlling for all other variables in the model.
    Table 4
    Table 4
    Logistic regression analysis of sociodemographic and clinical factors and likelihood of lifetime history of major depressive disorder or any mood or anxiety disorder among SLE patients.

    DISCUSSION
    Symptoms of depression and anxiety are commonly reported in patients with SLE and are likely associated with the physical disability and stress of living with a chronic disease (36). Our findings indicate that psychiatric manifestations are frequent in SLE patients and extend earlier work by documenting that more than one form of psychiatric disorder often occurs in the same patient.
    Most studies investigating psychological concomitants of SLE have focused on depression. Our study indicates that lifetime MDD, affecting 47% of the sample, was the most common diagnosis and two times more common than general population estimates. A similar lifetime prevalence of MDD (49%) was recently found in an outpatient sample of Brazilian female SLE patients (5). Our results are also consistent with those of Shih et al. (37), who using a nationally representative sample of U.S. adults, found that anxiety and depressive symptoms were more than twice as common in adults with arthritis than those without arthritis.
    In addition to MDD, we found that patients with SLE had higher lifetime rates of certain anxiety disorders and mania. Compared to prevalence estimates for Caucasian women in the U.S, SLE patients had a 6-fold increase in bipolar I disorder, an 11-fold increase in OCD and a 1.5-fold increase in specific phobia. Panic disorder was also more common, with rates up to 2.5 times higher. Few studies have examined anxiety and bipolar disorders in SLE, though elevated rates of such disorders are consistent with results from smaller clinical samples (3,5,14) and those of Lindal et al. (13) who studied an unselected population of 62 Icelandic patients with SLE. Indeed, Lindal et al. (13) found an increase in specific phobia, with a lifetime prevalence (26%) almost identical to ours, and like our study, a 2.5-fold increase in panic disorder. Consistent with our results, Slattery et al. (14) also observed about a 10-fold increase in OCD in clinic sample of 50 SLE patients, and Magner (3) found that hypomania (manic episodes with less marked impairment) was more common in SLE than RA, and was unrelated to corticosteroid use. Together, these findings highlight the importance of recognizing the spectrum of mood and anxiety disorders in SLE and the need to examine etiology.
    Contrary to expectation, GAD and dysthymic disorder were less common in our SLE sample, compared to national estimates. Chronic anxiety and depressed mood are common features of MDD, and diagnoses of GAD and dysthymic disorder each require that symptoms have occurred independently of an episode of major depression. It is possible that the high rates of MDD in this study made it difficult to assess lifetime GAD and dysthymic disorder. Prospective studies may be more effective in assessing rates of these disorders in SLE.
    Psychological distress may be associated with SLE outcomes, including fatigue (38), physical disability (39), and decreased functioning (40). While most research has focused on depression, it is well known that anxiety can also be debilitating. Without treatment, anxiety disorders are typically chronic and often lead to social and occupational impairment (41), substance dependence (42), depression (43), and in primary care patients, greater disability and utilization of general medical services (44). In our sample, 59% of patients who met criteria for lifetime MDD also had a comorbid anxiety disorder, suggesting that some of the observed effects of depression on health outcomes in SLE may be due to underlying difficulties with anxiety. Finally, to our knowledge, no one has studied the impact of bipolar disorder on lupus functioning. If rates of bipolar disorder are elevated in SLE as our study suggests, this warrants further investigation.
    Given the elevated rates of depressive and anxiety disorders observed in SLE, it is important to understand contributing factors. Disease activity and severity, duration of SLE, and central nervous system complications may increase vulnerability for psychiatric disorders in SLE, although findings are mixed (412). Psychosocial stressors associated with having a chronic illness may also increase risk for depression and anxiety (45). In our study, we found that self-reported disease activity in SLE, but not renal involvement (an important indicator of disease severity) predicted lifetime diagnoses of MDD and presence of any mood or anxiety disorder. It is possible that disease activity is more closely tied to mental health outcomes because it reflects symptomatology that interferes with day-to-day activities and quality of life, such as fatigue, rashes, pain, and swelling.
