Even though more than two out of five adult women and one out of five adult men experience sexual dysfunction in their lifetime, underdiagnosis occurs frequently. To increase recognition and care, multidisciplinary teams of experts recently published diagnostic algorithms and treatment guidelines.

The recommendations emanated from the 2nd International Consultation on Sexual Medicine held in Paris from June 28 to July 1, 2003, in collaboration with major urology and sexual medicine associations. Psychiatrists were among the 200 experts from 60 countries who prepared reports on such topics as revised definitions of women's sexual dysfunction, disorders of orgasm and ejaculation in men, and epidemiology and risk factors of sexual dysfunction. Several committees' summary findings and recommendations were published recently in the International Society for Sexual and Impotence Research's inaugural issue of the Journal of Sexual Medicine. Full text of the committees' reports is in Second International Consultation on Sexual Medicine: Sexual Medicine, Sexual Dysfunctions in Men and Women (Lue et al., 2004a).

"The First [International] Consultation in 1999 was restricted to the topic of erectile dysfunction. The second consultation broadened the focus widely to include all of the male and female sexual dysfunctions. The conference was truly multidisciplinary in orientation and patient-centered in its approach to treatment," Raymond Rosen, Ph.D., a vice chair of the international meeting, told Psychiatric Times. Rosen is also associate professor of psychiatry and medicine and director of the Human Sexuality Program at the University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School.

"Sexual problems are highly prevalent in men and women, yet frequently under-recognized and under-diagnosed in clinical practice," even among clinicians who acknowledge the relevance of addressing sexual issues, reported the Clinical Evaluation and Management Strategies Committee (Hatzichristou et al., 2004).

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Dysfunctions and Prevalence

Statistics gathered by the Epidemiology/Risk Factors Committee revealed that 40% to 45% of adult women and 20% to 30% of adult men have at least one manifest sexual dysfunction (Lewis et al., 2004). These estimates are similar to those found in a U.S. study (Laumann et al., 1999). In a national probability sample of 1,749 women and 1,410 men ages 18 to 59, among individuals who were sexually active, the prevalence of sexual dysfunction was 43% for women and 31% for men.

Sexual dysfunction in women can include persistent or recurrent disorders of sexual interest/desire, disorders of subjective and genital arousal, orgasmic disorder, and pain and difficulty with attempted or completed intercourse. At the meeting, the International Definitions Committee recommended several modifications to the existing definitions of female sexual disorders (Basson et al., 2004b). The changes include a new definition of sexual desire/interest disorder, division of arousal disorders into subtypes, proposal of a new arousal disorder (persistent genital arousal disorder), and the addition of descriptors indicating contextual factors and degree of distress.

Rosemary Basson, M.D., vice chair of the international meeting and clinical professor in the departments of psychiatry and obstetrics and gynecology at the University of British Columbia, told PT that the revised definitions have been published in the Journal of Psychosomatic Obstetrics and Gynecology (Basson et al., 2003) and are in press in the Journal of Menopause.

Some of the revised definitions are "based on theoretical constructs that we have yet to prove," Anita Clayton, M.D., told PT. Clayton is David C. Wilson professor of psychiatric medicine at the University of Virginia and was a participant in the Clinical Evaluation and Management Strategies Committee. "We need to study these in order to see if they are really going to help us better define sexual dysfunction in women, and therefore be better able to help women seeking treatment."

At the B.C. Centre for Sexual Medicine in Vancouver, which is directed by Basson, some clinicians are diagnosing sexual dysfunction in women using both the revised definitions and the DSM-IV diagnostic criteria for female sexual arousal disorder, hypoactive sexual desire disorder and female orgasmic disorder to help determine which definitions are of benefit in guiding further research and therapy.

For women, the prevalence of manifest low levels of sexual interest varies with age (Lewis et al., 2004). Approximately 10% of women up to age 49 have a low level of desire, but the percentage climbs to 47% among 66- to 74-year-olds. Manifest lubrication disability is prevalent in 8% to 15% of women, although three studies reported prevalence of 21% to 28% in sexually active women. Manifest orgasmic dysfunction is prevalent in one-fourth of women ages 18 to 74, based on studies in the United States, Australia, England and Sweden. Vaginismus is prevalent in 6% of women, as reported in studies of two widely divergent cultures: Morocco and Sweden. The prevalence of manifest dyspareunia, according to different studies, ranges from 2% in elderly women to 20% in adult women generally (Lewis et al., 2004).

Disorders of sexual function in men include erectile dysfunction (ED), orgasm/ejaculation disorders, priapism and Peyronie's disease (Lue et al., 2004b). The prevalence of ED increases with age. In men age 40 and younger, the prevalence of ED is 1% to 9% (Lewis et al., 2004). The prevalence climbs to 20% to 40% in most men ages 60 to 69 and is 50% to 75% in men in their 70s and 80s. Prevalence rates for ejaculatory disturbances range from 9% to 31%.

Comprehensive Assessments

Evaluation and treatment of sexual dysfunction problems in men and women need to include patient-physician dialogue, history taking (sexual, medical and psychosocial), focused physical examination, specific laboratory tests (as needed), specialist consultation and referral (as needed), shared decision making and treatment planning, and follow-up (Hatzichristou et al., 2004).

They warned, "Careful attention should always be paid to the presence of significant comorbidities or underlying etiologies." Potential etiologies for sexual dysfunction include a wide range of organic/medical factors, such as cardiovascular disease, hyperlipidemia, diabetes, and hypogonadism and/or psychiatric disorders, such as anxiety and depression. Additionally, organic and psychogenic factors may coexist. In some disorders, such as ED, diagnostic tests and procedures can be used to separate organically based cases from psychogenic cases. Medications that can cause problems in sexual functioning include antidepressants, conventional antipsychotics, benzodiazepines, antihypertensive drugs and even some medications for treating stomach acid and ulcers, Clayton noted to PT.

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When treating patients with psychiatric disorders, Clayton said clinicians should also consider the presence of sexual dysfunction.

"If you look at depression, the most common complaint is a diminished libido associated with other symptoms of depression," she said. "Sometimes people have arousal problems as well. Orgasmic dysfunction with depression is usually related to the medications, not to the condition itself."

Among patients with psychotic disorders, men in particular may experience significant sexual dysfunction, according to Clayton. They are less likely than women with psychotic conditions to be involved in sexual activity with another person, and they have problems throughout the phases of the sexual response cycle.

Individuals with anxiety disorders can have problems with arousal and orgasm, Clayton said. "If you don't get arousal, it is hard to have an orgasm. And then as a result, you start to see decreased desire--mostly avoidance, performance anxiety or concerns that it is not going to work right," she added.

Patients with substance use disorders, such as alcoholism, may also experience sexual dysfunction.

Psychosocial assessments should be an integral part of patient evaluations, several committees emphasized. For example, Hatzichristou et al. (2004) wrote:

The physician should carefully assess past and present partner relationships. Sexual dysfunction may affect the patient's self-esteem and coping ability, as well as his or her social relationships and occupational performance.

They added "the physician should not assume that every patient is involved in a monogamous, heterosexual relationship."

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More in-depth guidance on the psychosocial assessment was provided by the Committee on Sexual Dysfunctions in Men (Lue et al., 2004b). They presented a new screening tool for male sexual function (Male Scale) that includes psychosocial and sexual function assessments as well as a medical assessment. The psychosocial assessment asks the male patient, for example, whether he has sexual fears or inhibitions; problems finding partners; uncertainty about his sexual identity; a history of emotional or sexual abuse; significant relationship problems with family members; occupational and social stresses; and a history of depression, anxiety or emotional problems. Another critical aspect of assessment "is the identification of patient needs, expectations, priorities and treatment preferences, which may be significantly influenced by cultural, social, ethnic and religious perspectives" (Lue et al., 2004b).

The Committee on Sexual Dysfunctions in Women emphasized that assessment of psychosocial and psychosexual history is strongly recommended for all sexual dysfunctions (Basson et al., 2004a). The psychosocial history needs to establish the woman's current mood and mental health; identify the nature and duration of her current relationships, as well as societal values and beliefs impacting sexual problems; clarify the woman's developmental history as it relates to caregivers, siblings, traumas and losses; clarify circumstances, including relationship at the time of the onset of sexual problems; clarify the woman's personality factors; and clarify her partner's mood and mental health.

For women who disclose a history of past sexual abuse, further assessment was recommended (Basson et al., 2004a):

This includes assessment of the woman's recovery from the abuse (with or without past therapy), whether she has a history of recurrent depression, substance abuse, self-harm or promiscuity, if she is unable to trust people, especially those of the same gender as the perpetrator, or if she has an exaggerated need for control or need to please (and an inability to say no). The details of the abuse may be needed, especially if they were previously unaddressed. Assessment of the sexual dysfunctions per se may be deferred temporarily.

Sexual dysfunctions are often comorbid (e.g., sexual interest/desire disorder and subjective or combined sexual arousal disorder) (Bason et al., 2004a):

Occasionally women with emotionally traumatic pasts reveal that their sexual interest occurs only when emotional closeness with a partner is absent. In such cases, there is inability to sustain that interest when and if emotional intimacy with the partner develops. This is a fear of intimacy and is not strictly a sexual dysfunction.

With regard to sexual functioning, Clayton told PT the Clinical Evaluation and Management Strategies Committee looked at various instruments to assess the current level of sexual functioning. Several were found to be comprehensive and useful, including the Changes in Sexual Functioning Questionnaire (CSFQ) developed at the University of Virginia, the Derogatis Interview for sexual functioning (DISF-SR), the Female Sexual Function Index (FSFI), the Golombok-Rust Inventory of Sexual Satisfaction (GRISS), the International Index of Erectile Function (IIEF) and the Sexual Function Questionnaire (SFQ). The sexual function instruments can be used not only at the beginning stages of assessment but to follow patients through the course of treatment.

Treatment Considerations

After patients receive a comprehensive evaluation, patients (and their partners where possible) should be given a detailed description of available medical and nonmedical treatment options (Hatzichristou et al., 2004).

Rosen noted that treatment is the most advanced in the area of ED. "We have three approved drugs: , and tadalafil (Cialis) as first-line treatment agents, along with couple's or individual therapy for treatment of ED," he told PT. "Effective and safe treatments are lacking for most sexual dysfunctions in women."

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For psychological management of low sexual interest and comorbid arousal disorders in women, cognitive-behavioral techniques (CBT), traditional sex therapy and psychodynamic treatments are used (Basson et al., 2004a). There is limited evidence of the benefits of CBT in terms of controlled trials and some empirical support for traditional sex therapy with sensate focus. Psychodynamic treatment is currently recommended, but there are no randomized studies to support its use. For vaginismus, conventional psychotherapy has included psychoeducation and CBT. Cognitive-behavioral therapy is also used for treating anorgasmia, according to the Disorders of Orgasm in Women Committee (Meston et al., 2004):

Cognitive-behavioral therapy for anorgasmia focuses on promoting changes in attitudes and sexually-relevant thoughts, decreasing anxiety, and increasing orgasmic ability and satisfaction. Behavioral exercises traditionally prescribed to induce these changes include directed masturbation, sensate focus, and systematic desensitization. Sex education, communication skills training, and Kegel exercises are also often included.

For patients with ED, oral therapies, such as selective phosphodiesterase type 5 (PDE5) inhibitors (e.g., sildenafil citrate (Viagra), vardenafil (Levitra) and tadalafil (Cialis)); apomorphine SL (sublingual), a centrally acting nonselective dopamine agonist registered in several countries since 2002; and yohimbine, a peripherally and centrally acting α-blocker, "may be considered first-line therapies for the majority of patients with ED because of potential benefits and lack of invasiveness" (Lue et al., 2004b). It should be noted, however, that PDE5 inhibitors are contraindicated in patients receiving organic nitrates and nitrate donors.

For treatment of premature ejaculation, there are three drug treatment strategies: daily treatment with serotonergic antidepressants; as-needed treatment with antidepressants; and the use of topical local anesthetics, such as lignocaine or prilocaine (McMahon et al., 2004). A meta-analysis of daily treatment with paroxetine (Paxil), clomipramine (Anafranil), sertraline (Zoloft) and fluoxetine (Prozac) found that paroxetine exerts the strongest ejaculation delay (Kara et al., 1996, as cited in McMahon et al., 2004). (See related article on premature ejaculation on p16 of the printed version of this issue--Ed.)

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Administration of an antidepressant as needed four to six hours prior to intercourse is efficacious and well tolerated and associated with less ejaculatory delay. It is "unlikely that phosphodiesterase inhibitors have a significant role in the treatment of PE with the exception of men with acquired PE secondary to comorbid ED" (McMahon et al., 2004).

Clayton noted that the biggest sexual problem that women in the general population tend to have is low desire, adding that studies are underway to look for potential pharmacologic treatments.

There are no approved non-hormonal pharmacologic therapies for women with low sexual interest and arousal disorders (Basson et al., 2004a). These authors noted that the use of tibolone for postmenopausal women is promising, but the women in those two randomized clinical trials did not have sexual dysfunction. Tibolone is a steroid compound marketed in the United Kingdom; it combines oestrogenic, progestogenic and androgenic properties that mimic the action of the sex hormones. The use of bupropion (Wellbutrin) is of interest but needs further study (Basson et al., 2004a). The use of phosphodiesterase inhibitors is not recommended for low interest and comorbid arousal disorders in women. (Recently, Pfizer, Inc. reported that several large-scale, placebo-controlled studies including some 3,000 women with female sexual arousal disorder showed inconclusive results in the efficacy of sildenafil--Ed.)

While estrogen therapy may improve low interest and/or arousal disorders, low doses and the use of progesterogen to oppose estrogen's adverse effects are recommended in all women with an intact uterus (Basson et al., 2004a). More research is needed on the use of testosterone therapy.

In women with genital arousal disorder, the use of local estrogen therapy for sexual symptoms resulting from vulvovaginal atrophy is recommended. These include not only genital arousal disorder with its lack of pleasure from direct genital stimulation, vaginal dryness and dyspareunia, but also frequent urinary tract infections lowering sexual interest and arousability. However, long-term systemic estrogen therapy is not recommended because of the lack of safety versus benefit data. For genital arousal disorder unresponsive to estrogen therapy, the investigational use of phosphodiesterase inhibitors is "cautiously recommended" (Basson et al., 2004a).

For women suffering from vulvar vestibulitis syndrome, the use of tricyclic antidepressants, venlafaxine (Effexor, Effexor SR) or anticonvulsants, such as gabapentin (Neurontin), carbamazepine (Tegretol, Carbatrol) or topiramate (Topamax), was also "cautiously recommended" (Basson et al., 2004a).

In women suffering from female orgasmic disorder, data on pharmacological approaches were noted to be scarce (Meston et al., 2004):

Placebo-controlled research is needed to examine the effectiveness of agents with demonstrated success in case series or open-label trials (i.e., bupropion, granisetron [Kytril], and sildenafil) on orgasmic function in women.

Regardless of the treatment options chosen for specific sexual dysfunctions, "follow-up is essential to ensure the best treatment outcome" (Hatzichristou et al., 2004). Important aspects of follow-up include "monitoring of adverse events, assessing satisfaction or outcome associated with a given treatment, determining whether the partner may also suffer from a sexual dysfunction, and assessing overall health and psychosocial function."

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SOURCES:

Basson R, Althof S, Davis S et al. (2004a), Summary of the recommendations on sexual dysfunctions in women. Journal of Sexual Medicine 1(1):24-34.

Basson R, Leiblum S, Brotto L et al. (2003), Definitions of women's sexual dysfunction reconsidered: advocating expansion and revision. J Psychosom Obstet Gynecol 24(4):221-229.

Basson R, Leiblum S, Brotto L et al. (2004b), Revised definitions of women's sexual dysfunction. Journal of Sexual Medicine 1(1):40-48.

Hatzichristou D, Rosen RC, Broderick G et al. (2004), Clinical evaluation and management strategy for sexual dysfunction in men and women. Journal of Sexual Medicine 1(1):49-57.

Laumann EO, Paik A, Rosen RC (1999), Sexual dysfunction in the United States: prevalence and predictors. [Published erratum JAMA 281(13):1174.] JAMA 281(6):537-544 [see comment].

Lewis RW, Fugl-Meyer KS, Bosch R et al. (2004), Epidemiology/risk factors of sexual dysfunction. Journal of Sexual Medicine 1(1):35-39.

Lue TF, Basson R, Rosen R et al., eds. (2004a), Second International Consultation on Sexual Medicine: Sexual Dysfunctions in Men and Women. Paris: Health Publications.

Lue TF, Giuliano F, Montorsi F et al. (2004b), Summary of the recommendations on sexual dysfunctions in men. Journal of Sexual Medicine 1(1):6-23.

McMahon CG, Abdo C, Incrocci L et al. (2004), Disorders of orgasm and ejaculation in men. Journal of Sexual Medicine 1(1):58-65.

Meston CM, Hull E, Levin RJ, Sipski M (2004), Disorders of orgasm in women. Journal of Sexual Medicine 1(1):66-68.

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In-depth look at the major side effects of antipsychotic medications.

All medications have side effects. Different medications produce different side effects, and people differ in the amount and severity of side effects they experience. Side effects of antipsychotic medications can often be treated by changing the dose of the medication, switching to a different medication, or treating the side effect directly with an additional medication.

Common inconvenient side effects of all antipsychotic drugs used to treat schizophrenia include:

• dry mouth
• constipation
• blurred vision
• drowsiness

Some people experience sexual dysfunction or decreased sexual desire and menstrual changes.

Atypical Antipsychotics Linked to Diabetes

One of the most frequent complaints about atypical antipsychotics is that they induce significant weight gain. Because atypical antipsychotic drugs may increase the risk of obesity, diabetes, and high cholesterol, the FDA told makers of the drugs to include these risks in product labels.

Other common side effects relate to muscles and movement problems. These side effects include restlessness, stiffness, tremors, muscle spasms, and one of the most unpleasant and serious side effects, a condition called tardive dyskinesia.

• Tardive Dyskinesia is a movement disorder where there are uncontrolled facial movements and sometimes jerking or twisting movements of other body parts. This condition usually develops after several years of taking antipsychotic medications and more predominantly in older adults. Tardive dyskinesia affects 15 to 20 percent of people taking conventional antipsychotic medications. The risk of developing tardive dyskinesia is lower for people taking the newer antipsychotics. Tardive dyskinesia can be treated with additional medications or by lowering the dosage of the antipsychotic if possible. The symptoms of TD may persist even after the medication is discontinued.

