Journal editorial suggests the newer antidepressant drugs are overprescribed

There's no doubt the newer generation of antidepressants, which include Prozac and , have revolutionized the way depression is treated.

Was that change for the better?

No, says Dr. Giovanni Fava, a professor of clinical psychology at the University of Bologna in Italy and the department of psychiatry at the State University of New York at Buffalo.

In an editorial in the current issue of the journal Psychotherapy and Psychosomatics, Fava argues that drug company propaganda, rather than need or clinical evidence, is responsible for the soaring popularity of these newer antidepressant medications.

Other doctors and, not surprisingly, the pharmaceutical industry disagree with Fava's position.

Almost 10 percent of the U.S. population suffers from depression, according to the National Institute for Mental Health, though most don't seek treatment for the condition.

During the 1990s, Fava says, doctors started prescribing antidepressants for long-term use because several studies suggested a depression relapse was likely if an antidepressant drug was discontinued.

However, in his editorial, Fava says the evidence for long-term antidepressant use really isn't clear and other research has shown the duration of treatment -- whether three months or three years -- doesn't really matter because the drugs are most effective in the acute phase of depression. He says that despite the lack of evidence, these medications were touted in journal articles, symposia and practice guidelines.

He also contends the effectiveness of these antidepressant drugs has been overemphasized, and they're no more effective than older tricyclic medications; they just have fewer side effects. And, he adds, research has shown antidepressants don't actually change the course of depression; they just speed the recovery.

Fava also says that because the drugs have fewer side effects and are more tolerable, more patients with mild depression are being put on medications they may not need.

Fava says the effects of withdrawal from these antidepressant drugs are downplayed, and non-drug options such as cognitive behavioral therapy get short shrift in research literature.

Fava does, however, believe that antidepressants have a place in treatment. For patients who need them, he advocates a careful assessment after three months of antidepressant therapy, and then tapering the drug therapy down until the patient is off the medication. At the same time, he recommends cognitive behavioral therapy, lifestyle changes and more traditional well-being therapy.

After a patient has been off antidepressants for a month, Fava advises another assessment to make sure the depressive symptoms haven't returned.

Dr. Norman Sussman, a psychiatrist at New York University Medical School who has also studied the effects of antidepressants, says Fava raises several issues in his editorial that have been debated for years. The bottom line, he says, is that antidepressants work.

"The literature indicates they're effective, and I have seen them work," Sussman says.

He adds some of the clinical trials Fava uses to make his point were more rigidly constructed than a real-life treatment plan would be. Sussman says there's always an element of trial-and-error to antidepressant therapy to find what works best with the least side effects. In clinical trials, he says, researchers can't switch medications mid-trial, but in the real world doctors can adjust the amount of medication given.

There have been several studies where some patients were switched to placebo drugs after three months of antidepressant therapy, and that patients who stayed on the drugs were less likely to relapse into depression, Sussman says.

He acknowledges the newer medications probably aren't any more effective than the older medications in most cases. "The real breakthrough was in the tolerability," he says.

Before the newer drugs were introduced, antidepressants had a lot of unpleasant side effects. Patients had to be started on a low dose, which was gradually increased over a month or two before they were getting the full dose to minimize the unpleasant side effects, Sussman says.

Sussman does agree with Fava that pharmaceutical companies only present their best data and may sometimes overstate their products' efficacy. However, he says, that doesn't change the fact that antidepressants work.

Jeff Trewhitt, the national spokesman for the Pharmaceutical Research and Manufacturers of America, says he doesn't believe drug companies are guilty of propaganda, and explains that the industry is introducing new guidelines to ensure that firms avoid any appearance of impropriety.

"In the vast majority of cases, the relationship between sales representatives and physicians is appropriate and helpful," Trewhitt says. He adds the new guidelines forbid gifts of theater or sporting event tickets, and travel to information seminars can only be reimbursed if a physician is speaking at the conference.

As to whether the newer antidepressants are being prescribed appropriately, Trewhitt says, "Based on the anecdotal evidence, it seems clear to us in the vast majority of cases that physicians are using these antidepressant medications because they are effective, and in many cases have fewer side effects than many of the older drugs."

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We all feel moments of gloom or exhilaration on occasion. But few of us truly understand how far off-key the melodies of mood can drift. Here, a leading psychiatrist eloquently recounts two real-life tales of mania and depression--and shows how these disorders are indeed moods apart from our everyday experience.

TRY FOR A MOMENT TO IMAGINE a personal world drained of emotion, a world where perspective disappears. Where strangers, friends, and lovers are all held in similar affection, where the events of the day have no obvious priority. There is no guide to deciding which task is most important, which dress to wear, what food to eat. Life is without meaning or motivation.

This colorless state of being is exactly what happens to some victims of melancholic depression, one of the most severe mood disorders. Depression--and its polar opposite, mania--are more than illnesses in the everyday sense of the term. They cannot be understood merely as an aberrant biology that has invaded the brain; for by disturbing the brain the illnesses, enter and disturb the person--the feelings, behaviors, and beliefs that uniquely identify the individual self. These afflictions invade and change the very core of our being. And the chances are overwhelming that most of us, during our lifetime, will come face to face with mania or depression, seeing them in ourselves or in somebody close to us. It's estimated that in the United States 12 to 15 percent of women and eight to 10 percent of men will struggle with a serious mood disorder during their lifetime.

While in everyday speech the words mood and emotion are often used interchangeably, it is important to distinguish them. Emotions are usually transient--they constantly respond to our thoughts, activities, and social situations throughout the day. Moods, in contrast, are consistent extensions of emotion over time, sometimes lasting for hours, days, or even months in the case of some forms of depression. Our moods color our experiences and powerfully influence the way we interact. But moods can go wrong. And when they do, they significantly alter our normal behavior, changing the way we relate to the world and even our perception of who we are.

CLAIRE'S STORY. Claire Dubois was such a victim. It was the 1970s, when I was professor of psychiatry at Dartmouth Medical School. Elliot Parker, Claire's husband, had telephoned the hospital desperately worried about his wife, who he suspected had tried to kill herself with an overdose of sleeping pills. The family lived in Montreal, but were in Maine for the Christmas holidays. I agreed to see them that afternoon.

Before me was a handsome woman approaching 50 years of age. She sat mute, eyes cast down, holding her husband's hand without apparent anxiety or even interest in what was going on. In response to my questioning she said very quietly that it was not her intention to kill herself but merely to sleep. She could not cope with daily existence. There was nothing to look forward to and she felt of no value to her family. And she could no longer concentrate sufficiently to read, which had been her greatest passion.

Claire was describing what psychiatrists call anhedonia. The word literally means "the absence of pleasure," but in its most severe form anhedonia becomes an absence of feeling, a blunting of emotion so profound that life itself loses meaning. This lack of feeling is most frequently present in melancholia, which lies on a continuum with depression, extending the illness to its most disabling and frightening form. It is a depression that has taken root and grown independent, distorting and choking the feeling of being alive.

SLIP SLIDING AWAY. In Claire's mind and in Elliot's, the whole thing began after an automobile accident the winter before. On a snowy evening, while on her way to pick up her children from choir practice, Claire's car had slid off the road and down an embankment. The injuries she sustained were miraculously few but included a concussion from her head hitting the windshield. Despite this good fortune, she began to experience headaches in the weeks following the accident. Her sleep became fragmented, and with this insomnia came increasing fatigue. Eating held little attraction. She was irritable and inattentive, even to her children. By the spring, Claire was complaining of dizzy spells. She was seen by the best specialists in Montreal, but no explanation could be found. In the words of the family doctor, Claire was "a diagnostic puzzle."

