Chapter 8
Mental Health and Illness

Mental health may be measured in terms of an individual's abilities to think and communicate clearly, learn and grow emotionally, deal productively and realistically with change and stress, and form and maintain fulfilling relationships with others. Mental health is a principal component of wellness—self-esteem, resilience, and the ability to cope with adversity influence how people feel about themselves and whether they choose lifestyles and behaviors that promote or jeopardize their health.

Mental illness refers to all identifiable mental health disorders and mental health problems. The U.S. Department of Health and Human Services (HHS) in Mental Health: A Report of the Surgeon General, 1999 (http://www.mentalhealth.samhsa.gov/cmhs/surgeongeneral/surgeongeneralrpt.aspfront.pdf) defines mental disorders as "health conditions that are characterized by alterations in thinking, mood, or behavior (or some combination thereof) associated with distress and/or impaired functioning." The report distinguishes mental disorders from mental problems, describing the signs and symptoms of mental health problems as less intense and of shorter duration than those of mental health disorders. However, it acknowledges that both mental health disorders and problems may be distressing and disabling.

The symptoms of mental disorders differentiate one type of problem from another; however, the symptoms of mental illness vary far more widely in both type and intensity than do the symptoms of most physical illnesses. In general, people usually are considered mentally healthy if they are able to maintain their mental and emotional balance in times of crisis and stress and cope effectively with the problems of daily life. When coping ability is lost, then there is some degree of mental dysfunction. The goals of diagnosis and treatment of mental disorders are to recognize and understand the conditions, reduce their underlying causes, and work toward regaining mental and emotional equilibrium.

HOW MANY PEOPLE ARE MENTALLY ILL?

It is complicated to determine how many people suffer from mental illness because of changing definitions of mental illness and difficulties classifying, diagnosing, and reporting mental disorders. There are social stigmas attached to mental illness, such as being labeled "crazy," being treated as a danger to others, and being denied jobs or health insurance coverage, that keep some sufferers from seeking help, and many of those in treatment do not reveal it on surveys. Some patients do not realize that their symptoms are caused by mental disorders. Because knowledge about the way the brain works is relatively narrow, mental health professionals must continually reassess how mental illnesses are defined and diagnosed. In addition, what might be considered, for example, delusional thinking in one culture may well be widely accepted in another; the symptoms of mental illness are notoriously fluid, and diagnosis may be skewed by cultural differences or other bias on the part of both patient and practitioner.

The Surgeon General's report estimated that 20% of the United States population was affected by mental disorders and that 15% use some type of mental health service every year. Community surveys estimate that as many as 30% of the adult population in the United States suffer from mental disorders. The National Comorbidity Survey Replication (NCS-R), a nationally representative face-to-face household survey conducted by Harvard University, the University of Michigan, and the National Institute of Mental Health (NIMH) Intramural Research Program, between February 2001 and April 2003 used a structured diagnostic interview of 9,282 randomly selected English-speaking Americans age eighteen and older. Ronald Kessler et al in "Prevalence, Severity, and Comorbidity of 12-Month DSM-IV Disorders in the National Comorbidity Survey Replication" (Archives of General Psychiatry, June 2005) found that more than one-quarter (26.2%) of all Americans met the criteria for having a mental illness, and fully a quarter of those had a "serious" disorder that significantly disrupted their ability to function day to day. The exhaustive NIMH-sponsored effort also found that the prevalence of U.S. mental illness has not varied significantly in the past decade, unlike previous decades in which the prevalence of mental illness had been slowly increasing.

How Many Children Suffer from Mental Illness?

Studies of prevalence of mental illness, which included mental disorders and addictive disorders, estimate that more than one-fifth (nearly 21%) of U.S. children ages nine to seventeen suffer some degree of impaired functioning resulting from a mental or addictive disorder. (See Figure 8.1 and Table 8.1.) Although the same research found that just 11% of this group suffers from significant impairment, this prevalence estimate translates into four million children and teens for whom difficulties at school and with their families and friends are attributable to mental illness.

Table 8.2 lists the broad categories of mental disorders that begin during childhood and adolescence. Children and teens with mood and anxiety disorders suffer from unfounded fears, prolonged sadness or tearfulness, withdrawal, low self-esteem, and feelings of worthlessness and hopelessness. These children and adolescents often suffer from more than one mental health problem—for example, symptoms of depression and anxiety together.

Some Americans Experience Serious Mental Distress

The National Health Interview Survey (NHIS), a continuing, nationwide survey conducted by the National Center for Health Statistics (NCHS) of the Centers for Disease Control and Prevention (CDC), poses six questions about psychological distress. These questions ask how often a respondent experienced certain symptoms of psychological distress during the thirty days preceding the survey. In the first half of 2005, nearly 3% of adults age eighteen and older said they had experienced serious psychological distress during the past thirty days. Figure 8.2 shows that the percent of adults

source: "Table 3-2. Selected Mental Disorders of Childhood and Adolescence from the DSM-IV," in Mental Health: A Report of the Surgeon General, U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, with NIH, 1999, http://www.surgeongeneral.gov/library/mentalhealth/chapter3/sec3.html (accessed January 19, 2006)

TABLE 8.2

Selected mental disorders of childhood and adolescence

• Anxiety disorders
• Attention-deficit and disruptive behavior disorders
• Autism and other pervasive developmental disorders
• Eating disorders
• Elimination disorders
• Learning and communication disorders
• Mood disorders (e.g., depressive disorders)
• Schizophrenia
• Tic disorders

reporting serious psychological distress declined from 3.3% in 1997 to 2.4% in 1999 but increased to 3.2% in 2001 and has not varied significantly since.