• Low White Blood Cell Count (Agranulocytosis)
  Clozapine (Clozaril) was the first atypical antipsychotic in the United States and seems to be one of the most effective medications, particularly for people who have not responded well to other medications. However, in some people, it has a serious side effect of lowering the number of white blood cells produced. People taking clozapine must have their blood monitored every one or two weeks to count the number of white blood cells in the bloodstream. For this reason, clozapine is usually the last atypical antipsychotic prescribed and is usually used as a last line treatment for people that do not respond well to other medications or have frequent relapses.

• Neuroleptic Malignant Syndrome
  This is a rare, but very serious, side effect. Signs to watch for are muscle stiffness that occurs over one to three days, a high fever, and confusion. If these symptoms occur, seek medical help immediately - take your relative to the emergency room if you cannot reach his doctor.

Detailed info on atypical antipsychotic medications that help manage the positive and negative symptoms of Schizophrenia.

Medications help in relieving the symptoms of Schizophrenia, help the individual feel better, and can delay or prevent a relapse. The goal of medication therapy is to use the least amount of medication possible to manage the positive and negative symptoms of schizophrenia effectively, as well as to minimize unwanted side effects. Antipsychotic drug treatment for Schizophrenia is usually continuous, as relapse of symptoms is common when medication is discontinued.

Atypical Antipsychotic Medications

Schizophrenia is now being treated with new medications that are commonly called "atypical antipsychotics." These drugs have less severe side effects than the former generation of drugs used to treat this debilitating disease.

Antipsychotics or neuroleptic drugs (as they're sometimes called) help relieve the positive symptoms of schizophrenia by helping to correct an imbalance in the chemicals that enable brain cells to communicate with each other. As with drug treatments for other physical illnesses, many patients with severe mental illnesses may need to try several different antipsychotic medications before they find the one, or the combination of medications, that works best for them.

Conventional Antipsychotics

Conventional antipsychotics were introduced in the 1950s and all had similar ability to relieve the positive symptoms of schizophrenia. Most of these older "conventional" antipsychotics differed in the side effects they produced. These conventional antipsychotics include chlorpromazine (Thorazine), fluphenazine (Prolixin), haloperidol (Haldol), thiothixene (Navane), trifluoperazine (Stelazine), perphenazine (Trilafon), and thioridazine (Mellaril).

In the last decade, new "atypical" antipsychotics have been introduced. Compared to the older "conventional" antipsychotics these medications appear to be equally effective for helping reduce the positive symptoms like hallucinations and delusions - but may be better than the older medications at relieving the negative symptoms of the illness, such as withdrawal, thinking problems, and lack of energy. The atypical antipsychotics include aripiprazole (Abilify), risperidone (Risperdal), clozapine (Clozaril), olanzapine (Zyprexa), quetiapine (Seroquel), and ziprasidone (Geodon).

Current treatment guidelines recommend using one of the atypical antipsychotics other than clozapine as a first-line treatment option for newly diagnosed patients. However, for people already taking a conventional antipsychotic medication that is working well, a change to an atypical may not be the best option. People thinking of changing their medication should always consult with their doctor and work together to develop the safest and most effective treatment plan possible.

Antipsychotic medications help reduce symptoms of psychotic illness like schizophrenia and schizoaffective disorder.

A person who is psychotic is out of touch with reality. People with psychosis may hear "voices" or have strange and illogical ideas (for example, thinking that others can hear their thoughts, or are trying to harm them, or that they are the President of the United States or some other famous person). They may get excited or angry for no apparent reason, or spend a lot of time by themselves, or in bed, sleeping during the day and staying awake at night. The person may neglect appearance, not bathing or changing clothes, and may be hard to talk to--barely talking or saying things that make no sense. They often are initially unaware that their condition is an illness.

These kinds of behaviors are symptoms of a psychotic illness such as schizophrenia or schizoaffective disorder. Antipsychotic medications act against these symptoms. These medications cannot "cure" the illness, but they can take away many of the symptoms or make them milder. In some cases, they can shorten the course of an episode of the illness as well.

There are a number of antipsychotic (neuroleptic) medications available. These medications affect neurotransmitters that allow communication between nerve cells. One such neurotransmitter, dopamine, is thought to be relevant to schizophrenia symptoms. All these medications have been shown to be effective for schizophrenia. The main differences are in the potency--that is, the dosage (amount) prescribed to produce therapeutic effects-and the side effects. Some people might think that the higher the dose of medication prescribed, the more serious the illness; but this is not always true.

Older Conventional Antipsychotics

The first antipsychotic medications were introduced in the 1950s. Antipsychotic medications have helped many patients with psychosis lead a more normal and fulfilling life by alleviating such symptoms as hallucinations, both visual and auditory, and paranoid thoughts. However, the early antipsychotic medications often have unpleasant side effects, such as muscle stiffness, tremor, and abnormal movements, leading researchers to continue their search for better drugs.

Researchers are learning more and more about how the schizophrenia brain works. With this information, better medicines with fewer side effects can be developed so that people with schizophrenia can live without being limited by their illness.

Atypical Antipsychotics More Effective-Fewer Side Effects

The 1990s saw the development of several new drugs for schizophrenia, called atypical antipsychotics. Because they have fewer side effects than the older drugs, today they are often used as a first-line treatment.

The first atypical antipsychotic, clozapine (Clozaril), was introduced in the United States in 1990. In clinical trials, this medication was found to be more effective than conventional or "typical" antipsychotic medications in individuals with treatment-resistant schizophrenia (schizophrenia that has not responded to other drugs), and the risk of tardive dyskinesia (a movement disorder) was lower. However, because of the potential side effect of a serious blood disorder--agranulocytosis (loss of the white blood cells that fight infection)-patients who are on clozapine must have a blood test every 1 or 2 weeks. The inconvenience and cost of blood tests and the medication itself have made maintenance on clozapine difficult for many people. Clozapine, however, continues to be the drug of choice for treatment-resistant schizophrenia patients and Clozaril is the only FDA-approved- antipsychotic for preventing suicidal actions and thoughts in schizophrenia.

Several other atypical antipsychotics have been developed since clozapine was introduced. They are risperidone (Risperdal), aripiprazole (Abilify), olanzapine (Zyprexa), quetiapine (Seroquel), and ziprasidone (Geodon). Each has a unique side effect profile, but in general, these medications are better tolerated than the earlier drugs. Click on the links above to each drug for more information about side effects.