The summer months, when she was alone in Maine with her children, brought minor improvement, but with the onset of winter the disabling fatigue and insomnia returned. Claire withdrew to the world of books, turning to Virginia Woolf's novel The Wave, for which she had a particular affection. But as the shroud of melancholy fell upon her, she found sustaining her attention increasingly difficult, and a critical moment arrived when Woolf's woven prose could no longer occupy Claire's befuddled mind. Deprived of her last refuge, Claire had only one thought, drawn possibly from her identification with Woolf's own suicide: that the next chapter in Claire's life should be to fall asleep forever. This stream of thought, almost incomprehensible to those who have never experienced the dark vortex of melancholy, is what preoccupied Claire in the hours before she took the sleeping pills that brought her to my attention.

Why should sliding off an icy road have precipitated Claire into this black void of despair? Many things can trigger depression. In a sense it is the common cold of emotional life. In fact, depression can literally follow in the wake of the flu. Just about any trauma or debilitating illness, especially if it lasts a long time and limits physical activity and social interaction, increases our vulnerability to depression. But the roots of serious depression grow slowly over many years and are usually shaped by numerous separate events, which combine in a way unique to the individual. In some, a predisposing shyness is amplified and shaped by adverse circumstance, such as childhood neglect, trauma, or physical illness. In those who experience manic depression, there are also genetic factors that determine the shape and course of the mood disturbance. But even there the environment plays a major role in determining the timing and frequency of illness. So the only way to understand what kindles depression is to know the life story behind it.

THE TRIP THAT WASN'T. Claire Dubois was born in Paris. Her father was much older than her mother and died of a heart attack shortly after Claire's birth. Her mother remarried when Claire was eight, but drank heavily and was in and out of hospital with various ailments until she died in her late forties. By necessity a solitary child, Claire discovered literature at an early age. Books offered a fairy-tale adaptation to the reality of daily life. Indeed, one of her fondest memories of adolescence was of lying on the floor of her stepfather's study, sipping wine and reading Madame Bovary. The other good thing about adolescence was Paris. Within walking distance were all the bookstores and cafes an aspiring young woman of letters could desire. These few blocks of the city became Claire's personal world.

---

Just before the second World War, Claire left Paris to attend McGill University in Montreal. There, she spent the war years consuming every book she could lay her hands on, and after college she became a freelance editor. When the war ended, she returned to Paris at the invitation of a young man she had met in Canada. He proposed marriage, and Claire accepted. Her new husband offered her a sophisticated life among the city's intellectual elite, but after only 10 months he declared that he wanted a separation. Claire never fathomed the reason for his decision; she assumed he had discovered some deep flaw in her that he would not reveal. After months of turmoil she agreed to a divorce and resumed to Montreal to live with her stepsister.

Much saddened by her experience and considering herself a failure, she entered psychoanalysis and her life stabilized. Then, at age 33, Claire married Elliot Parker, a wealthy business associate of her brother-in-law's, and soon the couple had two daughters.

Claire initially valued the marriage. The sadness of her earlier years did not return, although at times she drank rather heavily. With her daughters now growing rapidly, Claire proposed that the family live in Paris for a year. She eagerly planned the year in every detail. "The children were signed up for school. I had rented houses and cars; we had paid deposits," she recalled. "Then, one month before it was to begin, Elliot came home to say that money was tight and it couldn't be done.

"I remember crying for three days. I felt angry but totally impotent. I had no allowance, no money of my own, and absolutely no flexibility." Four months later, Claire slid off the road and into the snowbank.

As Claire and Elliot and I explored her life story together, it was clear to all that the event that kindled her melancholia was not her automobile accident but the devastating disappointment of the canceled return to France. That was where her energy and emotional investment had been placed. She was grieving the loss of the dream of introducing her adolescent daughters to what she herself had loved as an adolescent: the streets and bookshops of Paris, where she had crafted a life for herself out of her lonely childhood.

Elliot Parker loved his wife, but he had not truly understood the emotional trauma of canceling the year in Paris. And it was not Claire's nature to explain how important it was to her or to request an explanation of Elliot's decision. After all, she had never received one from her first husband when he left her. The accident itself further obscured the true nature of her disability: Her restlessness and fatigue were taken as the residue of a nasty physical encounter.

THE LONG ROAD TO RECOVERY. Those bleak midwinter days marked the nadir of Claire's melancholia. Recovery required a hospital stay, which Claire welcomed, and she soon missed her daughters--a reassuring sign that the anhedonia was cracking. What she found difficult was our insistence that she follow a routine--getting out of bed, showering, eating breakfast with others. These simple things we do everyday were for Claire giant steps, comparable to walking on the moon. But a regular routine and social interaction are essential emotional exercises in any recovery program--calisthenics for the emotional brain. Toward the third week of her hospital stay, as the combination of behavioral treatment and antidepressant drugs took hold, Claire's emotional self showed signs of reawakening.

It was not difficult to imagine how her mother's whirlwind social life and repeated illnesses, plus the early death of her father, had made Claire's young life a chaotic experience, depriving her of the stable attachments from which most of us securely explore the world. She longed for intimacy and considered her isolation a mark of her unworthiness. Such patterns of thinking, common in those who suffer depression, can be shed through psychotherapy, an essential part of the recovery from any depression. Claire and I worked on reorganizing her thinking while she was still in the hospital, and we continued after she returned to Montreal. She was committed to change; each week she employed her commuting time to review the tape of our therapy session. All together, Claire and I worked intensively together for almost two years. It was not all smooth sailing. On more than one occasion, in the face of uncertainty, hopelessness returned, and sometimes Claire succumbed to the anesthetic beckoning of too much wine. But slowly she was able to put aside old patterns of behavior. While it is not the case for all, for Claire Dubois the experience of depression was ultimately one of renewal.

One reason that we do not diagnose depression earlier is that--as in Claire's case--the right questions are not asked. Unfortunately, this state of ignorance is often present as well in the lives of those who experience mania, the colorful and deadly cousin of melancholia.

STEPHAN'S TALE. "In the early stages of mania I feel good--about the world and everybody in it. There's a sense that my life will be full and exciting." Stephan Szabo, elbows on the bar, leaned closer as voices rose from the crush of people around us. We had met years earlier in medical school, and on one of my visits to London he agreed to a few beers at the Lamb and Flag, an old pub in the Covent Garden district. Despite the jostle of the evening crowd, Stephan seemed unperturbed. He was warming to his topic, one he knew well: his experience with manic depression.

"It's a very infectious thing. We all appreciate somebody who's positive and upbeat. Others respond to the energy. People I don't know very well--even people I don't know at all--seem happy around me.

"But the most extraordinary thing is how my thinking changes. Usually I think about what I'm doing with the future in mind; I'm almost a worrier. But in the early manic periods everything focuses upon the present. Suddenly I have the confidence that I can do what I had set out to do. People give me compliments about my insight, my vision. I fit the stereotype of the successful, intelligent male. It's a feeling that can last for days, sometimes weeks, and it's wonderful."

A TERRIBLE TORNADO. I felt fortunate Stephan was willing to talk openly about his experience. A Hungarian refugee, Stephan had begun his medical studies in Budapest before the Russian occupation of 1956, and in London we had studied anatomy together. He was a wry political commentator, an extraordinary chess player, an avowed optimist, and a good friend to all. Everything Stephan did was energetic and purposeful.

Then two years after graduation came his first episode of mania, and during the depression that followed he tried to hang himself. In recovery, Stephan had been quick to blame two unfortunate circumstances: He had been denied entry to the Oxford University graduate program and, worse, his father had committed suicide. Insisting that he was not ill, Stephan refused any long-term treatment and over the next decade suffered several further bouts of illness. When it came to describing mania from the inside, Stephan knew what he was talking about.

---

He lowered his voice. "As time rolls on, my head speeds up; ideas move so fast they stumble over each other. I begin to think of myself as having special insight, understanding things that others do not. I recognize now that these are warning signs. But typically, at this stage people still seem to enjoy listening to me, as if I have some special wisdom.

"Then at some point I start to believe that because I feel special, maybe I am special. I have never actually thought I was God, but a prophet, yes, that has occurred to me. Later--probably as I cross into psychosis--I sense that I am losing my own will, that others are trying to control me. It's at this stage that I first feel twinges of fear. I become suspicious; there's a vague feeling that I am the victim of some outside force. After that everything becomes a terrifying, confusing slide that is impossible to describe. It's a crescendo--a terrible tornado--that I wish never to experience again."

I asked at what point in the process he considered himself ill.

Stephan smiled. "It's a tough question to answer. I think the `illness' is there, in muted form, in some of the most successful among us--those leaders and captains of industry who sleep only four hours a night. My father was like that, and so was I in medical school. It's a feeling that you have the ability to live life fully in the present. What's different about mania is that it goes higher until it blows away your judgment. So it is not simple to determine when I go from being normal to being abnormal. Indeed, I'm not sure I know what a `normal' mood is."

EXHILARATION AND DANGER

I believe there is much truth in Stephan's musing. The experience of hypomania--of early mania--is described by many as comparable to the exhilaration of falling in love. When the extraordinary energy and self-confidence of the condition are harnessed with a natural talent--for leadership or the arts--such states can become the engine of achievement. Cromwell, Napoleon, Lincoln, and Churchill, to name a few, appear to have experienced periods of hypomania and discovered the ability to lead in times when lesser mortals failed. And many artists--Poe, Byron, Van Gogh, Schumann--had periods of hypomania in which they were extraordinarily productive. Handel, for example, is said to have written The Messiah in just three weeks, during an episode of exhilaration and inspiration.

But where early mania may be exciting, mania in full flower is confusing and dangerous, seeding violence and even self-destruction. In the United States, a suicide occurs every 20 minutes--some 30,000 people a year. Probably two-thirds are depressed at the time, and of those half will have suffered manic-depression. Indeed, it's been estimated that of every 100 people who suffer manic-depressive illness, at least 15 will eventually take their own lives--a sobering reminder that mood disorders are comparable to many other serious diseases in shortening the life span.

The crush of revelers in the Lamb and Flag had diminished. Stephan had changed little with the years. True, he had less hair, but there before me was the same nodding head, the long neck and square shoulders, the dissecting intellect. Stephan had been lucky. Over the past decade, since he had decided to accept his manic depression as an illness--something he had to control lest it control him--he had done well. Lithium Carbonate, a mood stabilizer, had smoothed his path, reducing the malignant manias to manageable form. The rest he had achieved for himself.

While we may aspire to the vivacity of early mania, at the other end of the continuum depression is still commonly considered evidence of failure and a lack of moral fiber. This will not change until we can speak openly about these illnesses and recognize them for what they are: human suffering driven by dysregulation of the emotional brain.

I reflected this to Stephan. He readily agreed. "Look at it this way," he said as we got up from the bar, "things are improving. Twenty years ago neither of us would have dreamed about meeting in a public place to discuss these things. People are interested now because they recognize that mood swings, in one form or another, touch everybody every day. Times really are changing."

I smiled to myself. Here was the Stephan I remembered. He was still in the saddle, still playing chess, and still optimistic. It was a good feeling.

THE MEANING OF MOODS

During a recent interview, I was asked what hope I could give those who suffer the "blues." "In the future," my interviewer asked, "will antidepressants eliminate sadness, just as fluoride has eradicated cavities in our teeth?" The answer is no--antidepressants are not mood elevators in those without depression--but the question is provocative for its cultural framing. In many countries, the pursuit of pleasure has become the socially accepted norm.

Behavioral evolutionists would argue that our increasing intolerance of negative moods perverts the function of emotion. Transient episodes of anxiety, sadness, or elation are part of normal experience, barometers of experience that have been essential to our successful evolution. Emotion is an instrument of social self-correction--when we are happy or sad, it has meaning. Seeking ways to blot out variation in mood is equivalent to the airline pilot ignoring his navigational devices.

Perhaps mania and melancholia endure because they have had survival value. The generative energy of hypomania, it can be argued, is good for the individual and social groups. And perhaps depression is the built-in braking system required to return the behavioral pendulum to its set point after a period of acceleration. Evolutionists have also suggested that depression helps maintain a stable social hierarchy. After the fight for dominance is over, the vanquished withdraws, no longer challenging the leader's authority. Such withdrawal provides a respite for recovery and an opportunity to consider alternatives to further bruising battles.

Thus the swings that mark mania and melancholia are musical variations upon a winning theme, variations that play easily but with a tendency to become progressively off-key. For a vulnerable few the adaptive behaviors of social engagement and withdrawal unravel under stress into mania and melancholic depression. These disorders are maladaptive for the individuals who suffer them, but their roots draw upon the same genetic reservoir that has enabled us to be successful social animals.

Several research groups are now searching for genes that increase vulnerability to manic depression or recurrent depression. Will neuroscience and genetics bring wisdom to our understanding of the disorders of mood and spur new treatments for those who suffer these painful afflictions? Or will some members of our society harness genetic insights to sharpen discrimination and drain compassion, to deprive and stigmatize? We must remain vigilant, but I am confident that humanity will prevail, for all of us have been touched by these disorders of the emotional self. Mania and melancholia are illnesses with a uniquely human face.

From A Mood Apart by Peter C. Whybrow, M.D. Copyright 1997 by Peter C. Whybrow. Reprinted by permission of BasicBooks, a division of HarperCollins Publishers, Inc.

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It's one of the most missed diagnoses in psychiatry. Bipolar disorder, involving moods that swing between the highs of mania and the lows of depression, is typically confused with everything from unipolar depression to schizophrenia to substance abuse, to borderline personality disorder, with just about all stops in between. Patients themselves often resist diagnosis, because they may not see as pathologic the surge in energy that accompanies the mania or hypomania that distinguishes the condition.

But on a few points consensus is emerging. Bipolar disorder is a chronically recurring illness. And the age of onset is dropping--in less than one generation it has gone from age 32 to 19. Whether there is a genuine increase in prevalence of the disorder is a matter of some debate, but there does seem to be a genuine increase among the young.

What's more, the depression of manic-depression is emerging as a particularly thorny problem for both patients and their doctors.

"Depression is the bane of treatment of bipolar disorder," says Robert M.A. Hirschfeld, M.D., head of psychiatry at the University of Texas Medical Branch in Galveston.

It's what is most likely to motivate patients to accept care. People spend more time in the depression phase of the disorder. And unlike unipolar depression, the depression of bipolar illness tends to be treatment-resistant.

"Antidepressants don't work very well in bipolar depression," says Dr. Hirschfeld. "They are underwhelming in their ability to treat the depression." In fact, a shift away from antidepressants is formally recognized in new treatment guidelines for bipolar disorder just released by the American Psychiatric Association.

As physicians gain experience in treating the disorder, they are discovering that antidepressants have two negative effects on the course of the disorder. Used by themselves, antidepressants can induce manic episodes. And over time they can accelerate mood cycling, increasing the frequency of episodes of depression or of mania followed by depression.