The NHIS revealed that persons age sixty-five and older (2.4%) were less likely to have experienced serious psychological distress during the thirty days preceding the survey than persons ages forty-five to sixty-four (3.5%). Among persons ages eighteen to forty-four, women were more likely than men to report serious psychological distress during the thirty days preceding the survey. (See Figure 8.3.)

The percentage of adults that experienced serious psychological distress during the thirty days preceding the survey did not vary significantly by race or ethnicity. The age-sex adjusted prevalence of serious psychological distress was 2.8% for non-Hispanic white persons, and 3.4% for both Hispanic persons and non-Hispanic African-American persons. (See Figure 8.4.)

Not All People Need or Seek Treatment

The NIMH observes that not all mental disorders require treatment, because many people with mental disorders have relatively brief, self-limiting illnesses that are not disabling enough to warrant treatment. As much as 70% of mental illness goes untreated, and many cases are believed to resolve spontaneously. Among people seeking help, about 23% see their primary care physicians and 12.3% visit psychiatrists (June 3, 2005, press conference with Thomas R. Insel, director, National Institute of Mental Health; Ronald C. Kessler, Ph.D., professor, health-care policy, Harvard Medical School; Philip Wang, M.D., assistant professor, health-care policy, Harvard Medical School; Richard Nakamura, Ph.D., deputy director, National Institute of Mental Health; Kathleen Ries Merikangas, Ph.D., chief, section on developmental genetic epidemiology, National Institute of Mental Health).

Philip Wang et al in "Twelve-Month Use of Mental Health Services in the United States" (Archives of General Psychiatry, June 2005) found that less than half of persons in need of mental health treatment receive it. Those who seek treatment generally delay pursuing help for a decade or more, and during this time they are likely to develop additional problems. Nonetheless, the survey revealed that the percent of the population treated for mental illness over a twelve-month period has grown by 4%, from 13% a decade ago to 17% in 2003. The researchers theorized that the increase in persons seeking treatment might be attributable to direct-to-consumer advertisements for antidepressants and other drugs, and to diminishing stigma associated with obtaining mental health treatment. Unfortunately, the survey found that the treatment received is frequently inadequate. The researchers attributed delays in seeking treatment to inattention to early warning signs, insufficient health insurance, and the lingering stigma that surrounds mental illness.

Even among persons with health insurance, one likely explanation for the relatively small number of people seeking help from psychiatrists, clinical psychologists, or other mental health professionals is the high cost of these services and the reluctance of many health insurance companies to cover treatment of mental health disorders or problems. Many private insurance policies offer only limited coverage for mental health services. In addition, mental health practitioners and facilities covered by insurance are unevenly distributed throughout the country. In January 1998, however, Congress made significant progress toward more equitable access to mental health treatment when the Mental Health Parity Act of 1996 (PL 104-204) took effect. The Act requires that mental health benefits be comparable to medical/surgical benefits in health plans that cover groups of fifty or more employees.

TYPES OF DISORDERS

Psychiatrists have identified a wide range of mental disorders, from phobias to depression to schizophrenia. Psychiatric diagnoses are made based on criteria described in the fourth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (2000) by the American Psychiatric Association (APA). Some disorders are relatively mild and affect an individual's life in only a minor way. Others can be overwhelming, completely debilitating, and life-threatening.

Anxiety disorders, which include phobias (intense, irrational, and persistent fears), and depression are the two most common mental disorders. The National Alliance for the Mentally Ill (NAMI) states that about twenty million Americans report at least one phobia serious enough to affect their daily routines, and the NIMH says that depression afflicts more than twenty million people each year. The medical community also classifies substance abuse as a mental disorder. According to the National Institute on Alcohol Abuse and Alcoholism (NIAAA), alcoholism affects close to fourteen million people (one in thirteen Americans) per year. Many people suffer from more than one mental disorder at a time (comorbidity)—millions of Americans suffer from substance (drug or alcohol) abuse combined with one or more other mental disorders.

Children suffer from many of the same mental disorders that afflict adults, but they also may be affected by developmental disorders. Children with disorganized thinking and difficulty communicating verbally, and those who have trouble understanding and navigating the world around them, may be diagnosed with autism or another pervasive developmental disorder. These disorders may be among the most disabling because they are associated with serious learning difficulties and impaired intelligence. Examples of pervasive developmental disorders include autism, Asperger's disorder, and Rett's disorder.

PERVASIVE DEVELOPMENTAL DISORDERS

Autism is a condition that results from a neurological disorder that typically appears during the first three years of childhood and continues throughout life. It was first described in 1943 by Dr. Leo Kanner, who reported on eleven children who displayed an unusual lack of interest in other people but were extremely interested in unusual aspects of the inanimate environment. Autistic children appear unattached to parents or caregivers, assume rigid or limp body postures when held, suffer impaired language, and exhibit behavior such as head banging, violent tantrums, and screaming. They are often self-destructive and uncooperative and experience delayed mental and social skills. Autism is associated with a variety of neurological symptoms such as seizures and persistence of reflexes that usually disappear during normal child development. Autism is the most common of the pervasive developmental disorders, and the CDC has estimated that it occurs in as many as ten to twelve in ten thousand individuals (http://www.cdc.gov/Washington/testimony/dd040600.htm). According to the National Autistic Society, its prevalence is four times more frequent in boys than girls. The CDC states that about 75% of autistic children also have some degree of mental retardation.

While it was once thought to have psychological origins or occur as the result of bad parenting, both of these hypotheses have been discarded in favor of a biological explanation of causality. Although the cause of autism remains unknown, the disorder has been associated with maternal rubella infection, phenylketonuria (an inherited disorder of metabolism), tuberous sclerosis (an inherited disease of the nervous system and skin), lack of oxygen at birth, and encephalitis. There is evidence of the heritability of autism; it affects approximately 0.2% of children in the general population, but the risk of bearing a second child with autism rises to between 12% and 20%. Studies have found that concordance for autism in identical twins is more likely than in fraternal twins or other siblings (P. Bolton et al, "A Case-Control Family History Study of Autism," Journal of Child Psychiatry, vol. 35, no. 5, July 1994).

Autism varies from mild to quite severe, and the prognosis depends on the extent of the individual's disabilities and whether he or she receives the early, intensive interventions associated with improved outcomes. A diagnosis of "atypical autism" or "pervasive developmental disorder not otherwise specified" (PDD-NOS) is generally used to refer to mild cases of autism or children with impaired social interaction and verbal and nonverbal communication who are not asocial enough to be considered autistic. Treatment of autism is individualized and may include applied behavior analysis, medications (the antipsychotic drug haloperidol; the tricyclic antidepressant clomipramine; and the selective serotonin reuptake inhibitor [SSRI] fluoxetine), dietary management and supplements, music therapy, occupational therapy, physical therapy, speech and language therapy, and vision therapy.

Asperger's disorder is a milder form of autism, and sufferers are sometimes called "high functioning children with autism." The disorder is named for the Austrian physician Hans Asperger, who first described it in 1944. JB Bertrand et al in "Prevalence of Autism in a United States Population" (Pediatrics, 2001) states that about three per one thousand children have Asperger's disorder. The DSM-IV states that Asperger's disorder appears to be more common in boys. Affected children tend to be socially isolated and behave oddly. They have impaired social interactions, are unable to express pleasure in others' happiness, and lack social and emotional reciprocity. They are below average in nonverbal communication, and their speech is marked by peculiar abnormalities of inflection and a repetitive pattern. Unlike in autism, however, cognitive and communicative development is normal or near normal during the first years of life, and verbal skills are usually relatively strong. Sufferers also have impaired gross motor skills, tend to be clumsy, and may engage in repetitive finger flapping, twisting, or awkward whole-body movements. They usually have very narrow areas of interest that are highly specific, idiosyncratic, and so consuming that they do not pursue age-appropriate activities. Examples of such interests include train schedules, spiders, or telegraph pole insulators.

Rett's disorder (also known as Rett's syndrome) is sometimes mistaken for autism when diagnosed in very young children (and is linked to autism, Asperger's syndrome, ADHD, and schizophrenia), but it is much less

prevalent and has a distinctive onset and course. The condition occurs primarily in girls who, after early normal development, experience slower-than-expected head growth in the first months of life and a loss of purposeful hand motions between ages five and thirty months. Affected children are usually profoundly mentally retarded and exhibit stereotypical repetitive behaviors such as hand wringing or hand washing. Interest in socialization diminishes during the first few years of the disorder but may resume later in life, despite severe impairment in expressive and receptive language development. Affected individuals experience problems in the coordination of gait or trunk movements, and walking may become difficult.

DEPRESSION

According to the NIMH, depressive disorders afflict about 20.9 million American adults—about 9.5% of the United States population—every year (http://www.nimh.nih.gov/publicat/depression.cfm). Women (12%) are affected almost twice as often as men (6.6%). Depression can strike at any age but usually begins during the second decade of life.

Defining Depression

Depression is a "whole body" illness, involving physical, mental, and emotional problems. A depressive disorder is not a temporary sad mood, and it is not a sign of personal weakness or a condition that can be willed away. People with depressive illness cannot just "pull themselves together" and hope they will become well. Without treatment, the symptoms can persist for months or even years. Table 8.3 is a list of symptoms that characterize depression. Not everyone who is depressed experiences all of the symptoms. Some people have very few symptoms; some have many. Like other mental illnesses, the severity and duration of the symptoms of depression may vary.

There are several types of depressive disorders. The most common form is dysthymic disorder (dysthymia), a less severe but chronic form of depression that by definition lasts at least two years in adults or one year in children. Dysthymic disorders commonly appear for the first time in children, teens, and young adults, and although they may not disable people as severely as other forms of depression, these disorders can ruin lives by robbing them of joy, energy, and productivity. The NIMH estimates 5.4% of American adults suffer from dysthymia, and many also suffer from major depression during the course of their lives.

Major depression (also called unipolar major depression) is a more severe and disabling form; nearly ten million Americans are affected every year. Major depression is second only to heart disease as a cause of

TABLE 8.3

Symptoms of depression and mania

Not everyone who is depressed or manic experiences every symptom. Some people experience a few symptoms, some many. Severity of symptoms varies with individuals and also varies over time.

Depression

• Persistent sad, anxious, or "empty" mood
• Feelings of hopelessness, pessimism
• Feelings of guilt, worthlessness, helplessness
• Loss of interest or pleasure in hobbies and activities that were once enjoyed, including sex
• Decreased energy, fatigue, being "slowed down"
• Difficulty concentrating, remembering, making decisions
• Insomnia, early-morning awakening, or oversleeping
• Appetite and/or weight loss or overeating and weight gain
• Thoughts of death or suicide; suicide attempts
• Restlessness, irritability
• Persistent physical symptoms that do not respond to treatment, such as headaches, digestive disorders, and chronic pain

Mania

• Abnormal or excessive elation
• Unusual irritability
• Decreased need for sleep
• Grandiose notions
• Increased talking
• Racing thoughts
• Increased sexual desire
• Markedly increased energy
• Poor judgment
• Inappropriate social behavior

source: "Symptoms of Depression and Mania," in Depression, National Institute of Mental Health, 2000, http://www.nimh.nih.gov/publicat/nimhdepression.pdf (accessed January 18, 2006)

disability when disability is measured in years of healthy life lost.