All these medications have their place in the treatment of schizophrenia, and doctors will choose among them. They will consider the person's symptoms, age, weight, and personal and family medication history.

Dosages and Side Effects of Antipsychotic Medications

Some drugs are very potent and the doctor may prescribe a low dose. Other drugs are not as potent and a higher dose may be prescribed.

Unlike some prescription drugs, which must be taken several times during the day, some antipsychotic medications can be taken just once a day. In order to reduce daytime side effects such as sleepiness, some medications can be taken at bedtime. Some antipsychotic medications are available in "depot" forms that can be injected once or twice a month.

Most side effects of antipsychotic medications are mild. Many common ones lessen or disappear after the first few weeks of treatment. These include drowsiness, rapid heartbeat, and dizziness when changing position.

FDA Warning: Antipsychotic Use Can Lead to Diabetes

Some people gain weight while taking antipsychotic medications and need to pay extra attention to diet and exercise to control their weight. The FDA has warned that patients taking antipsychotics risk hyperglycemia and diabetes. The relationship between atypical antipsychotic use and glucose abnormalities is complicated by the possibility of an increased background risk of diabetes mellitus in patients with schizophrenia and the increasing incidence of diabetes mellitus in the general population. Given that, the relationship between atypical antipsychotic use and hyperglycemia-related adverse events is not completely understood.

Other side effects may include a decrease in sexual ability or interest, problems with menstrual periods, sunburn, or skin rashes. If a side effect occurs, the doctor should be told. He or she may prescribe a different medication, change the dosage or schedule, or prescribe an additional medication to control the side effects.

Just as people vary in their responses to antipsychotic medications, they also vary in how quickly they improve. Some symptoms may diminish in days; others take weeks or months. Many people see substantial improvement by the sixth week of treatment. If there is no improvement, the doctor may try a different type of medication. The doctor cannot tell beforehand which medication will work for a person. Sometimes a person must try several medications before finding one that works.

If a person is feeling better or even completely well, the medication should not be stopped without talking to the doctor. It may be necessary to stay on the medication to continue feeling well. If, after consultation with the doctor, the decision is made to discontinue the medication, it is important to continue to see the doctor while tapering off medication. Many people with bipolar disorder, for instance, require antipsychotic medication only for a limited time during a manic episode until mood-stabilizing medication takes effect. On the other hand, some people may need to take antipsychotic medication for an extended period of time. These people usually have chronic (long-term, continuous) schizophrenic disorders, or have a history of repeated schizophrenic episodes, and are likely to become ill again. Also, in some cases a person who has experienced one or two severe episodes may need medication indefinitely. In these cases, medication may be continued in as low a dosage as possible to maintain control of symptoms. This approach, called maintenance treatment, prevents relapse in many people and removes or reduces symptoms for others.

Multiple medications. Antipsychotic medications can produce unwanted effects when taken with other medications. Therefore, the doctor should be told about all medicines being taken, including over-the-counter medications and vitamin, mineral, and herbal supplements, and the extent of alcohol use. Some antipsychotic medications interfere with antihypertensive medications (taken for high blood pressure), anticonvulsants (taken for epilepsy), and medications used for Parkinson's disease. Other antipsychotics add to the effect of alcohol and other central nervous system depressants such as antihistamines, antidepressants, barbiturates, some sleeping and pain medications, and narcotics.

Other effects. Long-term treatment of schizophrenia with one of the older, or "conventional," antipsychotics may cause a person to develop tardive dyskinesia (TD). Tardive dyskinesia is a condition characterized by involuntary movements, most often around the mouth. It may range from mild to severe. In some people, it cannot be reversed, while others recover partially or completely. Tardive dyskinesia is sometimes seen in people with schizophrenia who have never been treated with an antipsychotic medication; this is called "spontaneous dyskinesia." However, it is most often seen after long-term treatment with older antipsychotic medications. The risk has been reduced with the newer "atypical" medications. There is a higher incidence in women, and the risk rises with age. The possible risks of long-term treatment with an antipsychotic medication must be weighed against the benefits in each case. The risk for TD is 5 percent per year with older medications; it is less with the newer medications.

Source: NIMH

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Discussion on the needs of children who have parents with a mental illness. What is that like and what can be done to help children, even adult children, who have a parent with a mental illness?

Tina Kotulski, author of the Schizophrenia book: Saving Millie; A Daughter's Story of Surviving her Mother's Schizophrenia is our guest. She says children of parents with psychiatric disabilities are all too often ignored in every area of health care.

Natalie: is the HealthyPlace.com moderator

The people in blue are audience members

Natalie: Good evening. I'm Natalie, your moderator for tonight's Schizophrenia chat conference. I want to welcome everyone to the HealthyPlace.com website.

Tonight's conference topic is "Surviving A Family Member's Mental Illness." Our guest is Tina Kotulski. Tina's mother has schizophrenia. She went undiagnosed for 20-years; which made for a very difficult life for Tina.

Good Evening, Tina, and thank you for joining us tonight.

Tina Kotulski: Thank you for having me.

Natalie: Tonight, we're addressing the needs of children who have parents with a mental illness. We're going to discuss what that's like and what can be done to help children, and even adult children, who have a parent with a mental illness.

Your mother has schizophrenia. She went undiagnosed for 20 years. You say: "Mental illness, like any affliction, is a burden not only to those with a diagnosis, but family, friends, daughters and sons, husbands and wives, and medical professionals." I'd like you to elaborate on that.

Tina Kotulski: Being diagnosed with a mental illness is just the beginning. Regardless of how long a family member has been displaying symptoms, finding the appropriate treatments and physicians that are knowledgeable on drug interactions is a real struggle. As a family member, we know our mentally ill family member's baseline status. We know when things are starting to not go right for them. Yet, when we try to intervene and try to communicate that, to either the mentally ill relative, or to a mental health professional, we are not listened to until there is a crisis. Our system is set up to deal with a crisis, not preventative measures that save money, hardship, lives and time for all involved. That includes the mental health system, itself, that spends more money on crisis. Therefore, mental illness is a burden to all of society, not just the person who is diagnosed with the illness.

Natalie: Your mother has paranoid schizophrenia -- probably one of the most serious of all psychiatric disorders. How old were you when you began to realize something was wrong with your mother and what year was this?

Tina Kotulski: A person learns what they live and it was not until I was removed from my mother's care when I was thirteen, that I really understood that my mother was not well. Living with my mother when my sister and I were younger, I was left to straddle two worlds. One world was surviving in my mother's world; psychosis, paranoia and, at times, sweet and compassionate. The other was my sister's world. She preferred to avoid my mother, whereas I tried to control my environment, so I could get my needs met.

It was not until I went through my own therapy, after being removed from my mother's care, that I learned that straddling both of these worlds in order to survive was harmful to my very existence. There had been no consistency, structure or nurturing. That always quickly changed with my mother's moods. My identity was based on my successes and failures at trying to care for my mother and keeping her in a mindset that was healthy and nurturing for me and my sister. Essentially, I was the caregiver.

Natalie: What was life like for you during this time? Your relationship with your parents, sister? Did you have friends? How were things going for you in school? Do you remember how you felt about yourself; your self-image?

Tina Kotulski: Lonely, isolated, sad.

Natalie: That is a very tough existence! especially for a child....a teenager. Was your father was home at that time? If so, did he try and help?

Tina Kotulski: My father moved out when I was six months old. Occasionally I went to visit, often at Christmas time and once during the summer. But their environment was restrictive and unfriendly in its own way. My sister preferred to visit my father more often, but I was confused by their relationship. My father witnessed abuse and walked away from it to save himself, yet he left my sister and me in that environment he escaped from. I felt uncomfortable to be around someone who didn't try to, or at least, didn't appear to want to be around me except for brief visits once or twice a year. I felt out of place, as if I was a trouble or bother to him.

Natalie: Your father left home. Do you know what motivated him to do that - knowing full well that your mother was not fit to raise children alone?

Tina Kotulski: In an interview, my father said very clearly that he left to save himself. He started a new family and from my take on things, how I saw it and understand it according to his interview and what I witnessed growing up, is that he was truly ashamed that he ever was involved with a woman that was mentally unstable. He didn't count on having to deal with the added stress of having to care for a mentally ill woman, on top of a new daughter and unfinished dreams. My father's interview, that was heavily edited for the film, Out of the Shadow, is much more brazen than what I have expressed.

Natalie: Then, at age 12, your sister left to live with your father's new family. So you're home alone with your mother. You were physically and emotionally abused by her. So that our audience members have an understanding of what that part of your life was like, can you please provide us with a few details?

Tina Kotulski: Life with my mother, Millie, wasn't always bad. There were times when I enjoyed being with her and my sister. However, times like that were hard because I always knew they would end and most times they would end abruptly. But I still relished those times and held on to the notion that my mother would someday be the mother that I always dreamt of. When my sister left, however, Millie became more withdrawn and her paranoia became very frightening for me. So I spent more time away by simply riding my bike around town and getting into trouble. I describe those lonely days in my book.

Natalie: I want to flash forward to today. As an adult looking back on that period, do you wish you would have left home as your sister did?

Tina Kotulski: I don't have an answer that would satisfy even myself. Because my father was deeply ashamed of his past relationship with my mother, I felt as if he were ashamed of me as well. What he said about my mother, to me, growing up when I visited him made me feel as if I was entering a world that was less friendly than what I lived in with Millie. I was put in the middle of how he felt about my mother and wanting deeply to be accepted and loved unconditionally. I felt as if I had to choose sides when I visited him and it became worse when I had to live with him. I didn't want to abandon my mother to win my father's approval.

Natalie: How did living through this period of time as a child impact you as an adult?

Tina Kotulski: It's made me an advocate not only for myself, my family and others who grow up in the shadow of mental illness but it has made me believe that good things can come from bad experiences. I don't let my past dictate my future, but I do allow my past experiences to guide me in the mission of Extraordinary Voices Press. Children of parents with psychiatric disabilities are all too often ignored in every area of health care. Extraordinary Voices Press is working on changing that so policies can be enacted to protect the children and family.

Natalie: You have been married for 19 years. You have 3 children. I know that you are very involved with consumer mental health groups. In another interview you did, you said "The psychologists and psychiatrists that treat children who have been severely physically and mentally abused often put studies out saying that many of us would be incapable of having children and not repeating that abuse and having a successful relationship with a spouse. It was my dream to dispel that myth." Do you think it's a myth in general or for you specifically?

Tina Kotulski: I believe it is a myth that undermines the ability of persons to overcome situations when the odds are not in their favor. When a medical professional sees a parent with diabetes in the office, that medical professional will most likely go over nutrition and the genetic factors that their children are predisposed to and counsel the parent on ways to avoid diabetes in their children. Proper nutrition, adequate exercise, etc.

When a parent with a mental illness comes into the mental health office or even a medical office, what counseling is given to the extended family members about prevention? None! Instead, behaviors that undermine our ability to overcome our predetermined genetic disposition are not even mentioned. We are handed more prescriptions and complementary family involvement is never even considered. Instead, crisis management is what comes into play. And when the system looks at crisis management and the treatment of a disease instead of prevention, then families will always lose, especially the children. I'd like to see every diabetic patient ignored until his or her sugar levels are in the 800 range. Or how about every patient with heart disease ignored until they are in cardiac arrest.

When people have a medical diagnosis, there is at least some prevention. Not much, but at least it's not considered impossible, nor is it considered malpractice. If you counsel your patients on proper nutrition and exercise and you have a medical diagnosis, then it is considered a part of their treatment plan. When a person with a mental illness is diagnosed, nutrition and exercise are never even considered to be a part of the treatment plan. Why not? And what about when there is a crisis? What preventative measures are put into place when a parent needs to be hospitalized? It's the child that gets shuffled around.

Natalie: A lot of your story took place over 25 years ago. Mental illness was even more stigmatized than it is today and let me preface that by saying there's still a lot of stigma and shame attached to mental illness even today. Was there a lot of denial in your family about what was going on with your mom?

Tina Kotulski: Yes.

Natalie: Were you ashamed of her and your situation? How did you handle that?

Tina Kotulski: I wasn't ashamed of my mother. I was ashamed of who I was at that time in my life. My very self-esteem was built on caring for my mother. If my mother was happy, then I felt good about myself. If my mother was not doing well, then I thought I was to blame for my mother's condition. So to survive in that type of situation, my needs came last. I did what I had to do to survive and I suppressed my needs for love and nurturing by doing what I could to stay alive. My basic needs came first and I was overjoyed and took in like a sponge when I was given warmth and tenderness; love.

Natalie: I think that's a very important point you make and hopefully parents in the audience tonight will remember that children feel a very heavy burden and responsibility for trying to "make their parents happy." As you said, your very happiness was tied into that.

What was your mom's experience with the mental health system? Was she getting the treatment she needed? Did it improve over the years? How is she today?

Tina Kotulski: My mother didn't get involved with the mental health system until I had moved out. No, she wasn't getting the treatment she needed because it was so inconsistent from county-to-county. Today is a different story. She is involved with the mental health system, but on a very limited basis. And for now, she is doing very well.

Natalie: How do you view your mother today?

Tina Kotulski: She's a wonderful grandparent. She's self-sufficient provided she is in an environment that she can thrive in. She can't live on her own, but she has her own space in our home. We take one day at a time.

Natalie: There are a lot of people in the audience tonight who face similar situations in dealing with a family member who has a mental illness. What suggestions do you have regarding caring for a family member? And what about taking care of yourself?

Tina Kotulski: Always care for yourself first. Stress can lead to poor health. So take time for yourself and try to enjoy the small things.

Natalie: And finally, your suggestions when there's a child in the home? Are there any special considerations that need to be taken into account?

Tina Kotulski: Keep all medications out of children's reach. And remember that children sometimes are placed in vulnerable situations as a result of a parent's mental illness. Therefore, looking after the needs of children is incredibly important, even outside of the parent who has a mental illness.

Natalie: Tina, here's the first audience question:

akamkin: I am a young woman who was diagnosed with bipolar at the age of 24. I have always struggled with the idea of having children and passing my bad genes along. If you had bipolar yourself would you have your own children after what you went through?

Tina Kotulski: I believe I would be selling myself short if I gave into the notion that I would pass the illness onto my children. Having diabetes, heart disease or other medical conditions don't stop others from having children. Having a child, no matter what your condition, is the best part of you. Only you can take that away from yourself.

Robin45: Do you think this book would be good for a parent caring for an adult child with schizoaffective disorder, in other words, visa verse?

Tina Kotulski: Absolutely. Saving Millie is about making changes within our system. I use my story to launch changes we all need to see...and are ready to see occur.

ladydairhean: I believe that my mother has severe schizophrenia. The problem I have is that I can't tell how much of her behavior is caused by the illness and how much of it is an act for attention because she's smart enough to know what she's doing.

Tina Kotulski: One of my mother's abilities as a young mother (I know better now) was that she could be very manipulative. She would play the battered woman. "Whoa is me." As a child, I fell into that trap and it backfired for me. Now as an adult, I have boundaries that she must abide by in order to remain in our home. I will not let her talk that way in front of me or my children. You have to make boundaries for yourself.

kitkat: You mentioned that children's needs are often ignored. This effects self-esteem sometimes into adulthood. What precautions do you or other people who interact with these children or adult children need to take when they open up about their lives?

Tina Kotulski: I am not a mental health provider. What I am is an adult child with a parent who has a mental illness. And when I train mental health providers or go on speaking engagements, I always say "let us have our feelings validated." We are entitled to feel every emotion you can think of. Not only do many of us not realize we lost our childhood until we are adults, but we lack the trust essential to believe we are special to other people. Our common experiences make us special. We need our own voice. That is why I started Extraordinary Voices Press.

lindabe: Have you had the experience of therapists telling you that you are codependent because you are so involved in your mother's survival? If so, how do you feel about that? I have had that experience and I didn't feel that the therapist knew what it's like.

Tina Kotulski: Yes, I have had mental health professionals tell me that and act as if I know not what is in my mother's best interest. In fact, recently that happened. I said my mother has high liver enzymes. I was told, no, she has the flu. Sure enough, my mother's liver enzymes were in the 800 range. That is toxic. She is better now.

dwm: Having grown up with a mother who had an undiagnosed mental illness, I wholeheartedly enjoyed your book, Tina. My mother now has a diagnosis but is still not receiving treatment (frankly, I think she never will). For those of us who are caring for a mentally ill parent and cannot, for whatever reason, go the route of the mental healthcare system, have you personally found any help for your mother using alternative methods (alternative/complementary health)? If so, what have you found the most effective route?

Tina Kotulski: Because my mother lives with me, I can monitor the amount of sugar she consumes. She loves sugar and it leads to health problems which lead to more medications. Also, she is on a treatment plan that Dr. Abram Hoffer wrote about in his many books, one in particular, Healing Schizophrenia by natural nutrition. He has years of research to back his treatment. I suggest you read some of his work. It's phenomenal. Also, my mother is on a low dose of an antipsychotic, but nothing like she was before she moved in with us two years ago. 

Natalie: Our time is up tonight. Thank you, Tina, for being our guest, for sharing your personal story, providing some excellent information and for answering audience questions. We appreciate you being here.

Tina Kotulski: Thank you all for listening and asking such wonderful questions.

Natalie: Thank you, everybody, for coming. I hope you found the chat interesting and helpful.

Good night everyone.

Disclaimer: We are not recommending or endorsing any of the suggestions of our guest. In fact, we strongly encourage you to talk over any therapies, remedies or suggestions with your doctor BEFORE you implement them or make any changes in your treatment.

Schizophrenia, Schizoaffective Disorder, Mood Disorders Chat Conference Transcripts

1. Surviving A Family Member's Mental Illness
   Guest: Tina Kotulski
2. Addictions and Dual Diagnosis
   Guest: Thomas Schear, Ph.D.
3. Coping With Feelings and Thoughts of Suicide
   Guest: Dr. Alan Lewis
4. Dealing with Depression Naturally
   Guest: Syd Baumel
5. Depression Medications, Bipolar Medications
   Guest: Dr. Carol Watkins
6. Depression Treatments
   Guest: Dr. Louis Cady
7. Electroconvulsive Therapy Experiences
   Guests: Sasha and Julaine
8. Food and Your Moods
   Guest: Dr. Kathleen DesMaisons
9. Living Without Depression and Manic Depression: A Guide To Maintaining Mood Stability
   Guest: Mary Ellen Copeland
10. Mood Disorders in Children
    Guest: Trudy Carlson.
11. Self-Help Stuff That Works
    Guest: Adam Khan
12. Thought Field Therapy
    Guests: Dr. Frank Patton and Phyllis
13. Treating Self-Injury
    Guest: Michelle Seliner
14. Undoing Depression
    Guest: Dr. Richard O'Connor

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Antipsychotic drugs have proven to be crucial in relieving the psychotic symptoms of schizophrenia - hallucinations, delusions, and incoherence - but are not consistent in relieving the behavioral symptoms of schizophrenia. Even when patients with schizophrenia are relatively free of psychotic symptoms, many still have extraordinary difficulty with communication, motivation, self-care, and establishing and maintaining relationships with others. Moreover, because patients with schizophrenia frequently become ill during the critical career-forming years of life (e.g., ages 18 to 35), they are less likely to complete the training required for skilled work. As a result, many with schizophrenia not only suffer thinking and emotional difficulties but lack social and work skills and experience as well.