Instead, research points to the value of drugs that work as mood stabilizers for the depression of bipolar disorder, either alone or in combination with antidepressants. If antidepressants have any use at all in bipolar disorder, it may be as acute treatment for bouts of severe depression before mood stabilizers are added or substituted.

Even in cases of severe depression, the new guidelines favor increasing the dosage of mood stabilizers over other strategies.

Until recently, mood stabilizers could be summed up in a single word--lithium, in use since the 1960s to tame mania. But over the past decade research has additionally demonstrated the effectiveness of divalproex sodium (Depakote) and lamotrigine (Lamictal), drugs that were initially developed for use as anticonvulsants in seizure disorders. Divalproex sodium has been approved for use as a mood stabilizer in bipolar disorder for several years, while lamotrigine is currently undergoing clinical trials for such an application.

"Optimizing the dose of lithium or divalproex has good antidepressant effects," reports Dr. Hirschfeld. "We also now know that divalproex and lamotrigine are very good for preventing recurrence in bipolar patients." A recent study showed that lamotrigine not only delays the time to any mood events but is notably effective against the depressive lows of bipolar illness.

No one knows for sure exactly how anticonvulsants work in bipolar disorder. For that matter, the condition has been described since the time of Hippocrates, but it is still not clear what goes awry in manic-depression.

Despite the unknowns, medications for treating the disorder are proliferating. In contrast to downplaying antidepressants in the depressive phase of the disorder, clinical research is ramping up the value of antipsychotic drugs for combating the manic phase, albeit a new generation of such drugs, collectively called atypical antipsychotics. Chief among them are olanzapine (Zyprexa and risperidone (Risperdal). They are now considered a first-line approach to acute mania, and adjuncts for long-term therapy along with mood stabilizers.

In the long term, however, observes Nassir Ghaemi, M.D., assistant professor of psychiatry at Harvard and head of bipolar research at Cambridge Hospital, medication goes only so far. "Drugs are not effective enough. It may have to do with the overuse of antidepressants; they interfere with the benefits of mood stabilizers.

"Medications don't take you to the finish line." There seem to be residual symptoms of depression that don't clear. Even when patients stabilize into a normal, or euthymic, mood state, he says, some troubling signs can appear.

"Sometimes we see in euthymic patients cognitive dysfunction that we didn't expect in the past--word-finding difficulties, trouble maintaining concentration," Dr. Ghaemi explains. "Cumulative cognitive impairment seems to emerge with time. It may be related to findings of decreased size of the hippocampus, a brain structure that serves memory. We are on the verge of recognizing long-term cognitive impairment as a result of bipolar disorder."

He believes there is a role for aggressive psychotherapy for keeping patients well, for keeping everyday ups and downs from becoming full-blown episodes. At the very least, he finds, psychotherapy can help patients resolve the work and relationship problems that often outlast symptoms.

In addition, psychotherapy can help patients learn new coping styles and interpersonal habits. "Many of the ways patients deal with their illness are not relevant when they are well," explains Dr. Ghaemi.

For example, he says, many people develop the habit of staying up late as a way of coping with the manic symptoms. "What they couldn't change before because of the illness needs to be changed after treatment if, for example, it bothers a spouse. People have to learn to change. But the longer one is ill, the harder it is to become completely well, because the harder it is to change the habits of one's life."

And for young people diagnosed with bipolar illness, he considers psychotherapy essential. "The younger patients are, the less convinced they are that they have bipolar disorder," he says. "They have impaired insight. They're especially concerned about the need to take medications. They should be in psychotherapy to get educated about the illness and medication."

He also stresses the value of support groups, especially for young people. "It's another, important layer of validation."

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Anxiety in mothers during pregnancy is strongly linked to children having emotional and behavioral problems as they grow up, researchers say.

A study found that expectant mothers who reported high levels of on anxiety were generally two to three times more likely to have a child with problems.

The research is published in the British Journal of Psychiatry and looked at women who gave birth in the geographical area of Avon, England.

Maternal anxiety and depression were assessed at 32 and 18 weeks before birth, and at eight weeks, eight months, 21 months and 33 months after birth.

Researchers found there were "strong and significant links" between antenatal anxiety and children's behavioural and or emotional problems at the age of four.

They discovered that elevated levels of anxiety in late pregnancy were associated with hyperactivity and or inattention in boys, and overall behavioural and or emotional problems in both sexes.

The researchers, led by Dr Thomas O'Connor of the Institute of Psychiatry, suggest that a neuroendocrine process might be adversely affecting the infant's brain during pregnancy.

"This study shows a new and additional mode of transmission connecting maternal anxiety and children's behavioural and or emotional problems," they conclude.

They call for more research into the biological mechanisms involved and into the potential benefits of an intervention programme specifically targeted on anxiety in pregnant women.

Source: British Journal of Psychiatry, June 2002

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Examples of MAOIs

• isocarboxazid ( Marplan )
• phenelzine sulfate (Nardil)
• tranylcypromine sulfate (Parnate)

How MAOIs Work

These medications balance certain brain chemicals (neurotransmitters). When these brain chemicals are in proper balance, the symptoms of anxiety are relieved. Monoamine oxidase inhibitors do this by reducing the amount of monoamine oxidase, the substance that breaks down the neurotransmitters.

Why It Is Used

Monoamine oxidase inhibitors (MAOIs) usually are not the first medications given for anxiety because they have serious side effects when combined with certain foods and/or medications. They are usually given to people with anxiety who:

• Did not get better with other antidepressants.
• Cannot tolerate the side effects of other antidepressants.
• Have a family or personal history of successful treatment with MAOIs.
• Have unusual depression or anxiety symptoms.

When these drugs are not recommended

MAOIs are not recommended for children or teens.

How Well It Works

Current research suggests that monoamine oxidase inhibitors (MAOIs) may be less effective than other antidepressants (such as tricyclics) in treating anxiety disorders or major depressive illness.¹ However, MAOIs are still the treatment of choice in cases of anxiety or depression with unusual features, such as a heavy feeling in the arms and legs, sensitivity to rejection, and a reactive mood. MAOIs are often used as an alternative treatment for anxiety or depression that has not responded to other medications.

MAOI Side Effects

Side effects of monoamine oxidase inhibitors include:

• Difficulty getting to sleep.
• Dizziness, lightheadedness, and fainting.
• Dry mouth, blurred vision, and appetite changes.
• High blood pressure and changes in heart rate and rhythm.
• Muscle twitching and feelings of restlessness.
• Loss of sexual desire or ability.
• Weight gain.
• Negative interactions with other medications and some foods.

Considerations When Taking MAOIs

People who are taking monoamine oxidase inhibitors (MAOIs) need to avoid eating certain foods, such as some cheeses, broad beans like fava beans, pickled foods like sauerkraut, and red wine. Eating these foods can cause high blood pressure.

People who take MAOIs also need to avoid some nonprescription medications, particularly certain cold remedies and diet pills.

People who stop taking MAOIs need to wait at least 14 days before taking another antidepressant.

MAOIs can cause death if they are combined with certain foods, taken with certain medications, or taken as an overdose. Talk with your health professional about diet and medication restrictions you need to follow if you are planning to take an MAOI.

MAOIs are not recommended for children or teens.

Sources:

• Doris A, et al. (1999). Depressive illness. Lancet, 354: 1369-1375.

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Study finds similar brain changes for those taking placebo and antidepressant

The depressed brain seems able to heal itself in the short run, although antidepressants may still be the key to long-term recovery from depression.

That's the claim of a new study in which researchers took brain scans of 17 depressed men who received either a placebo or the popular antidepressant Prozac for six weeks.