    Disease activity in SLE may also contribute to psychiatric symptomatology through shared pathophysiological mechanisms, including antineuronal and antiphospholipid antibodies (46), proinflammatory cytokines (47), and calcifications in the basal ganglia, a brain region that is implicated in OCD (4).
    In this study, we assessed the degree to which patients reported symptoms of anxiety or depression to a medical provider. Over 90% of participants who met criteria for lifetime MDD or bipolar 1 disorder reported symptoms of depression to their medical providers. This disclosure rate is higher than reported by Sleath et al. (20), possibly because they focused on current depressed mood and reporting to a rheumatologist. Like Sleath et al., we found reporting to be higher when depressive symptoms were more severe; only 50% of our sample reported symptoms of dysthymia to their providers. In contrast, close to one-third of those with panic disorder did not report their symptoms to a provider and well over one-half of patients (66%) never told a provider about their obsessive-compulsive symptoms or social anxiety concerns (60%). Such findings are important as medical providers are usually the first line of intervention for psychiatric problems, providing direct treatment or referrals to mental health specialists. Untreated psychiatric disorders may compromise adherence to treatment regimens, quality of sleep, and other factors associated with health outcomes (20).
    Several limitations need to be considered when interpreting the present findings. Our cohort is not a population-based sample of adults with SLE in the U.S. However, participants were recruited from diverse sources, including non-clinical sources, which represented three-fourths of our sample. Moreover, we found that participants did not differ from non-participants with respect to important clinical variables, and were comparable to other SLE cohorts with respect to prevalence of kidney involvement and age of diagnosis (35,48).
    Because our study included only Caucasian women, results may not be generalizeable to women of other ethnic groups, or to men. In the U.S., rates of certain depressive and anxiety disorders are often reported higher among African Americans and Hispanics, but largely accounted for by socioeconomic status (SES) differences in income and education (49). Our sample is likely to have a higher educational attainment than the general population of patients with SLE in the U.S., and indeed, was more likely to have graduated college than our comparison group in the NCS-R. Although education was not associated with psychiatric diagnoses in our study, the odds of an anxiety or depressive disorder was higher in participants with household incomes below $50,000. Thus, the inclusion of other ethnic groups with disadvantaged SES may yield higher rates than reported here.
    This study also did not include a medically ill comparison group, so we are unable to determine if the increased rates of psychiatric disorders found in our sample are specific to SLE. Finally, although many patients in our study reported the onset of psychiatric disorders after being diagnosed with SLE, the use of cross-sectional data cannot be used to infer causation.
    In conclusion, we believe that this is the largest study to date to examine depressive and anxiety disorders in a single sample of SLE patients, using DSM-IV criteria. Our results clearly suggest that rates of depressive and some anxiety disorders (including OCD and phobias) are elevated in SLE and that comorbidity of psychiatric disorders is common in this population. Although most patients reported severe depression or mania to a medical provider, a large percentage of patients with anxiety disorders did not. Because patients with anxiety disorders often feel embarrassed to openly disclose their symptoms (50), other methods of assessment, such as brief self-report questionnaires may be helpful in identifying patients with these conditions, so that treatment can be delivered to alleviate psychological distress and improve overall function (16,20).

    ACKNOWLEGEMENTS
    The authors wish to acknowledge Dr. Jianping He and Dr. Kathleen Merikangas for their assistance in accessing the NCS-R data; Dr. Stuart Gansky of UCSF and Jennifer Dillon for their assistance with the data analysis; and Dr. Laura Lee Johnson of NCCAM for her analytic consultation and helpful advice on the manuscript.
    This study was supported by a grant from the Arthritis Foundation (E.A.B.); RO1 AR44804, K24 AR02175, and Kirkland Scholar Award (L.A.C).
    This study was performed in part in the General Clinical Research Center, Moffitt Hospital, University of California, San Francisco, with funds provided by the National Center for Research Resources, 5 M01 RR-00079, U.S. Public Health Service.

2 comments: