Serotonin syndrome is a potentialyl life-threatening drug reaction that causes the body to have too much serotonin, a chemical produced by nerve cells.

Hyperserotonemia; Serotonergic syndrome

Serotonin syndrome most often occurs when two drugs that affect the body's level of serotonin are taken together at the same time. The drugs cause too much serotonin to be released or to remain in the brain area.

For example, you can develop this syndrome if you take migraine medicines called triptans together with antidepressants called selective serotonin reuptake inhibitors (SSRIs) and selective serotonin/norepinephrine reuptake inhibitors (SSNRIs). Popular SSRI's include Celexa, Zoloft, Prozac, Zoloft, Paxil, and Lexapro. SNRI's include Cymbalta and Effexor. Brand names of triptans include Imitrex, Zomig, Frova, Maxalt, Axert, Amerge, and Relpax.

The FDA recently asked the manufacturers of these types of drugs to include warning labels on their products that tell you about the potential risk of serotonin syndrome. Talk to your doctor before stopping any medication.

Serotonin syndrome is more likely to occur when you first start or increase the medicine.

Older antidepressants called monoamine oxidase inhibitors (MAOIs) can also cause serotonin syndrome with the medicines describe above, as well as meperidine (Demerol, a painkiller) or dextromethorphan (cough medicine).

Drugs of abuse, such as ecstasy and LSD have also been associated with serotonin syndrome.

Symptoms occur within minutes to hours, and may include:

• Agitation or restlessness
• Diarrhea
• Fast heart beat
• Hallucinations
• Increased body temperature
• Loss of coordination
• Nausea
• Overactive reflexes
• Rapid changes in blood pressure
• Vomiting

The diagnosis is usually made by asking questions about your medical history, including the types of drugs you take.

To be diagnosed with serotonin syndrome, you must have been taking a drug that changes the body's serotonin levels (serotonergic drug) and have at least three of the following signs or symptoms:

• Agitation
• Diarrhea
• Heavy sweating not due to activity
• Fever
• Mental status changes such as confusion or hypomania
• Muscle spasms (myoclonus)
• Overactive reflexes (hyperreflexia)
• Shivering
• Tremor
• Uncoordinated movements (ataxia)

Serotonin syndrome is not diagnosed until all other possible causes have been ruled out, including infections, intoxications, metabolic and hormone problems, and drug withdrawal. Some symptoms of serotonin syndrome can mimic those due to an overdose of cocaine, lithium, or an MAOI.

If you have just start taking or increased the dosage of a tranquilizer (neuroleptic drug), other conditions such as neuroleptic malignant syndrome will be considered.

Tests may include:

• Blood cultures (to check for infection)
• Complete blood count (CBC)
• Drug (toxicology) screen
• Electrolyte levels
• Electrocardiogram (ECG)
• Kidney and liver function tests
• Thyroid function tests

Patients with serotonin syndrome should stay in the hospital for at least 24 hours for close observation.

Treatment may include:

• Benzodiazepines such as diazepam (Valium) or lorazepam (Ativan) to decrease agitation, seizure-like movements, and muscle stiffness
• Cyproheptadine (Periactin), a drug that blocks serotonin production
• Fluids by IV
• Withdrawal of medicines that caused the syndrome

In life-threatening cases, medicines that keep your muscles still (paralyze them) and a temporary breathing tube and breathing machine will be needed to prevent further muscle damage.

Patients may get slowly worse and can become severely ill if not quickly treated. Untreated serotonin syndrome can be deadly. However, with treatment, symptoms can usually go away in less than 24 hours.

Uncontrolled muscle spasms can cause severe muscle breakdown. The products produced when the muscles break down are released into your blood and eventually go through the kidneys. This can cause severe kidney damage if not recognized and treated appropriately. With appropriate treatment, the condition is reversible.

Always tell all of your healthcare providers what medicines you take. Patients who take triptans with SSRIs or SNRIs should be closely followed, especially right after starting a medicine or increasing its dosage.

US Food and Drug Administration. FDA Public Health Advisory: Combined Use of 5-Hydroxytryptamine Receptor Agonists (Triptans), Selective Serotonin Reuptake Inhibitors (SSRIs) or Selective Serotonin/Norepinephrine Reuptake Inhibitors (SNRIs) May Result in Life-threatening Serotonin Syndrome. Rockville, MD: Center for Drug Evaluation and Research; July 19, 2006.

Prator BC. Serotonin syndrome. J Neurosci Nurs. 2006 Apr;38(2):102-5.

Ford MD, Clinical Toxicology. 1st ed. Philadelphia, Pa: WB Saunders; 2001:150, 522, 547, 550.