Those who responded to the placebo and those who responded to the antidepressant had similar, but not identical, changes in the areas of their brains that control thinking and emotion, says lead author Dr. Helen Mayberg, who is currently a neuroscientist at the Rotman Research Institute at the Baycrest Centre for Geriatric Care in Toronto. The research was conducted at the University of Texas Health Science Center in San Antonio.

While the people taking placebo and those taking Prozac did show similarities in those two brain areas, the people taking Prozac had additional changes in other brain areas -- the brainstem, striatum and hippocampus, Mayberg says.

That difference might be critical.

The drug-triggered changes in these other brain regions may promote long-term recovery from depression and prevent a recurrence of depression, says Mayberg, who has done previous research on how different parts of the brain can work in concert to make the depressed brain better.

"So, the drug provides what may be in fact a filter, cushion or barrier that helps prevent depression relapse. Getting well is just one step. Staying well is a second step," Mayberg says.

She stresses this study in no way suggests a placebo is all that's needed to treat depression.

"That would be a terrible, terrible message. It would be the wrong message," Mayberg says.

This is the first time that positron emission tomography (PET) has been used to pinpoint and compare specific brain regions that respond to a placebo and an antidepressant. PET can detect changes in the metabolism of different parts of the brain.

"What we've looked at in the experiment is the process of getting better, and what are the brain correlates of that change," Mayberg says. "Our experiment actually identifies what needs to happen to get well."

The study included 17 depressed, hospitalized men who were given either Prozac or placebo over six weeks. Neither the patients nor the doctors knew who was getting a placebo and who was getting Prozac. Of the 15 people who completed the study, eight got better. Of those, four received the placebo and four were given Prozac.

The research was funded by the National Institutes of Mental Health and Eli Lilly and Co., the maker of Prozac -- a selective serotonin reuptake inhibitor (SSRI). Such drugs act in the brain on a chemical messenger called serotonin.

It's no surprise that some people on placebo got better, Mayberg says. The expectation of treatment and being in a hospital setting can contribute to a hopeful feeling and positive outcome in patients.

The fact that some of the placebo recipients improved indicates the brain may have some ability to heal itself of depression, Mayberg adds. Previous studies have indicated that effect is likely short-lived, she says.

There was no long-term follow-up of the people in this study. Because all the patients were put on medication after the six weeks ended, researchers don't know whether those on the placebo would have remained well following their discharge from the hospital.

The research appears in the May 2002 issue of the American Journal of Psychiatry.

"The most recent study in the American Journal of Psychiatry is not news, but rather supports a growing body of research that is finding evidence for a physical response in the brain from placebo compared to SSRIs," says a statement from Eli Lilly.

The Indianapolis-based company says it has funded more than 400 Prozac studies to increase understanding of the drug.

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Researchers examine mental health problems among minorities and the way in which mental illness affects racial and ethnic groups.

Follow-up to Surgeon General's Report on Mental Health

Words like depression and anxiety do not exist in certain American Indian languages, but the suicide rate for American Indian and Alaskan Native (AI/AN) males between the ages of 15 and 24 is two to three times higher than the national rate. The overall prevalence of mental health problems among Asian Americans and Pacific Islanders (AA/PIs) does not significantly differ from the prevalence rates for other Americans, but AA/PIs have the lowest utilization rates of mental health services among ethnic populations. Mexican Americans born outside the United States have lower prevalence rates of any lifetime disorders than Mexican Americans born in the United States, and 25% of Mexican-born immigrants show signs of mental illness or substance abuse, compared with 48% of U.S.-born Mexican Americans. Somatic symptoms are almost twice as likely to be found among African Americans than among white American populations.

There have been numerous efforts, both government- and privately-funded, to develop plans and policies to assist the mentally ill minorities in the United States. With the recent influx of immigrants to the United States from poorer countries, it is vital to address their mental health care needs.

A 2002 report from U.S. Surgeon General David Satcher, M.D., examined mental health care issues among minorities. "The cultures from which people hail affect all aspects of mental health and illness," wrote Satcher in Mental Health: Culture, Race and Ethnicity, a supplement to his 1999 Mental Health: A Report of the Surgeon General.

Culture affects the ways in which patients from a given culture communicate and manifest symptoms of mental illness, their style of coping, their family and community supports and their willingness to seek treatment, Satcher wrote. The cultures of the clinician and the service system influence diagnosis, treatment and service delivery, he added. Cultural and social influences are not the only determinants of mental illness and patterns of service use, but they do play important roles.

Two important points emerge from the supplement: there are wide disparities in the kinds of treatment available to members of ethnic minorities in the United States, and there are significant gaps in the available research about the way in which mental illness affects racial and ethnic groups.

Further, the report notes that wide differences exist within minority groups that are lumped together in statistical analyses and in many aid programs. American Indians and Alaskan Natives (AI/ANs), for example, include 561 separate tribes with some 200 languages recognized by the Bureau of Indian Affairs. Hispanic Americans come from cultures as diverse as Mexico and Cuba. Asian Americans and Pacific Islanders represent 43 separate ethnic groups from countries ranging from India to Indonesia. Fifty-three percent of African Americans live in the South and have different cultural experiences from those who live in other parts of the country. The report states:

Minorities are overrepresented among the Nation's vulnerable, high-need groups, such as homeless and incarcerated persons. These subpopulations have higher rates of mental disorders than people living in the community. Taken together, the evidence suggests that the disability burden from unmet mental health needs is disproportionately high for racial and ethnic minorities relative to whites.

The supplement consists of an overview of the collective mental health care needs of minority populations, followed by separate studies of each of four minority populations, including a historical perspective and analysis of the geographic distribution, family structure, education, income and physical health status of the group as a whole.

For example, African Americans are more likely to suffer from a broad range of physical diseases than are white Americans. Rates of heart disease, diabetes, prostate and breast cancer, infant mortality, and HIV/AIDS are all substantially greater for this group than for white Americans.

According to the report, American Indians "are five times more likely to die of alcohol-related causes than whites, but they are less likely to die from cancer and heart disease." The Pima tribe in Arizona, for example, has one of the highest rates of diabetes in the world. The incidence of end-stage renal disease, a known complication of diabetes, is higher among American Indians than for both white Americans and African Americans.

Satcher uses historical and sociocultural factors to analyze the particular mental health care needs of each minority group. Then, specific mental health care needs for both adults and children are discussed and attention is given to high-need populations and culturally-influenced syndromes within the group. Each chapter includes a discussion of the availability of care, the appropriateness of available treatments, diagnostic issues and best practices relating to the group.

Some factors relating to mental illness appear to be common to most ethnic and racial minorities. In general, according to the report, minorities "face a social and economic environment of inequality that includes greater exposure to racism, discrimination, violence and poverty. Living in poverty has the most measurable effect on the rates of mental illness. People in the lowest stratum of income...are about two to three times more likely than those in the highest stratum to have a mental disorder."

Stresses caused by racism and discrimination "place minorities at risk for mental disorders such as depression and anxiety." In addition, the report states, "The cultures of racial and ethnic minorities alter the types of mental health services they use. Cultural misunderstandings or communication problems between patients and clinicians may prevent minorities from using services and receiving appropriate care." Health care practitioners who are not attuned to racial differences may not be aware of unique physical conditions as well. For example, because of differences in their rates of drug metabolism, some AA/PIs may require lower doses of certain drugs than those prescribed for white Americans. African Americans also are found to metabolize antidepressants more slowly than white Americans and may experience serious side effects from inappropriate dosages.

---

Specific analyses for each ethnic group included a wide range of findings, including those outlined below.