Causes of Depression

Combinations of genetic, psychological, and environmental factors are involved in the development of depressive disorders. Some types of depression run in families, and research studies of twins have demonstrated that genetic factors determine susceptibility to depression. Major depression seems to recur in generation after generation of some families, but it also occurs in people with no family history of depression.

Studies of the brain support the premise that depression may have a biological and chemical basis. Although there are clearly differences between the brain imaging studies, it is not yet known if these differences cause the depression or result from it. Researchers speculate that the problem may be caused by the complex neurotransmission (chemical messaging) system of the brain and that persons suffering depression have either too much or too little of certain neurochemicals in the brain. Investigators believe that depressed patients with normal levels of neurotransmitters may suffer from an inability to regulate them. Most antidepressant drugs currently used to treat the disorder attempt to correct these chemical imbalances.

A person's psychological makeup is another factor in depressive disorders. People who are easily overwhelmed by stress or who suffer from low self-esteem or a pessimistic view of life, of themselves, and of the world tend to be prone to depression. Events outside the person's control also can trigger a depressive episode. A major change in the patterns of daily living—such as a serious loss, a chronic illness, a difficult relationship, or financial problems—can trigger the onset of depression.

Treatment of Depression

Antidepressant medications that alter brain chemistry have been used to treat depressive disorders effectively. Antidepressant medications—including SSRIs such as Prozac, tricyclic antidepressants such as Elavil, and monoamine oxidase inhibitors (MAOIs)—work by influencing the function of neurotransmitters such as dopamine or norepinephrine. The SSRIs have fewer reported side effects (such as sedation, headache, weight gain or loss, and nausea) than tricyclic antidepressants.

Antidepressants do not offer immediate relief from symptoms; most take full effect in about four weeks, and some take up to eight weeks to achieve optimal therapeutic effects. Patients must be closely monitored by health professionals for side effects, dosage, and effectiveness. Table 8.4 lists the most common side effects of antidepressants. In some cases of chronic depression, medication may be needed continuously, on a long-term basis, to prevent recurrence of the disease.

In March 2004 the U.S. Food and Drug Administration (FDA) issued a warning that depression may worsen or suicidal thoughts may occur in people, particularly children and adolescents, who take any of the popular antidepressants. This is most likely to occur at the beginning of treatment or when the doses are increased or decreased. The FDA ordered manufacturers to revise labeling of Prozac (also sold generically as fluoxetine), Zoloft, Paxil, Luvox, Celexa, Lexapro, Wellbutrin, Effexor, Serzone, and Remeron to increase awareness of these side effects.

Psychotherapy also has been demonstrated as effective therapy for mild to moderate depression. Talking about problems with mental health professionals can help patients better understand their feelings. Two types of short-term therapy lasting ten to twenty weeks appear to improve symptoms of depression. Interpersonal therapy concentrates on helping patients improve personal relationships with family and friends. Cognitive behavioral therapy attempts to help patients replace negative thoughts and feelings with more positive, optimistic approaches and actions.

Some people respond well to psychotherapy, and others respond well to antidepressants. Many do best with a combination of treatment—drugs for relatively quick relief of symptoms and therapy to learn how to cope with life's problems more effectively.

TABLE 8.4

Side effects of antidepressants

Antidepressants may cause mild and, usually, temporary side effects (sometimes referred to as adverse effects) in some people. Typically these are annoying, but not serious However, any unusual reactions or side effects or those that interfere with functioning should be reported to the doctor immediately. The most common side effects of tricyclic antidepressants, and ways to deal with them, are:

• Dry mouth —it is helpful to drink sips of water; chew sugarless gum; clean teeth daily.
• Constipation —bran cereals, prunes, fruit, and vegetables should be in the diet.
• Bladder problems —emptying the bladder may be troublesome, and the urine stream may not be as strong as usual; the doctor should be notified if there is marked difficulty or pain.
• Sexual problems —sexual functioning may change; if worrisome, it should be discussed with the doctor.
• Blurred vision —this will pass soon and will not usually necessitate new glasses.
• Dizziness —rising from the bed or chair slowly is helpful.
• Drowsiness as a daytime problem —this usually passes soon. A person feeling drowsy or sedated should not drive or operate heavy equipment. The more sedating antidepressants are generally taken at bedtime to help sleep and minimize daytime drowsiness.

The newer antidepressants have different types of side effects:

• Headache —this will usually go away.
• Nausea —this is also temporary, but even when it occurs, it is transient after each dose.
• Nervousness and insomnia (trouble falling asleep or waking often during the night) —these may occur during the first few weeks; dosage reductions or time will usually resolve them.
• Agitation (feeling jittery) —if this happens for the first time after the drug is taken and is more than transient, the doctor should be notified.
• Sexual problems —the doctor should be consulted if the problem is persistent or worrisome.

source: "Side Effects of Antidepressants," in Depression, National Institute of Mental Health, 2000, http://www.nimh.nih.gov/publicat/nimhdepression.pdf (accessed January 18, 2006)

Less commonly, electrical stimulation of the brain, known as electroconvulsive therapy (ECT), is used to treat people with severe depression that has not responded to medication. Electric shocks administered to one side of the patient's head while he or she is under general anesthesia cause brain seizures that somehow relieve depression. The mechanism by which ECT works is unknown. The treatment requires multiple sessions to achieve results; patients usually receive one, sometimes two, treatments per week over the course of nine to twelve weeks. Because ECT has the potential for serious side effects—reactions to anesthesia and memory loss, for example—and because of the history of abuses of the treatment, ECT is a controversial treatment of last resort for people with the most refractory (treatment-resistant) depression.