Bilden EF, Walter FG. Antidepressants. In Marx J, ed. Rosen's Emergency Medicine: Concepts and Clinical Practice. 6th ed. St. Louis, Mo: Mosby; 2006: chap 149.

Sternbach H. The Serotonin Syndrome. Am J Psychiatry. 1991: 148:705.

Parrot AC. Recreational Ecstasy/MDMA, the serotonin syndrome, and serotonergic neurotoxicity. Pharmacol Biochem Behav. 2002 Apr;71(4):837-44. Review.

Brent J, Palmer R. Monoamine oxidase inhibitors and serotonin syndrome. In: Shannon MW, Borron SW, Burns MJ, eds. Haddad and Winchester's Clinical Management of Poisoning and Drug Overdose. 4th ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 29.

Panic disorder with agoraphobia is an anxiety disorder in which there are repeated attacks of intense fear and anxiety, and a fear of being in places where escape might be difficult, or where help might not be available.

Agoraphobia usually involves fear of crowds, bridges, or of being outside alone.

This article discusses panic disorder with agoraphobia. For information on panic disorder itself, see also: Panic disorder

Agoraphobia; Anxiety disorder- agoraphobia

The exact causes of panic disorder and agoraphobia are unknown. Because panic attacks often occur in areas or situations where they have happened in the past, panic may be a learned behavior. Agoraphobia sometimes occurs when a person has had a panic attack and begins to fear situations that might lead to another panic attack.

Anyone can develop a panic disorder, but it usually starts around age 25. Panic disorder is more common in women than men.

Panic attacks involve short periods of intense anxiety symptoms, which peak within 10 minutes. Panic attack symptoms can include:

• Chest pain or discomfort
• Choking
• Dizziness or faintness
• Fear of being out of control
• Fear of dying
• Fear of "going crazy"
• Hot flashes or chills
• Nausea or other stomach distress
• Numbness or tingling
• Racing heart
• Shortness of breath
• Sweating
• Trembling

Agoraphobia is considered to be present when places or situations are being avoided. People with agoraphobia generally do not feel safe in public places. Their fear is worse when the place is crowded. Symptoms of agoraphobia include:

• Becoming housebound for prolonged periods of time
• Dependence on others
• Fear of being alone
• Fear of being in places where escape might be difficult
• Fear of losing control in a public place
• Feelings of detachment or estrangement from others
• Feelings of helplessness
• Feeling that the body is unreal
• Feeling that the environment is unreal
• Unusual temper or agitation

People who first experience panic sometimes fear they have a serious illness, or are even dying. Often, people will go to an emergency room or other urgent care center because they think they are having a heart attack.

A physical examination and psychological evaluation can help diagnose panic disorder. It is important to rule out any medical disorders, such as problems involving the heart, hormones, breathing, nervous system, and substance abuse. Which tests are done to rule out these conditions depends on the symptoms.

The goal of treatment is to help you feel and function better. The success of treatment usually depends in part on how severe the agoraphobia is.

The standard treatment approach combines cognitive-behavioral therapy (CBT) with an antidepressant medication.

• Selective serotonin reuptake inhibitors (SSRIs) are usually the first choice of antidepressant.
• Serotonin-norepinephrine reuptake inhibitors (SNRIs) are another choice. Other antidepressants and some anti-seizure drugs may be used for more severe cases.
• Other anti-anxiety medications may also be prescribed. For example, your health care provider may recommend benzodiazepines when antidepressants don't help or before they take effect.

CBT involves 10 to 20 visits with a mental health professional over a number of weeks. CBT helps you change the thoughts that cause your condition. It may involve:

• Gaining understanding and control of distorted feelings or views of stressful events or situations
• Learning to recognize and replace panic-causing thoughts
• Learning stress management and relaxation techniques
• Systematic desensitization and exposure therapy, in which you are asked to relax, then imagine the things that cause the anxiety, working from the least fearful to the most fearful.

Gradually exposing the patient to the real-life situation that causes the fear has also helped some people overcome their fears.

A healthy lifestyle that includes exercise, enough rest, and good nutrition can also help be helpful.

Most patients can get better with medications or behavioral therapy. However, without early and effective help, the disorder may become more difficult to treat.

• Some people may abuse alcohol or other drugs while trying to self-medicate.
• Some people may be unable to function at work or in social situations.
• Some people may feel isolated, lonely, depressed, or suicidal.

Call for an appointment with your health care provider if you have symptoms of panic attacks or agoraphobia.

Early treatment of panic disorder can often prevent agoraphobia.

Taylor CT, Pollack MH, LeBeau RT, Simon NM. Anxiety disorders: panic, social anxiety, and generalized anxiety. In: Stern TA, Rosenbaum JF, Fava M, Biederman J, Rauch SL, eds. Massachusetts General Hospital Comprehensive Clinical Psychiatry. 1st ed. Philadelphia, Pa: Mosby Elsevier;2008:chap 32.

Panic disorder is a type of anxiety disorder in which someone has repeated attacks of intense fear that something bad will occur when not expected. The person lives in fear that another attack will occur.

See also: Generalized anxiety disorder

Panic attacks

The exact cause of panic disorders is unknown. Genetics may play a role. Studies suggest that if one identical twin has panic disorder, the other twin will also develop the condition 40% of the time. However, panic disorder often occurs when there is no family history.

Panic disorder is twice as common in women as in men. Symptoms usually begin before age 25, but may occur in the mid 30s. Although panic disorder may occur in children, it is often not diagnosed until they are older.

Before a diagnosis of panic disorder is made, people with this condition often have had visits to emergency rooms and health care providers for symptoms related to possible heart attack or other physical symptoms.

A panic attack begins suddenly, and most often peaks within 10 - 20 minutes. Some symptoms may linger for 1 or more hours afterwards. During a panic attack, the person believes he or she is "going crazy," having a heart attack, or about to die.

Panic attacks cannot be predicted. At least in the early stages of the disorder, there is no cue or trigger that starts the attack. Recalling a past attack may trigger panic attacks. How often and in what pattern they occur can vary.

Panic attacks may include anxiety about being in a situation where an escape may be difficult (such as being in a crowd or traveling in a car or bus).

A person with panic disorder often lives in fear of another attack, and may be afraid to be alone or far from medical help.

With panic disorder, at least four of the following symptoms occur during an attack:

• Chest pain or discomfort
• Dizziness or faintness
• Fear of dying
• Fear of losing control or impending doom
• Feeling of choking
• Feelings of detachment
• Feelings of unreality
• Nausea or upset stomach
• Numbness or tingling in the hands, feet, or face
• Palpitations, fast heart rate, or pounding heart
• Sensation of shortness of breath or smothering
• Sweating, chills, or hot flashes
• Trembling or shaking

Panic attacks may change behavior and function at home, school, or work. People with the disorder often worry about the effects of their panic attacks.

People with panic disorder may have symptoms of:

• Alcoholism
• Depression
• Drug abuse

A health care provider will perform a physical examination, including blood tests and a psychiatric evaluation. Medical disorders must be ruled out before panic disorder can be diagnosed.

Disorders related to substance abuse should also be considered, because some can mimic panic attacks. Substance abuse also can occur when people who have panic attacks try to cope with their fear by using alcohol or illegal drugs.

Cardiovascular, endocrine, respiratory, and nervous system (neurologic) disorders can be present at the same time as panic disorders. Specific tests will vary from person to person depending on the symptoms.

Many people with panic disorder first seek treatment in the emergency room, because the panic attack feels like a heart attack.

The goal of treatment is to help you function well during everyday life. Cognitive-behavioral therapy (CBT) and medications are the mainstays of treatment.

Medications are an important part of treatment. Once you start taking them, do not suddenly stop without talking with your health care provider.

Medications that may be used include:

• Antidepressants called SSRIs (selective serotonin reuptake inhibitors) are the most commonly used medications for panic disorder. They include fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), fluvoxamine (Luvox), citalopram (Celexa), and escitalopram (Lexapro).
• Serotonin-norepinephrine reuptake inhibitors (SNRIs) and other antidepressants.
• If SSRIs or SNRIs do not help, benzodiazepines may be used. They include alprazolam (Xanax), clonazepam (Klonopin), and lorazepam (Ativan). However, people can become dependant on or addicted to drugs in this class of medications. Ideally, these drugs should be used only on a temporary basis.
• Other antidepressants and some anti-seizure drugs may be used for severe cases.
• Monoamine oxidase inhibitors (MAOIs), such as phenelzine (Nardil), tranylcypramine (Parnate), and isocarboxazid (Marplan), are only used when the other drugs do not work. Although they can be very helpful for treating panic disorders, MAOIs have serious side effects and can interact with other drugs and foods.

Cognitive-behavioral therapies should be used together with drug therapy. Ten to 20 visits with a mental health professional should take place over a number of weeks. Common parts of this therapy include:

• Gaining understanding of and control over distorted views of life stressors, such as other people's behavior or life events.
• Learning to recognize and replace panic-causing thoughts to decrease the sense of helplessness.
• Learning stress management and relaxation techniques to help when symptoms occur.
• Practicing systematic desensitization and exposure therapy, in which you are asked to relax, then imagine the things that cause the anxiety, working from the least fearful to the most fearful. Gradual exposure to the real-life situation also has been used with success to help people overcome their fears.