African Americans

• "Safety net" providers furnish a disproportionate share of the mental health care services, but the survival of these providers is threatened by uncertain sources of financing.
• The stigma of mental illness prevents African Americans from seeking care. About 25% of African Americans are uninsured. Additionally, "many African Americans with adequate private insurance coverage are still less-inclined to use mental health services."
• Only about one African American in three who needs care receives it. African Americans are also more likely than white Americans to terminate treatment early.
• If African Americans do receive treatment, they are more likely to have sought help through primary care than through specialist services. As a result, they are frequently overrepresented in emergency departments and psychiatric hospitals.
• For certain disorders (e.g., schizophrenia and mood disorders) errors in diagnosis are made more often for African Americans than for white Americans.
• African Americans respond as well as white Americans to some behavioral treatments but were found to be less likely than white Americans to receive appropriate care for depression or anxiety.

American Indians and Alaskan Natives

• Past attempts to eradicate native culture, including forced transfers of youngsters to government-run boarding schools away from their families and homes, have been associated with negative mental health consequences. American Indians and Alaskan Natives are also the most impoverished of today's minority groups. More than one-quarter live in poverty.
• Certain DSM diagnoses, such as major depressive disorder, do not correspond directly to the categories of illness recognized by some American Indians.
• Four out of five American Indians do not live on reservations, but most of the facilities run by the government's Indian Health Service are located on reservation lands.
• One study found higher rates of posttraumatic stress disorder (PTSD) and long-term alcohol abuse among American Indian veterans of the Vietnam war than among their white American, African American or Japanese American counterparts.
• In one study, American Indian youth were found to have rates of psychiatric disorders comparable to their white American counterparts, but "for white children, poverty doubled the risk of mental disorders, whereas poverty was not associated with increased risk of mental disorders among American Indian children." American Indian youngsters were also much more likely to be found suffering from attention-deficit/hyperactivity disorder and substance abuse or substance dependence disorders.
• Twenty percent of American Indian elders who were studied in one urban clinic reported significant psychiatric symptoms.
• While many AI/ANs prefer ethnically matched providers, only about 101 AI/AN mental health care professionals are available per 100,000 members of this ethnic group, compared with 173 per 100,000 for white Americans. In 1996, only an estimated 29 psychiatrists in the United States were of AI/AN heritage.
• As many as two-thirds of AI/ANs continue to use traditional healers, sometimes in combination with mental health care providers.

Hispanic Americans

• For Hispanic Americans, per capita income is among the lowest of the minority groups covered by this supplement. Additionally, they are the least likely ethnic group to have health insurance. Their rate of uninsurance is 37%, double that of white Americans.
• About 40% of the Hispanic Americans in the 1990 census reported that they do not speak English well, but very few providers identify themselves as Hispanic or Spanish-speaking, limiting the opportunities for Hispanic American patients to match with providers who are ethnically or linguistically similar providers.
• The suicide rate for Latinos is approximately half the rate of white Americans, but a national survey of over 16,000 high school students found that Hispanic Americans of both sexes reported more suicidal ideation and suicide attempts than African Americans and white Americans.
• Many immigrants from Central American countries exhibit symptoms of PTSD. Overall, however, Latino immigrants have lower prevalence rates of mental illness than Hispanics born in the United States.

Asian Americans and Pacific Islanders

• No study has addressed the rates of mental disorders for Pacific Islander American ethnic groups, and very few studies have been done on Hmong and Filipino ethnic groups.
• When symptom scales are used, Asian Americans show an elevated level of depressive symptoms compared to white Americans, but these studies focus primarily on Chinese Americans, Japanese Americans and Southeast Asians. Additionally, relatively few studies have been conducted in the subjects' native language.
• Asian Americans have lower rates of some disorders than white Americans, but higher rates of neuresthenia. Those who are less Westernized exhibit culture-bound syndromes more frequently.
• Asian Americans and Pacific Islanders have the lowest rates of utilization of mental health services of any ethnic population. This is attributed to cultural stigmas and financial shortcomings. Overall poverty rates for AA/PIs are much higher than the national average.
• Ethnic matching of AA/PI therapists and patients results in greater utilization of mental health care services.

(For more information on ethnicity and psychiatric diagnosis, please see related story, Effects of Ethnicity on Psychiatric Diagnosis: A Developmental Perspective -- Ed.)

Source: Psychiatric Times, March 2002, Vol. XIX Issue 3

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Description of mass psychogenic illness, it's causes and how an outbreak of mass psychogenic illness can be halted.

What is mass psychogenic illness?

Mass psychogenic illness is when groups of people (such as a class in a school or workers in an office) start feeling sick at the same time even though there is no physical or environmental reason for them to be sick.

Is mass psychogenic illness common?

Mass psychogenic illness has been talked about and written about for hundreds of years, all around the world and in many different social settings. No one keeps track of these outbreaks, but they are probably a lot more common than we realize.

What causes an outbreak of mass psychogenic illness?

Many outbreaks of mass psychogenic illness start with an environmental "trigger." The environmental trigger can be a bad smell, a suspicious-looking substance or something else that makes people in a group believe they have been exposed to a germ or a poison.

When an environmental trigger makes a group of people believe they might have been exposed to something dangerous, many of them may begin to experience signs of sickness at the same time. They might experience headache, dizziness, faintness, weakness or a choking feeling. In some cases, one person gets sick and then other people in the group also start feeling sick.

How do we know an outbreak of sickness is caused by mass psychogenic illness?

The following might indicate that a group sickness is caused by mass psychogenic illness:

• Many people get sick at the same time.
• Physical exams and tests show normal results.
• Doctors can't find anything in the group's environment that would make people sick (for example, some kind of poison in the air).

The patterns of the outbreak (for example, the kinds of illnesses that are reported, the kinds of people who are affected, the way the illness spreads) might also give evidence of mass psychogenic illness.

However, if the following are true, you should see your doctor to be checked for a different reason for your health problem:

• Your illness lasts several days.
• You have a fever.
• Your muscles are twitching.
• Tears keep coming from your eyes.
• Your skin feels like it has been burned.

Why do people with mass psychogenic illness feel sick?

Think of how "stage fright" can cause nausea, shortness of breath, headache, dizziness, a racing heart, a stomachache or diarrhea. Your body can have a similar strong reaction to the stressful situations involved in mass psychogenic illness. Outbreaks of mass psychogenic illness show us how much stress and other people's feelings and behavior can effect the way we feel.

People who feel sick in an outbreak of mass psychogenic illness really believe it is possible that they have been exposed to something harmful. For example, when several cases of anthrax infection were confirmed in the United States, it was easy for people to believe it could happen to them too.

An outbreak of mass psychogenic illness is a time of anxiety and worry. During an outbreak, a lot of media coverage and the presence of ambulances or emergency workers can make you and other people feel more anxious and at risk. At such a time, if you hear about someone getting sick or if you see someone get sick, it can be enough to make you feel sick too.

Does this mean that the sickness is "all in my head"?

No, it doesn't. People who are involved in these outbreaks have real signs of sickness that are not imagined. They really do have headaches, or they really do feel dizzy. But in cases of mass psychogenic illness, these symptoms are not caused by a poison or a germ. The symptoms are caused by stress and anxiety, or by your belief that you have been exposed to something harmful.

Psychogenic illness can affect normal, healthy people. Just because you reacted this way to the threat of something dangerous does not mean there is something wrong with your mind.

How can an outbreak of mass psychogenic illness be stopped?

Most of these outbreaks stop when people get away from the place where the illness started. The signs of illness tends to go away once people are examined and doctors tell them that they do not have a dangerous illness. It is important to keep the people who feel sick away from the commotion and stress of the outbreak.

After experts check out the place where the outbreak started, they can tell people whether it is safe to go back to that place.