Children Suffer from Depression Too

The most frequently diagnosed mood disorders in children and adolescents are major depressive disorder, dysthymic disorder, and bipolar disorder. Children who are depressed are not unlike their adult counterparts. They may be teary and sad, lose interest in friends and activities, and become listless, self-critical, and hypersensitive to criticism from others. They feel unloved, helpless, and hopeless about the future, and they may think about suicide. Depressed children and adolescents also may be irritable, aggressive, and indecisive. They may have problems concentrating and sleeping and often become careless about their appearance and hygiene. The Surgeon General's report distinguishes childhood depression from adult depression, noting that children display fewer psychotic symptoms, such as hallucinations and delusions, and more anxiety symptoms, such as clinging to parents or unwillingness to go to school. Depressed children also experience more somatic symptoms, such as general aches and pains, stomachaches, and headaches, than adults with depression.

Dysthymic disorder usually begins in childhood or early adolescence and is a chronic but milder depressive disorder with fewer symptoms. The child or adolescent is continuously depressed for months to years. Because the average duration of the disorder is about four years, some children become so accustomed to feeling depressed that they may not identify themselves as depressed or complain about symptoms. Nearly three-quarters of children and adolescents with dysthymic disorder experience at least one major depressive episode in the course of their lives.

Reactive depression (formerly termed adjustment disorder with depressed mood) is the most common mental health problem in children and adolescents. It is not considered a mental disorder, and many health professionals consider occasional bouts of reactive depression as entirely consistent with normal adolescent development. It is characterized by transient depressed feelings in response to some negative experience, such as a rejection from a boyfriend or girlfriend or a failing grade. Sadness or listlessness spontaneously resolves in a few hours or may last as long as two weeks. Generally distraction, in the form of a change of activity or setting, helps to improve the mood of affected individuals.

According to the NIMH, until recently, physicians and family members did not recognize depression in children and often attributed mood changes in children and adolescents to a normal process of development. During the past ten years, there has been increasing recognition that clinical depression occurs in children and adolescents. Recent epidemiological studies suggest that up to 1% of preschoolers, 2% of schoolchildren, and 8% of adolescents may have major depressive disorder. The lifetime risk of major depressive disorder and dysthymia among adolescents has been estimated at about 15%, which is comparable to the adult lifetime risk ("Depression Research at the National Institute of Mental Health," February 17, 2006, http://www.nimh.nih.gov/publicat/depresfact.cfm, and G. Saluja et al, "Prevalence of and Risk Factors for Depressive Symptoms among Young Adolescents," Archives of Pediatric and Adolescent Medicine, vol. 158, August 2004, http://intramural.nimh.nih.gov/research/pubs/giedd04.pdf).

Prepubescent girls and boys are equally likely to experience major depression and dysthymic disorder, but from ten to fourteen years of age, girls outpace boys, soon reaching the two-to-one ratio observed among adults, according to the NIMH. Depression in young people often occurs along with anxiety and behavioral problems and predicts continued and possibly more severe depression in adulthood. Depression also increases the risk for substance abuse and is a major risk factor for suicide. The incidence of suicide attempts peaks during adolescence. Mortality from suicide increases through the teens and is the third-leading cause of death among adolescents and young adults. (See Table 1.12 in Chapter 1.)

BIPOLAR DISORDER

Bipolar disorder, also known as manic depression, is characterized by alternating periods of persistently elevated, expansive, or irritable mood—called mania—and periods of depression. During a manic episode, a person may feel inflated self-esteem, decreased need for sleep, unusually talkative or pressure to keep talking, and easily distracted. He or she may also have flights of ideas, racing thoughts, increased goal-directed activity such as shopping, and excessive involvement in high-risk activities. (See Table 8.3 for symptoms of bipolar disorder.) According to the NIMH, bipolar disorder strikes about 2.3 million adult Americans, about 1.2% of the population, and it affects males and females equally.

In the early stages of the illness, patients may experience few symptoms or even symptom-free periods between relatively mild episodes of mania and depression. As the illness progresses, however, manic and depressive episodes become more serious and more frequent. Patients are less likely to experience intermissions, manic euphoria is increasingly replaced by irritability, and depressions deepen. Some individuals suffer psychotic episodes during periods of mania or depression. Bipolar disorder is one of the most lethal illnesses. According to Frederick K. Goodwin and Kay Redfield Jamison in their Manic-Depressive Illness (New York: Oxford University Press, 1990):

Patients with depressive and manic-depressive illnesses are far more likely to commit suicide than individuals in any other psychiatric or medical risk group. The mortality rate for untreated manic-depressive patients is higher than it is for most types of heart disease and many types of cancer.

The onset of bipolar illness is usually a depressive episode during adolescence. Manic episodes may not appear for months or even years. During manic episodes adolescents are tireless, overly confident, and tend to have rapid-fire or pressured speech. They may perform tasks and schoolwork quickly and energetically but in a wildly disorganized manner. Manic adolescents may seriously overestimate their capabilities, and the combination of bravado and loosened inhibitions may prompt them to participate in high-risk behaviors, such as vandalism, drug abuse, or unsafe sex.