Behavioral treatment appears to have long-lasting benefits.

Regular exercise, adequate sleep, and regularly scheduled meals may help reduce the frequency of the attacks. Reduce or avoid the use of caffeine, some over-the-counter cold medicines, and other stimulants, because they may make symptoms worse.

Panic disorders may be long-lasting and difficult to treat. Some people with this disorder may not be cured with treatment. However, most people can expect rapid improvement with drug and behavioral therapies.

Substance abuse can occur when people who have panic attacks try to cope with their fear by using alcohol or illegal drugs.

People with panic disorder are more likely to be unemployed, less productive at work, and to have difficult personal relationships, including marital problems. Work, social, and family function are all disrupted.

Agoraphobia is when the fear of future panic attacks causes someone to avoid situations or places that are thought to cause the attacks. This can lead a person to place severe restrictions on where they go or who they are around. See: Panic disorder with agoraphobia

Dependence on anti-anxiety medications is a possible complication of treatment. Dependence involves needing a medication to be able to function and to avoid withdrawal symptoms. It is not the same as addiction.

Call for an appointment with your health care provider if panic attacks are interfering with your work, relationships, or self-esteem.

If you get panic attacks, avoid the following:

• Alcohol
• Stimulants such as caffeine and cocaine

These substances may trigger or worsen the symptoms.

Hofmann SG, Smits JA. Cognitive-behavioral therapy for adult anxiety disorders: a meta-analysis of randomized placebo-controlled trials. J Clin Psychiatry. 2008;69:621-632.

Taylor CT, Pollack MH, LeBeau RT, Simon NM. Anxiety disorders: Panic, social anxiety, and generalized anxiety. In: Stern TA, Rosenbaum JF, Fava M, Biederman J, Rauch SL, eds. Massachusetts General Hospital Comprehensive Clinical Psychiatry. 1st ed. Philadelphia, Pa: Mosby Elsevier;2008:chap 32.

Pollack MH, Kinrys G, Delong H, Vasconcelos e Sa D, Simon NM. The pharmacotherapy of anxiety disorders. Stern TA, Rosenbaum JF, Fava M, Biederman J, Rauch SL, eds. Massachusetts General Hospital Comprehensive Clinical Psychiatry. 1st ed. Philadelphia, Pa: Mosby Elsevier;2008:chap 41.

Generalized anxiety disorder (GAD) is a pattern of frequent, constant worry and anxiety over many different activities and events.

GAD; Anxiety disorder

Generalized anxiety disorder (GAD) is a common condition. Genes may play a role. Stressful life situations or learned behavior may also contribute to the development of GAD.

The disorder may start at any time in life, including childhood. Most people with the disorder report that they have been anxious for as long as they can remember. GAD occurs somewhat more often in women than in men.

The main symptom is the almost constant presence of worry or tension, even when there is little or no cause. Worries seem to float from one problem to another, such as family or relationship problems, work issues, money, health, and other problems.

Even when aware that their worries or fears are stronger than needed, a person with GAD still has difficulty controlling them.

Other symptoms include:

• Difficulty concentrating
• Fatigue
• Irritability
• Problems falling or staying asleep, and sleep that is often restless and unsatisfying
• Restlessness or feeling keyed up or "on the edge," often becoming startled very easily

Along with the worries and anxieties, a number of physical symptoms may also be present, including muscle tension (shakiness, headaches).

Depression and substance abuse may occur with an anxiety disorder.

A physical examination and psychological evaluation can rule out other causes of anxiety. The health care provider should rule out physical disorders that may mimic anxiety, as well as symptoms caused by drugs. This process may include different tests.

The goal of treatment is to help you function well during day-to-day life. Cognitive-behavioral therapy (CBT) and medications are the mainstays of treatment.

Medications are an important part of treatment. Once you start them, do not suddenly stop without talking with your health care provider. Medications that may be used include:

• Selective serotonin reuptake inhibitors (SSRIs) are usually the first choice in medications. Serotonin-norepinephrine reuptake inhibitors (SNRIs) are another choice.
• Other antidepressants and some antiseizure drugs may be used for severe cases.
• Benzodiazepines such as alprazolam (Xanax), clonazepam (Klonopin), and lorazepam (Ativan) may be used if antidepressants don't help enough with symptoms. Long-term dependence on these drugs is a concern. Short-term memory problems may also develop with long-term use.
• A medication called buspirone may also be used.

Cognitive-behavioral therapies should be used together with drug therapy. Ten to 20 visits with a mental health professional should take place over a number of weeks. Common parts of this therapy include:

• Gaining an understanding of, and control over distorted views of life stressors, such as other people's behavior or life events.
• Learning to recognize and replace panic-causing thoughts, decreasing the sense of helplessness.
• Learning stress management and relaxation techniques to help when symptoms occur.
• Learning not to quickly think that minor worries will develop into very bad problems.