Source: American Academy of Family Physicians, March 2002

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John Nash's Genius Is Extraordinary. Recovering From Schizophrenia Is Anything But.

The end of "A Beautiful Mind," the Oscar-nominated movie based loosely on the life of Nobel Prize winner John Forbes Nash Jr., depicts the Princeton mathematician's emergence from the stranglehold of paranoid schizophrenia, the most feared and disabling of mental illnesses. Moviegoers who have watched the cinematic metamorphosis of actor Russell Crowe from the disheveled genius who furiously covers his office walls with delusional scribblings to the silver-haired academic perfectly at home in the rarefied company of fellow laureates in Stockholm might assume that Nash's recovery from three decades of psychosis is unique.

But mental health experts say that while Nash's life is undeniably remarkable, his gradual recovery from schizophrenia is not.

That contention is likely to surprise many people, including some psychiatrists, who continue to believe the theory, promulgated a century ago by Sigmund Freud and his contemporaries, that the serious thought and mood disorder is a relentless, degenerative illness that robs victims of social and intellectual function, invariably dooming them to a miserable life in a homeless shelter, a prison cell or, at best, a group home.

Schizophrenia Recovery Not That Unusual

Psychiatric researchers who have tracked patients after they left mental hospitals, as well as a growing number of recovered patients who have banded together to form a mental health consumer movement, contend that recovery of the kind Nash experienced is not rare.

"The stereotype everyone has of this disease is that there's no such thing as recovery," said Washington psychiatrist E. Fuller Torrey, who has written extensively about schizophrenia, an illness he has studied for decades and one that has afflicted his younger sister for nearly half a century. "The fact is that recovery is more common than people have been led to believe. . . . But I don't think any of us know for sure how many people recover." (See also: Why Schizophrenia Patients Are Difficult to Treat.)

The notion that Nash's recovery is exceptional "is very pervasive even though the facts don't support it, because that's what generations of psychiatrists have been taught," said Daniel B. Fisher, a board-certified Massachusetts psychiatrist and activist who has fully recovered from schizophrenia for which he was hospitalized three times between the ages of 25 and 30.

"Many of us who have spoken about our recovery are confronted with the statement that you couldn't have been schizophrenic, you must have been misdiagnosed," added Fisher, 58, who holds a Ph.D. in biochemistry and went to medical school after his hospitalizations.

The belief that recovery from schizophrenia occurs only occasionally is belied by at least seven studies of patients who were followed for more than 20 years after their discharge from mental hospitals in the United States, Western Europe, and Japan. In papers published between 1972 and 1995, researchers found that between 46 and 68 percent of patients had either fully recovered they had no symptoms of mental illness, took no psychiatric medication, worked and had normal relationships or were, like John Nash, significantly improved but impaired in one area of functioning.

Although the patients received a variety of treatments, researchers speculate that the improvement may reflect both an ability to manage illness that accompanies age coupled with the natural decline, beginning in the mid-forties, in the levels of brain chemicals that may be linked to schizophrenia.

"One reason nobody knows about recovery is that most folks don't tell anybody because the stigma is too great," said Frederick J. Frese III, 61, who was hospitalized 10 times for paranoid schizophrenia in his twenties and thirties.

Despite his illness, Frese, who considers himself "definitely not fully recovered but in pretty good shape," earned a doctorate in psychology and was, for 15 years, director of psychology at Western Reserve Psychiatric Hospital in Ohio, the state's largest mental hospital. Frese holds faculty appointments at Case Western Reserve University and Northern Ohio Universities College of Medicine.

He has been married for 25 years and is the father of four children as well as past president of the National Mental Health Consumers Association. These achievements are hardly consistent with the prognosis Frese was given at 27, when a psychiatrist told him he had a "degenerative brain disorder" and would probably spend the rest of his life in the state mental hospital to which he had recently been committed.

Not Everybody Recovers From Schizophrenia

No mental health expert nor any of the eight recovered schizophrenia patients interviewed for this story would suggest that recovery or even marked improvement is possible for all the 2.2 million Americans afflicted with the confounding illness that typically strikes in late adolescence or early adulthood.

Sometimes schizophrenia, which is believed to result from an elusive combination of biological and environmental factors, is simply too severe. In other cases medications have little or no effect, leaving people vulnerable to suicide, which claims more than 10 percent of those diagnosed, according to epidemiological studies.

For others, mental illness is complicated by other serious problems: substance abuse, homelessness, poverty and an increasingly dysfunctional mental health system that favors 10-minute monthly medication checks, which are covered by insurance, over more effective but time-consuming forms of support, which are not.

The improvement seen in many schizophrenia patients as they reach their fifties and sixties generally affects only the most acute psychotic symptoms such as vivid hallucinations and imaginary voices. Patients rarely revert spontaneously to the way they were before they got sick, experts say, and many in whom the disease burns out are left with the emotional flatness and extreme apathy that also characterize schizophrenia.

While a growing number of mental health workers agree that recovery occurs, there is no consensus on how to define or measure it. Academic researchers typically adhere to a strict definition of recovery as a return to normal functioning without reliance on psychiatric drugs. Others, many of them ex-patients, embrace a more elastic definition that would encompass people like Fred Frese and John Nash, who continue to have symptoms they have learned to manage.

"I'd say there's a gradation of severity of illness and a gradation of recovery," said Francine Cournos, a professor of psychiatry at Columbia University who directs a clinic in Manhattan for people with severe mental illness. "The number of people who wind up completely symptom-free and without relapse is probably small. But everyone we treat we can help."

A Bleak Prognosis

In 1972, Swiss psychiatrist Manfred Bleuler published a landmark study that appeared to refute the teachings of his eminent father, Eugen Bleuler, who in 1908 coined the term schizophrenia. The elder Bleuler, an influential colleague of Freud's, believed that schizophrenia had an inexorable downhill course, much like premature dementia.

His son, curious about the natural history of the disease, tracked down 208 patients who had been discharged from one hospital an average of 20 years earlier. Manfred Bleuler found that 20 percent were fully recovered, while another 30 percent were greatly improved. Within a few years, research teams in other countries essentially replicated his findings.

In 1987, psychologist Courtenay M. Harding, then at the Yale University School of Medicine, published a series of rigorous studies involving 269 former residents of the back wards of Vermont's only state mental hospital, where they had spent years. Widely considered to have been the sickest patients in the hospital, they had participated in a 10-year model rehabilitation program that included housing in the community, training in jobs and social skills and individualized treatment.

Two decades after they completed the program, 97 percent of the patients were interviewed by researchers. Harding, a former psychiatric nurse who expected only modest improvement, said she was stunned to discover that about 62 percent were judged by researchers to be either fully recovered they took no medication and were indistinguishable from people who had no diagnosable mental illness or functioned well but had not recovered in one area. (They took medication or heard voices.) A study comparing the Vermont patients to a matched group in Maine, a state with much more parsimonious mental health services, found that 49 percent of the Maine patients had recovered or improved significantly.

So why has the almost universally gloomy prognosis for schizophrenia persisted in the face of convincing empirical evidence to the contrary?

"Psychiatry has always clung to a narrow medical model," observed Harding, who directs Boston University's Institute for the Study of Human Resilience. "Psychiatric dictionaries still do not have a definition of recovery," but speak instead of remission, which "carries the heavy time bomb of impending illness," she observed.

Columbia's Francine Cournos, an internist as well as a psychiatrist, agrees. "A lot of research is done in academic settings, and a lot of people who get seen there are sicker," she said. "And if you're working in a state hospital, all you ever see are the sickest patients."