Treatments for Bipolar Disorder

Lithium has been widely used to treat bipolar disorder since the 1960s, and it is still the medication of choice for controlling the illness. In the 1970s psychiatrists also began using anticonvulsant drugs, including valproate, carbamazepine, and clonazepam to treat patients who could not tolerate lithium or for whom the drug did not work. Chlorpromazine and haloperidol, both antipsychotics, are also helpful in some cases. Antimanic and antipsychotic agents are often combined with antidepressants to relieve depressive symptoms and promote better sleep patterns, an important factor in maintaining patients' mood stability. These medication strategies have proven highly effective in treating bipolar disorder; however, many patients still experience a residual pattern of ups and downs

Medications may become less effective over time and have to be changed. Another major concern among practitioners and patients are medication side effects, especially of lithium. Because therapeutic blood levels of the drug are very close to fatal levels, patients taking lithium must consume adequate amounts of water and salt to prevent dehydration, which would cause lithium blood levels to rise to toxic levels. People who take lithium must have their blood levels of the drug checked frequently, and they must also be aware of the signs of lithium poisoning. Long-term usage of the drug has been shown to cause kidney damage; adequate consumption of water and careful dosage monitoring are believed to reduce the risk of kidney disease.

SCHIZOPHRENIA

A person who hears voices, becomes violent, and sometimes ends up as a homeless person, muttering and shouting incomprehensibly, frequently suffers from schizophrenia. This disease generally presents in adolescence, causing hallucinations, paranoia, delusions, and social isolation. The effects begin slowly and, initially, are often considered the normal behavioral changes of adolescence. Gradually, voices take over in the schizophrenic's mind, obliterating reality and directing the person to all kinds of erratic behaviors. Suicide attempts and violent attacks are not uncommon in the lives of schizophrenics. Many schizophrenics turn to drugs in an attempt to escape the torment inflicted by their brains. NIMH estimated that as many as half of all schizophrenics are also drug abusers.

In 2006 the NIMH reported that 2.4 million Americans suffered from schizophrenia and similar disorders ("When Someone Has Schizophrenia," May 9, 2006, http://www.nimh.nih.gov/publicat/schizsoms.cfm#5). Although the precise causes of schizophrenia are unknown, for years researchers have hypothesized that genetic susceptibility is a risk factor for schizophrenia and bipolar disorder. The disease affects an estimated 1% of persons worldwide, but an individual with a parent or sibling who has schizophrenia has a 10% chance of developing the disease compared with the 1% chance of an individual with no family history. A prenatal developmental problem, or a combination of genetic, developmental, and environmental factors, may also be causative factors. Although physical and emotional stress can aggravate symptoms of schizophrenia, they do not cause the disease.

Imaging studies of the brain have revealed abnormal brain development in children who have schizophrenia, and imaging studies of adults with the disease have found enlargement of the ventricles of the brain. Some studies suggest that the brain of a person with schizophrenia manufactures too much dopamine, a chemical vital to normal nerve activity. Conventional drug treatment focuses on blocking dopamine receptors in the brain, but not all people with schizophrenia respond to treatment; it also can produce serious side effects. Newer antipsychotic medications used to treat the disorder, such as risperidone, have fewer side effects than previously used medications. Patients who take these medications must be monitored closely for serious side effects such as loss of the white blood cells that fight infection.

ANXIETY DISORDERS

Everyone experiences some degree of anxiety almost every day. In today's world, a certain amount of anxiety is unavoidable and, in some cases, may even be beneficial. For example, mild anxiety before an exam or a job interview actually may improve performance. Anxiety prior to a surgical operation, giving a speech, or driving in bad weather is normal.

Nevertheless, when anxiety becomes extreme or when an attack of anxiety strikes suddenly, without an apparent external cause, it can be both debilitating and destructive. Its symptoms may include nervousness, fear, a "knot" in the stomach, rapid heartbeat, or increased blood pressure. If the anxiety is severe and long lasting, more serious problems may develop. People suffering from anxiety over an extended period may have headaches, ulcers, irritable bowel syndrome, insomnia, and depression. Because anxiety tends to create various other emotional and physical symptoms, a "snowball" effect can occur in which these problems produce even more anxiety.

Chronic anxiety can interfere with an individual's ability to lead a normal life. Mental health professionals consider a person who has prolonged anxiety as having an anxiety disorder. The NIMH estimates that approximately nineteen million Americans suffer from anxiety disorders. Table 8.5 shows the estimated prevalence of various types of anxiety disorders.

Panic Disorder

Extremely high levels of anxiety may produce panic attacks that are both unanticipated and seemingly without cause. In one type of panic attack, termed "unexpected," the sufferer is unable to predict when an attack will occur. Other types of panic attacks are linked to a particular location, circumstance, or event and are called "situationally bound" or "situationally predisposed" panic attacks. These panic episodes can last as long as thirty minutes and are marked by an overwhelming sense of impending doom while the person's heart races and breathing quickens to the point of gasping for air. Sweating, weakness, dizziness, terror, and feelings of unreality are also typical. Individuals undergoing a panic attack fear they are going to die; "lose their mind"; or, at the very least, lose control.

Repeated panic attacks may be termed a panic disorder. However, panic attacks do not necessarily indicate a mental disorder—up to 10% of people with no other problems experience a single panic attack each year. According to the APA, panic disorder occurs twice as often among women than men, it can run in families, and most sufferers begin to experience attacks in their twenties. Research has revealed that persons who experience panic attacks tend to suppress their emotions. Investigators hypothesize that this tendency leads to an emotional buildup for which a panic attack is a form of release. Interestingly, most persons who suffer from panic attacks do not experience anxiety between attacks.