Avoiding caffeine, illicit drugs, and even some cold medicines may also help reduce symptoms.

A healthy lifestyle that includes exercise, enough rest, and good nutrition can help reduce the impact of anxiety.

Support groups may be helpful for some patients with GAD. Patients have the opportunity to learn that they are not unique in experiencing excessive worry and anxiety.

Support groups are not a substitute for effective treatment, but can be a helpful addition to it.

The success of treatment usually depends on the severity of the generalized anxiety disorder. The disorder may continue and be difficult to treat, but most patients see great improvement with medications or behavioral therapy.

People with GAD may develop other psychiatric disorders, such as panic disorder or depression. Substance abuse or dependence may become a problem if you try to self-medicate with drugs or alcohol to relieve anxiety.

Call your health care provider if you are experiencing the signs and symptoms of generalized anxiety disorder, and they are interfering with your daily life and well-being.

Anxiety Disorders. National Institute of Mental Health. U.S. Department of Health and Human Services. Accessed February 5, 2010.

Hoffmann SG, Smits JA. Cognitive-behavioral therapy for adult anxiety disorders: a meta-analysis of randomized placebo-controlled trials. J Clin Psychiatry. 2008;69:621-632.

Pollack MH, Kinrys G, Delong H, Vasconcelos e Sa D, Simon NM. The pharmacotherapy of anxiety disorders. In: Stern TA, Rosenbaum JF, Fava M, Biederman J, Rauch SL, eds. Massachusetts General Hospital Comprehensive Clinical Psychiatry. 1st ed. Philadelphia, Pa: Mosby Elsevier;2008:chap 41.

Connolly SD, Bernstein GA. Work Group on Quality Issues. Practice parameter for the assessment and treatmetn of children and adolescents with anxiety disorders. J Am Acad Child Adolesc Psychiatry. 2007;46:267-283.

Prescription medicines:

There are generally two approaches to treating anxiety and depression, one is anti-depressants, and the other is anti-anxiety meds. While anti-anxiety meds (think Xanax, and other benzodiazepines) work in the short-term, very effectively, they quickly cause tolerance and dependence (addiction). There is evidence that they can make anxiety worse in the long-run.

Anti-depressants have more mixed evidence on their use. There is some evidence that they work, while people are still taking them, but there is concern over publication bias skewing results, leading people to suspect that they may be little more effective than placebo. They also provide no benefit after the person stops taking them.

Among these drugs, probably the first choices to be considered are newer types of antidepressants, namely the selective serotonin reuptake inhibitors (SSRIs) like Zoloft, Paxil, and even newer types like Lexapro - these are approved for treatment of both types of disorders. In addition, another class of antidepressant drugs, called the serotonin-norepinephrine reuptake inhibitors (SNRIs), which includes Effexor XR, Cymbalta, and now in 2008 Pristiq, is also approved to treat major depression. For depression that is accompanied by symptoms of anxiety, these drugs have been shown to significantly relieve both types of symptoms, usually within 4 weeks of beginning treatment. Effexor XR and Cymbalta also have separate indications for treatment of certain anxiety disorders like generalized anxiety disorder, panic disorder and post-traumatic stress disorder (possibly others - one can check the official labeling on the internet).

Traditional medicine and herbals:

There are many traditional herbal medications for anxiety and derpession, including hypericum, Withania Somnifera, Terminalis Arjuna, Conium, Cadmium Sulph, Calcerea Carb, etc.

Many common herbal teas are used to treat anxiety as well. The process of drinking herbal teas can be relaxing, and can help reduce anxiety and depression through promoting mindfulness. Relaxing herbs include chamomile, tulsi or holy basil, lemon balm, and passionflower.

Dysthymia is a chronic type of depression in which a person's moods are regularly low. However, it is not as extreme as other types of depression.

Neurotic depression (dysthymia); Dysthymic disorder; Chronic depression; Depression - chronic

The exact cause of dysthymia is unknown.

As with major depressive disorder, dysthymia occurs more in women than in men and affects up to 5% of the general population. Dysthymia can occur alone, or together with more severe depression or another mood or psychiatric disorder.

The main symptom of dysthymia is low, dark, or sad mood nearly every day for at least 2 years. The symptoms are less severe than in patients with major depression, but people with this condition can still struggle with:

• Feelings of hopelessness
• Insomnia or hypersomnia
• Low energy or fatigue
• Low self-esteem
• Poor appetiteor overeating
• Poor concentration

Your health care provider will take a history of your mood and other mental health symptoms over the past several months.