Psychiatrists traditionally have not made a distinction between symptoms and the ability to function, Cournos added. "It's important to remember that there is a difference between the two. We've had patients here who are very high-functioning and psychotic, including a woman who ran a very high-powered executive program but at work wouldn't write anything down. She coped by memorizing everything she had to do because it drowned out the voices."

Tale of Two Former Schizophrenia Patients

The lives of Dan Fisher and Moe Armstrong illustrate the possibilities of recovery from schizophrenia. The two men have a lot a lot in common: They are neighbors in Cambridge, Mass., they are the same age, they both work with psychiatric patients, are well-known mental health advocates and they both have been hospitalized for schizophrenia. By any measure, Fisher has recovered completely. Armstrong is the first to say he has not.

Fisher's unusual odyssey from schizophrenic to psychiatrist embodies the most optimistic vision of recovery.

For the past 28 years, Fisher said, he has taken no psychiatric medication. He has not been hospitalized since 1974, when he spent two weeks at Washington's Sibley Hospital. He has been married for 23 years, is the father of two teenagers and shuttles between a community mental health center where he has worked as a psychiatrist for 15 years and the National Empowerment Center, a nonprofit consumer organization he helped found a decade ago. A few weeks ago he attended a White House meeting on disability issues.

Fisher was first diagnosed with schizophrenia in 1969. Armed with an undergraduate degree from Princeton and a PhD in biochemistry from the University of Wisconsin, he was 25 and investigating dopamine and its role in schizophrenia at the National Institute of Mental Health when he suffered his first psychotic break.

"I put more and more energy into my work, and I literally felt that I was the chemical I was studying," said Fisher, who recalled that he was desperately unhappy and that his first marriage was unraveling. "And the more I believed my life was being run by chemicals, the more suicidal I felt." He was hospitalized briefly at Johns Hopkins Hospital, where his father was on the medical faculty, given Thorazine, a powerful antipsychotic, and soon returned to his lab.

The following year Fisher was hospitalized again, this time for four months at Bethesda Naval Hospital, across the street from his lab. A panel of five psychiatrists diagnosed him as schizophrenic and he left his job. After his discharge from Bethesda, Fisher decided that he had to make some radical changes. He jettisoned his once-promising career as a biochemist and decided, with the encouragement of his psychiatrist and his physician brother-in-law, to become a doctor so he could help people.

In 1976 Fisher graduated from George Washington University School of Medicine, then moved to Boston to complete a psychiatry residency at Harvard. He passed his board exams and began practicing at a state hospital and seeing private patients. In 1980 his career as a consumer advocate was launched when he disclosed his psychiatric history on a Boston TV talk show. A decade later he helped found the National Empowerment Center, a resource center for psychiatric patients funded by the federal Center for Mental Health Services.

"I'm sure it helped me that I came from a professional family and I was educated," Fisher said of the factors that led to his recovery. "What helped me recover was not drugs which were one tool I used it was people. I had a psychiatrist who always believed in me, and family and friends who stood by me. Changing my career and following my dream becoming a doctor was very important."

Moe Armstrong Eagle Scout, high school football star, decorated Marine has come a long way from the nomadic decade that began when he was 21, following his psychiatric discharge from the military after combat in Vietnam.

Between 1965 and 1975, Armstrong said, he lived on the streets of San Francisco, in the rugged mountains of Colombia and in his parents' house in southern Illinois, "where I wore a housecoat and told everyone I was St. Francis."

He received no treatment but developed an addiction to alcohol and drugs.

In the mid-1970s, Armstrong sought mental health treatment through the Veterans Administration. He managed to stop drinking and using drugs and moved to New Mexico, where he graduated from college, earned a master's degree and became known as a mental health consumer advocate.

In 1993 he moved to Boston and became director of consumer affairs for a nonprofit company that provides services to the mentally ill. Six years ago he met his fourth wife, who has also been diagnosed with schizophrenia; the couple lives in an apartment they bought several years ago.

For Armstrong, every day is a struggle. "I have to continually watch myself," said Armstrong, who has taken pains to arrange his life in a way that minimizes the chance of a relapse. He takes antipsychotic medication, eschews movies because they often make him feel "over-amped" and tries to be in "supportive, gentle, loving environments."

"I have many more limitations than other people, and that's very hard," Armstrong said.

"And I had to give up the notion that I would be Moe Armstrong, career soldier, which is what I wanted to be. I think I've recovered as much as I have because I'm still the guy that's the scout, looking for the way out."

Source: Washington Post

Overview of schizophrenia and atypical antipsychotics used in the treatment of schizophrenia.

From the American Academy of Family Physicians

What is schizophrenia?

Schizophrenia is a chronic, disabling illness that may be caused by abnormal amounts of certain chemicals in the brain. These chemicals are called neurotransmitters. Neurotransmitters control our thought processes and emotions. (more on schizophrenia signs, causes of schizophrenia, and schizophrenia treatment)

How do schizophrenic people think and act?

Schizophrenic people may seem different from other people. They may seem to show fewer emotions than other people. They may keep to themselves, withdrawing from social contact. At times they may seem slowed down, as if they don't have enough energy.

Schizophrenic patients may have unusual beliefs, called delusions. They may believe that others are spying on them or that they are a famous person from history. Sometimes they hear voices telling them what to do or saying things about them. Voices that others can't hear and visions others can't see are called hallucinations. A schizophrenic person's thoughts may also race through his or her mind, becoming confused and disorganized. These symptoms come and go, often occurring after stressful events.

How is schizophrenia treated?

In the past, schizophrenia has been treated with antipsychotic medicines that block the action of a brain chemical called dopamine. These medicines help control the abnormal thinking of people with schizophrenia. Unfortunately, the medicines also decrease a person's ability to show emotion and cause slowing and stiffness in the muscles. The medicines can cause other unpleasant side effects, like unusual movements of the tongue and face. This condition is called tardive dyskinesia. A dangerous syndrome, neuroleptic malignant syndrome (also called NMS) can develop in people who use these medicines. A person with NMS may have rigid muscles or a very high body temperature. He or she may even go into a coma.

What is different about the new antipsychotics?

Newer medicines (called atypical antipsychotics) for treating schizophrenia block the brain chemical called serotonin in addition to blocking dopamine. The medicines help control the abnormal thinking associated with schizophrenia. They also improve the social withdrawal and lack of emotion that make people with schizophrenia seem different even when they are not having hallucinations or delusions.

Do the newer drugs have any side effects?

Like most medicines, the newer medicines for treating schizophrenia can cause side effects. Not everyone gets these side effects. Any side effects you have will depend on which medicine your doctor has chosen for you.

While you're taking medicine to treat schizophrenia, you may need to see your doctor on a regular basis for certain tests. For example, a medicine called clozapine (brand name: Clozaril) can lower the number of white blood cells in your body. This makes it easier for you to get an infection. People taking clozapine must have their blood checked every week. Your doctor will tell you if you need to see him or her for tests.

What else should I know about these medicines?

People who take these medicines need to drink plenty of liquids. They should avoid spending too much time in the sun because they will tend to get overheated. Since these people are also more sensitive to the cold, they should dress warmly in cold weather. People who take these medicines should try to take them at the same time every day. They should not stop taking the medicine without talking with their doctor first. If they notice that their thinking problems are getting worse or if they have any unusual symptoms or fevers, they should report these problems to their doctor.

What is in the future for people with schizophrenia?

The less time people with schizophrenia have hallucinations or delusions, the better they do in the long run. Taking the right medicine regularly will prevent outbreaks of abnormal thinking and limit the consequences of having schizophrenia.

Researchers are learning more and more about how the 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.