These symptoms often mimic those of a heart attack, so the diagnosis of panic disorder often is not made until extensive and costly medical procedures fail to provide a diagnosis. These patients then may turn to neurologists and other specialists to seek answers. Research has found that of the patients who make the most visits to doctors, spend the most time in the hospital, and use the most prescription medications, approximately 12% suffer from undiagnosed panic disorders.

The usual treatment for panic disorder is cognitive behavioral therapy combined with antianxiety drugs to treat the fear of the attacks. Sometimes antidepressant medications are used, although persons suffering from anxiety disorders are usually not clinically depressed. Relaxation therapy also has proved beneficial.

Phobias

Phobias are defined as unreasonable fears associated with a particular situation or object. The most common of the many varieties of phobias are specific phobias. Fear of bees, snakes, rodents, heights, odors, blood, injections, and storms are examples of common specific phobias. Specific phobias, especially animal phobias, are common in children, but they can occur at any age. About 8% of American adults (11.5 million) suffer from specific phobias. (See Table 8.5.) Most people with a phobia understand that their fears are unreasonable, but that awareness does not make them feel any less anxious.

Some specific phobias, such as a fear of heights, usually do not interfere with daily life or cause as much distress as more severe forms, such as agoraphobia (see later in this chapter). People suffering from severe phobias may rearrange their lives drastically to avoid the situations they fear will trigger panic attacks.

SOCIAL PHOBIAS

Social phobias (also called social anxiety disorders) can be more serious than specific phobias. The person with a social phobia is intensely afraid of being judged by others. At social gatherings the person with social phobia expects to be singled out, scrutinized, judged, and found lacking. People with social phobias are usually very anxious about feeling humiliated or embarrassed. They are often so crippled by their own fears that they may have a hard time thinking clearly, remembering facts, or carrying on normal conversations. The individual with social phobia may tremble, sweat, or blush and often fears fainting or losing bladder or bowel control in social settings. In response to these overwhelming fears, the person with social phobia tries to avoid public situations and gatherings of people. Social phobias tend to start between the ages of fifteen and twenty years and, if not treated, can continue throughout life.

Because social phobics fear being the center of attention or the subject of criticism, public speaking, asking questions, eating in front of others, or even attending social events create anxiety. Social phobias should not be confused with shyness, which is considered a normal variation in personality. Social phobias can be disabling, preventing sufferers from attending school, working, and having friends.

AGORAPHOBIA

Many people who experience panic attacks go on to develop agoraphobia—the fear of crowds and open spaces. The term comes from the Greek word "agora," which means "marketplace." This type of phobia is a severely disabling disorder that often traps its victims, rendering them virtual prisoners in their own homes, unable to work, shop, or attend social activities.

Agoraphobia normally develops slowly, following an initial unexpected panic attack. For example, on an ordinary day, while shopping, driving to work, or doing errands, the individual is suddenly struck by a wave of terror characterized by symptoms such as trembling, a pounding heart, profuse sweating, and difficulty in breathing normally. The person desperately seeks safety, reassurance from friends and family, or a physician. The panic subsides and all is well—until another panic attack occurs.

The person with agoraphobia begins to avoid all places and situations where an attack occurred and then begins to avoid places where an attack could possibly occur or where it might be difficult to escape and get help. Gradually, the victim becomes more and more limited in the choice of places that are "safe." Eventually, the person with agoraphobia cannot venture outside the immediate neighborhood or leave the house. The fear ultimately expands to touch every aspect of life.

Agoraphobia usually begins during the late teens or twenties. The Surgeon General states about 5% of the adult population suffers from it, and women tend to be affected two times more often than men.

PHOBIA TREATMENT PROGRAMS

Phobia treatment centers exist throughout the United States. The programs use a wide variety of cognitive behavioral therapy techniques to help patients face and overcome their fears. In addition, drugs may be used to ease the symptoms of anxiety, fear, and depression and to help the person return to a normal life more quickly. Antidepressants have been shown to help people who suffer from panic attacks and agoraphobia. In addition, anti-anxiety drugs are useful in treating the generalized anxiety that frequently accompanies phobias.

Obsessive-Compulsive Disorder

Obsessive-compulsive disorder (OCD) is an anxiety disorder marked by unwanted, often unpleasant recurring thoughts (obsessions) and repetitive, often mechanical behaviors (compulsions). The repetitive behaviors, such as continually checking to be certain windows and doors are locked or repeated hand washing, are intended to dispel the obsessive thoughts that trigger them—that an intruder will enter the house through an unlocked door or window, or that disease will be prevented by hand washing. The vicious cycle of obsessions and compulsions only serves to heighten anxiety; OCD can debilitate those who have the disorder.

The NIMH estimates that about 2.3% of adults between the ages of eighteen and fifty-four suffer from OCD annually. (See Table 8.5.) OCD strikes men and women equally; it sometimes coexists with other disorders such as substance abuse, eating disorders, or depression; and its symptoms generally appear during childhood or adolescence. Imaging studies using positron emission tomography (PET) reveal that people with OCD have different patterns of brain activity than those without the disorder. Further, the PET scans show that the part of the brain most affected by OCD (the striatum) changes and responds to both medication and behavioral therapy.

Many of the medications used to treat other anxiety disorders appear effective for patients with OCD along with a behavioral type of therapy called "exposure and response prevention," during which patients with OCD learn new ways to manage their obsessive thoughts without resorting to compulsive behaviors.

Anxiety among Children and Adolescents

Children and adolescents suffer from many of the same anxiety disorders as do adults. Taken together, the different types of anxiety disorders constitute the mental disorders most prevalent among children and adolescents. According to the Surgeon General's report, 13% of children ages nine to seventeen suffer from some form of anxiety disorder. (See Table 8.1.)