As with other forms of depression, there are a number of treatment options for people with dysthymia:

• Selective serotonin reuptake inhibitors such as fluoxetine (Prozac)
• Tricyclic antidepressants
• Talk therapies, such as cognitive/behavioral therapy and interpersonal therapy

Medications do not work as well for dysthymia as they do for depression. It also may take longer after starting medication for you to feel better.

Some evidence suggests that combining medication and psychotherapy may lead to the most improvement.

Dysthymia is a chronic condition that lasts many years. Though some people completely recover, others continue to have some symptoms, even with treatment. Some people need to continue taking medication and undergoing therapy.

Antidepressant drugs have side effects that can complicate treatment. For example, selective serotonin reuptake inhibitors may cause stomach upset, mild insomnia, and reduced sex drive.

If not treated, dysthymia can turn into a major depressive episode. This is known as "double depression."

Call for an appointment with your health care provider if you regularly feel depressed or low.

Institute for Clinical Systems Improvement. Health Care Guidelines: Major Depression in Adults in Primary Care. 11th ed. 2008.

Stewart JW. Treating depression with atypical features. J Clin Psychiatry. 2007;68:25-29.

Depression may be described as feeling sad, blue, unhappy, miserable, or down in the dumps. Most of us feel this way at one time or another for short periods.

True clinical depression is a mood disorder in which feelings of sadness, loss, anger, or frustration interfere with everyday life for a long period of time.

Depression - major; Unipolar depression; Major depressive disorder

The exact cause of depression is not known. Many researchers believe it is caused by chemical imbalances in the brain, which may be hereditary or caused by events in a person's life.

Some types of depression seem to run in families, but depression can also occur in people who have no family history of the illness. Stressful life changes or events can trigger depression in some people. Usually, a combination of factors is involved.

Men and women of all ages, races, and economic levels can have depression. Depression can also occur in children and teenagers.

A number of factors can play a role in depression:

• Alcohol or drug abuse
• Life events or situations, such as:
  • Breaking up with a boyfriend or girlfriend, failing a class, illness or death in the family, or parents divorcing (for adolescents)
  • Childhood events, such as abuse or neglect
  • Divorce, death of a friend or relative, or loss of a job (for adults)
  • Social isolation (common in the elderly)
• Medical conditions such as hypothyroidism (underactive thyroid), medications (such as sedatives and high blood pressure medications), cancer, major illness, or prolonged pain
• Sleeping problems

See also: Adolescent depression

Depression can change or distort the way adolescents see themselves and their lives, as well as other people around them. People who have depression usually see everything with a more negative attitude, unable to imagine that any problem or situation can be solved in a positive way.

Symptoms include:

• Agitation, restlessness, and irritability
• Dramatic change in appetite, often with weight gain or loss
• Extreme difficulty concentrating
• Fatigue and lack of energy
• Feelings of hopelessness and helplessness
• Feelings of worthlessness, self-hate, and inappropriate guilt
• Inactivity and withdrawal from usual activities, a loss of interest or pleasure in activities that were once enjoyed (such as sex)
• Thoughts of death or suicide
• Trouble sleeping or excessive sleeping

Depression can appear as anger and discouragement, rather than as feelings of hopelessness and helplessness. Use of alcohol or illegal substances may be more likely to occur.

If depression is very severe, there may also be psychotic symptoms, such as hallucinations and delusions. These symptoms may focus on themes of guilt, inadequacy, or disease.

Major depression is diagnosed if a person reports having five or more depressive symptoms for at least 2 weeks. Beck's Depression Scale Inventory or other screening tests for depression can be helpful in making the diagnosis.

Before diagnosing depression, the health care provider should rule out medical conditions that can cause symptoms of depression.

Medicines that you take for other problems could cause or worsen depression. You may need to change them. DO NOT change or stop taking any of your medications without consulting your doctor.

People who are so severely depressed that they are unable to function, or who are suicidal and cannot be safely cared for in the community may need to be treated in a psychiatric hospital.

Most people benefit from antidepressant drug therapy, along with psychotherapy. As treatment takes effect, negative thinking diminishes. It takes time to feel better, but there are usually day-to-day improvements.

MEDICATIONS FOR DEPRESSION

Drugs used to treat depression are called antidepressants.

• Selective serotonin re-uptake inhibitors (SSRIs) are the most commonly used antidepressants. Names include: fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), fluvoxamine (Luvox), citalopram (Celexa), and escitalopram (Lexapro).
• Serotonin norepinephrine reuptake inhibitors (SNRIs) are also commonly used. Names include desvenlafaxine (Pristiq), venlafaxine (Effexor), and duloxetine (Cymbalta).
• Other medicines used to treat depression include: tricyclic antidepressants, bupropion (Wellbutrin), and monoamine oxidase inhibitors.
• People with psychotic symptoms, such as delusions or hallucinations, may need antipsychotic medications.