It is with these psychological, social, and occupational problems that psychosocial treatments may help most. While psychosocial approaches have limited value for acutely psychotic patients (those who are out of touch with reality or have prominent hallucinations or delusions), they may be useful for patients with less severe symptoms or for patients whose psychotic symptoms are under control. Numerous forms of psychosocial therapy are available for people with schizophrenia, and most focus on improving the patient's social functioning - whether in the hospital or community, at home, or on the job. Some of these approaches are described here. Unfortunately, the availability of different forms of treatment varies greatly from place to place.

Rehabilitation

Broadly defined, rehabilitation includes a wide array of non-medical interventions for those with schizophrenia. Rehabilitation programs emphasize social and vocational training to help patients and former patients overcome difficulties in these areas. Programs may include vocational counseling, job training, problem-solving and money management skills, use of public transportation, and social skills training. These approaches are important for the success of the community-centered treatment of schizophrenia because they provide discharged patients with the skills necessary to lead productive lives outside the sheltered confines of a mental hospital.

Individual Psychotherapy

Individual psychotherapy for schizophrenia patients involves regularly scheduled talks between the patient and a mental health professional such as a psychiatrist, psychologist, psychiatric social worker, or nurse. The sessions may focus on current or past problems, experiences, thoughts, feelings, or relationships. By sharing experiences with a trained empathic person - talking about their world with someone outside it - individuals with schizophrenia may gradually come to understand more about themselves and their problems. They can also learn to sort out the real from the unreal and distorted. Recent studies indicate that supportive, reality-oriented, individual psychotherapy, and cognitive-behavioral approaches that teach coping and problem-solving skills can be beneficial for outpatients with schizophrenia. However, psychotherapy is not a substitute for antipsychotic medication, and it is most helpful once drug treatment first has relieved a patient's psychotic symptoms.

Family Education

Very often, patients with schizophrenia are discharged from the hospital into the care of their family; so it is important that family members learn all they can about schizophrenia and understand the difficulties and problems associated with the illness. It is also helpful for family members to learn ways to minimize the patient's chance of relapse - for example, by using different treatment adherence strategies - and to be aware of the various kinds of outpatient and family services available in the period after hospitalization. Family "psychoeducation," which includes teaching various coping strategies and problem-solving skills, may help families deal more effectively with their ill relative and may contribute to an improved outcome for the patient.

Self-Help Groups

Schizophrenia self-help groups for people and families dealing with schizophrenia are becoming increasingly common. Although not led by a professional therapist, these groups may be therapeutic because members provide continuing mutual support as well as comfort in knowing that they are not alone in the problems they face. Self-help groups may also serve other important functions. Families working together can more effectively serve as advocates for needed research and hospital and community treatment programs. Patients acting as a group rather than individually may be better able to dispel stigma and draw public attention to such abuses as discrimination against the mentally ill.

Family and peer support and advocacy groups are very active and provide useful information and assistance for patients and families of patients with schizophrenia and other mental disorders.

If unsure where to go for help, talk to someone you trust who has experience in mental health - for example, a doctor, nurse, social worker, or religious counselor. Ask their advice on where to seek treatment. If there is a university nearby, its departments of psychiatry or psychology may offer private and/or sliding-scale fee clinic treatment options. Otherwise, check the Internet or the Yellow Pages under "mental health," "health," "social services," "suicide prevention," "crisis intervention services," "hotlines," "hospitals," or "physicians" for phone numbers and addresses. In times of crisis, the emergency room doctor at a hospital may be able to provide temporary help for a mental health problem and will be able to tell you where and how to get further help.

Listed below are the types of people and places that will make a referral to or provide mental health diagnostic and treatment services.

• Family doctors
• Mental health specialists, such as psychiatrists, psychologists, social workers, or mental health counselors
• Religious leaders/counselors
• Health maintenance organizations
• Community mental health centers
• Hospital psychiatry departments and outpatient clinics
• University- or medical school-affiliated programs
• State hospital outpatient clinics
• Social service agencies
• Private clinics and facilities
• Employee assistance programs
• Local medical and/or psychiatric societies

Additional Resources for Getting Information and Assistance:

Locate Mental Health Services in Your Area: Within the Federal government, the Substance Abuse and Mental Health Services Administration (SAMHSA) offers a Services Locator for mental health and substance abuse treatment programs and resources nationwide.

Locate NIMH Clinical Trials currently seeking participants.

Locate a Veterans Administration (VA) Medical Center for a broad spectrum of healthcare services, including medical and rehabilitative, as well as readjustment counseling services after war. The Gateway to VA Healthcare also provides eligibility information, programs, and additional resources.

General Resources List

IF YOU ARE IN CRISIS AND NEED IMMEDIATE HELP

If you are thinking about harming yourself or attempting suicide, tell someone who can help right away:

• Call your doctor's office.
• Call 911 for emergency services.
• Go to the nearest hospital emergency room.
• Call the toll-free, 24-hour hotline of the National Hopeline Network at 1-800-SUICIDE (1-800-784-2433) to be connected to a trained counselor at a suicide crisis center nearest you.

Ask a family member or friend to help you make these calls or take you to the hospital.

IF YOU HAVE A FAMILY MEMBER OR FRIEND IN A CRISIS

If you have a family member or friend who is suicidal, do not leave him or her alone. Try to get the person to seek help immediately from an emergency room, physician, or mental health professional. Take seriously any comments about suicide or wishing to die. Even if you do not believe your family member or friend will actually attempt suicide, the person is clearly in distress and can benefit from your help in receiving mental health treatment.

In-depth information on suicide, suicidal thoughts.