Some people with major depression may feel better after taking antidepressants for a few weeks. However, many people need to take medication for 4 - 9 months to get a full response and to prevent depression from coming back.

Some people who do not improve with routine dosages of antidepressants and talk therapy have what is called treatment-resistant depression. They are often prescribed higher (but still safe) doses of their antidepressants, or a combination of medications. Lithium and thyroid hormone supplements also may be added to help the antidepressants work better.

Women being treated for depression who are pregnant or thinking about becoming pregnant should not stop taking antidepressants without first talking to their doctors.

An over-the-counter herb called St. John's wort may help some people with mild depression only. It can change the way other medicines work in your body, including antidepressants and birth control pills. Always talk to your doctor before trying this herb.

Note: Young adults ages 18 - 24 should be watched more closely for suicidal behavior, especially during the first few months after starting medications.

See also: Bipolar disorder

TALK THERAPY

People with depression benefit from some type of talk therapy and counseling. Talk therapy is a good place to talk about feelings and thoughts, and most importantly, learn ways to deal with them.

Types of talk therapy include:

• Cognitive behavioral therapy teaches depressed people ways of fighting negative thoughts. People can learn to be more aware of their symptoms, learn what seems to make depression worse, and learn problem-solving skills.
• Psychotherapy can help someone with depression understand the issues that may be behind their behaviors, thoughts, and feelings.
• Joining a support group of people who are experiencing problems like yours can also help. Ask your therapist or doctor for a recommendation.

OTHER THERAPIES

Electroconvulsive therapy (ECT) may improve the mood of severely depressed or suicidal people who don't respond to other treatments. It may also help with depressed patients who have psychotic symptoms.

Transcranial magnetic stimulation (TMS) uses high frequency magnetic pulses that target affected areas of the brain. It is often thought to be a second-line treatment after ECT.

Use of light therapy for depressive symptoms may help in the winter months to restore a normal sleep cycle. However, by itself it is not an effective treatment for major depression.

For more information and resources, see depression support group.

The outcome with treatment is usually good, but not for everyone. Depression is a recurring problem for many people.

For people who have repeated episodes of depression, quick and ongoing treatment may be needed to prevent more severe, long-term depression. Sometimes people will need to stay on medications for long periods of time.

• Alcohol- and drug-related problems, as well as tobacco dependence are more likely in people with long-term depression
• Increased risk of problems with physical health and premature death due to medical illness
• Suicide (up to 15% of people with major depressive disorder die by suicide)

Call 911, a suicide hotline, or get safely to a nearby emergency room if you have thoughts of suicide, a suicidal plan, thoughts of harming yourself or others, or other suicide warning signs.

There are numbers you can call from anywhere in the United States, 24 hours a day, 7 days a week: 1-800-SUICIDE or 1-800-999-9999.

Call your doctor right away if:

• You hear voices that are not there.
• You have frequent crying spells with little or no provocation.
• Your depression is disrupting work, school, or family life.
• You think that your current medications are not working or are causing side effects. DO NOT change or stop any medications without consulting your doctor.
• You believe that you should cut back on drinking, a family member or friend has asked you to cut back, you feel guilty about the amount of alcohol you drink, or you drink alcohol first thing in the morning.

To better manage your depression at home:

• Take medications correctly and learn how to manage side effects.
• Learn to watch for early signs that depression is becoming worse and know how to react when it does.
• Try to exercise more, seek out other activities that bring you pleasure, and maintain good sleep habits.
• Avoid alcohol and illegal drugs. These substances can make the depression worse over time, and may also impair your judgment about suicide.
• When struggling with your depression, talk to someone you trust about how you are feeling. Try to be around people who are caring and positive.
• Try volunteering or getting involved in group activities.

Fava M, Cassano P. Mood disorders: Major depressive disorder and dysthymic disorder. In: Stern TA, Rosenbaum JF, Fava M, Biederman J, Rauch SL, eds. Massachusette General Hospital Comprehensive Clinical Psychiatry. 1st ed. Philadelphia, Pa: Mosby Elsevier; 2008:chap 29.

American Psychiatric Association. Practice guidelines for the treatment of patients with major depressive disorder. 2nd ed. September 2007. Accessed January 22, 2010.

Little A. Treatment-resistant depression. Am Fam Physician. 2009;80:167-172.

Narcolepsy is a sleep disorder that causes excessive sleepiness and frequent daytime sleep attacks.

Daytime sleep disorder; Cataplexy

Narcolepsy is a nervous system disorder, not a mental illness. Anxiety does not cause narcolepsy.

Experts believe that narcolepsy is caused by reduced amounts of a protein called hypocretin, which is made in the brain. What causes the brain to produce less of this protein is unclear.

Narcolepsy tends to run in families.

Conditions that cause insomnia, such as disrupted work schedules, can make narcolepsy worse.

The most common symptoms of narcolepsy are:

• Periods of extreme drowsiness every 3 to 4 hours during the day. You may feel a strong urge to sleep, often followed by a short nap (sleep attack).
  • These periods last for about 15 minutes each, although they can be longer.
  • They often happen after eating, but may occur while driving, talking to someone, or during other situations.
  • You wake up feeling refreshed.
• Dream-like hallucinations may occur during the stage between sleep and wakefulness. They involve seeing or hearing, and possibly other senses.
• Sleep paralysis is when you are unable to move when you first wake up. It may also happen when you first become drowsy.
• Cataplexy is a sudden loss of muscle tone while awake, resulting in the inability to move. Strong emotions, such as laughter or anger, will often bring on cataplexy.
  • Most attacks last for less than 30 seconds and can be missed.
  • Your head will suddenly fall forward, your jaw will become slack, and your knees will buckle.
  • In severe cases, a person may fall and stay paralyzed for as long as several minutes.

Not all patients have all four symptoms.

The doctor will perform a physical exam and order blood work to rule out conditions that can cause similar symptoms. Conditions that can cause excessive sleepiness include:

• Insomnia and other sleep disorders
• Restless leg syndrome
• Seizures
• Sleep apnea
• Other medical, psychiatric, or nervous system diseases

Other tests may include:

• ECG (measures the heart's electrical activity)
• EEG (brain activity measurements)
• Monitoring of breathing
• Genetic testing to look for narcolepsy gene

Tests will also include a sleep study(polysomnogram). The Multiple Sleep Latency Test (MSLT) may be used to help diagnose narcolepsy. This test measures how long it takes you to fall asleep during a daytime nap. Patients with narcolepsy fall asleep much faster than people without the condition.

There is no known cure for narcolepsy. The goal of treatment is to control symptoms.

Lifestyle adjustments and learning to cope with the emotional and other effects of the disorder may help you function better in work and social activities. This involves:

• Eating light or vegetarian meals during the day and avoiding heavy meals before important activities
• Scheduling a brief nap (10 to 15 minutes) after meals, if possible
• Planning naps to control daytime sleep and reduce the number of unplanned, sudden sleep attacks
• Informing teachers and supervisors about the condition so you are not punished for being "lazy" at school or work

You may need to take prescription medications. The stimulant drug modafinil (Provigil) is the first choice of treatment for narcolepsy. It is much less likely to be abused than other stimulants. The medicine also helps you stay awake. Other stimulants include dextroamphetamine (Dexedrine, DextroStat) and methylphenidate (Ritalin).

Antidepressant medications can help reduce episodes of cataplexy, sleep paralysis, and hallucinations. Antidepressants include:

• Selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine, paroxetine, sertraline, and venlafaxine
• Tricyclic antidepressants such as protriptyline, clomipramine, imipramine, and desipramine

Sodium oxybate (Xyrem) is prescribed to certain patients for use at night.

If you have narcolepsy, you may have driving restrictions. Restrictions vary from state to state.

Narcolepsy is a chronic, lifelong condition. It is not a deadly illness, but it may be dangerous if episodes occur during driving, operating machinery, or similar activities. Narcolepsy can usually be controlled with treatment. Treating other underlying sleep disorders can improve symptoms of narcolepsy.

• Injuries and accidents, if attacks occur during activities
• Impairment of functioning at work
• Impairment of social activities
• Side effects of medications used to treat the disorder

Call your health care provider if:

• You have symptoms of narcolepsy
• Narcolepsy does not respond to treatment, or you develop other symptoms

There is no known way to prevent narcolepsy. Treatment may reduce the number of attacks. Avoid situations that aggravate the condition if you are prone to attacks of narcolepsy.

Dauvilliers Y, Arnulf I, Mignot E. Narcolepsy with cataplexy. Lancet. 2007;369(9560):499-511.

Morgenthaler TI, Kapur VK, Brown T, Swick TJ, Alessi C, Aurora RN, et al. Practice parameters for the treatment of narcolepsy and other hypersomnias of central origin. Sleep. 2007;30(12):1705-1711.

NEC = Not Elsewhere Classified

NEC is an acronym for Not Elsewhere Classified

2007 ICD-9-CM Diagnosis Code 311 Depressive disorder not elsewhere classified