Separation anxiety disorder is a type of anxiety disorder found specifically in children. It is normal for infants, toddlers, and very young children to experience anxiety when separated from their parents or caregivers. For example, nearly every child experiences at least a momentary pang of separation anxiety on the first day of preschool or kindergarten. When this condition occurs in older children or adolescents and it is severe enough to impair social, academic, or job functioning for at least one month, it is considered separation anxiety disorder. The risk factors associated with separation anxiety disorder include stress, such as the illness or death of a family member, geographic relocation, and physical or sexual assault.

Children with separation anxiety may be clingy, and often they harbor fears that accidents or natural disasters will forever separate them from their parents. Because they fear being apart from their parents, they may resist attending school or going anywhere without a parent. Separation anxiety can produce physical symptoms such as dizziness, nausea, or palpitations. It is often associated with symptoms of depression. Young children with separation anxiety may have difficulties falling asleep alone in their rooms and may have recurrent nightmares.

Obsessive-compulsive disorder (OCD) often begins during childhood or adolescence. There is evidence from twin studies of both genetic susceptibility and environmental influences. When one twin has OCD, the other twin is more likely to have OCD if the children are identical twins rather than fraternal twins. There is also increased incidence of the disorder among first-degree relatives of children with OCD. Researchers do not think that OCD is a learned behavior—that the affected child is mimicking the family member's behavior—because children with OCD tend to display different symptoms from those of relatives with the disease.

According to the Surgeon General's report, research suggests that some children develop OCD following an infection with a specific type of streptococcus. This condition is known as Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections (PANDAS). It is believed that antibodies intended to combat the strep infection mistakenly attack a region of the brain and trigger an inflammatory reaction, which in turn leads to development of OCD. SSRIs are effective in reducing or even eliminating the symptoms of OCD in many affected children and adolescents. However, side effects such as dry mouth, sleepiness, dizziness, fatigue, tremors, and constipation are common and may themselves impair functioning.

ATTENTION DEFICIT HYPERACTIVITY DISORDER

Attention deficit hyperactivity disorder (ADHD) is a relatively new name for a psychiatric disorder that usually begins or becomes apparent in preschool- and elementary school-aged children. Children with ADHD cannot sit still, have difficulty controlling their impulsive actions, and are unable to focus on projects long enough to complete them. Although teachers originally dubbed ADHD a "learning problem," the disorder affects more than just schoolwork. Children with ADHD have trouble socializing, are often unable to make friends, and suffer from low self-esteem. Left untreated, ADHD can leave children unable to cope academically or socially, possibly leading to depression.

The NIMH estimates that 3-5% of children—about two million—suffer from ADHD. Boys are affected two to three times more frequently than girls. ADHD frequently coexists with other mental health problems such as substance abuse, anxiety disorders, depression, or antisocial behavior. Children diagnosed with ADHD are usually affected into their teen years, but for most, symptoms subside in adulthood and adults become more adept at controlling their behavior. Vigilance is warranted, however, because research reveals an increased incidence in juvenile delinquency and subsequent encounters with the criminal justice system among adults who were diagnosed with ADHD in their youth.

The reported incidence of ADHD has increased over the past twenty years, possibly because of better diagnosis, changing expectations, or insufficient supportive social structures. In the absence of clear criteria for ADHD or guidelines by which to diagnose it, researchers fear that the disorder may be underdiagnosed or over-diagnosed. The cause of ADHD is as yet unknown. Factors thought to contribute to increased risk of developing the disorder include prenatal toxic exposures and premature birth as well as a family history of school problems, behavioral disorders, or other psychosocial problems. A biological explanation of ADHD arose because its symptoms respond to treatment with stimulants such as methylphenidate, which increase the availability of dopamine—the neurotransmitter that is vital for purposeful movement, motivation, and alertness. This led researchers to theorize that ADHD may be caused by unavailability of dopamine in the central nervous system.

The evidence of a genetic component is inconclusive. There is an increased incidence of ADHD in children with a first-degree relative with ADHD, conduct disorders, antisocial personality, substance abuse, and others, but this observation does not resolve the question of whether nature (genetics) or nurture (family and environmental influences) contributes more strongly to the origins of ADHD. Twin studies have found that when ADHD is present in one twin, it is significantly more likely also to be present in an identical twin than in a fraternal twin. These findings support inheritance as an important risk in a proportion of children with ADHD.

Although imaging studies have revealed differences in the brains of children with ADHD, and scientists have found a link between inability to pay attention and diminished utilization of glucose in parts of the brain, some researchers question whether these changes cause the disorder. They argue that the observed changes may result from the disorder, or simply coexist with it. Today, there are mental health professionals and educators who concede that while some children are legitimately diagnosed with ADHD, others are mislabeled. They speculate that maybe the latter group may be simply high-spirited, undisciplined, or misbehaving.

Treatment for ADHD

Much controversy about ADHD has focused on its treatment. Prescription stimulants—such as methylphenidate (Ritalin), dextromethamphetamine (Dexedrine), and amphetamine (Adderall)—have proved to be safe and effective for short-term treatment of ADHD. Despite the results of a study of six hundred children reported by the NIMH in December 1999 confirming the safety of this treatment, some researchers still question the wisdom of treatment with potentially addicting, powerful stimulants. NIMH research has indicated that there are two effective treatment methods for elementary-school children with ADHD—a closely monitored medication regimen and a combination of medication and behavioral interventions. Behavioral interventions include psychotherapy, cognitive behavioral therapy, social skills training, support groups, and parent and educator skills training.

Alternatives to drug treatment include therapy techniques such as behavior modification and parent counseling along with modifying the environment to minimize distractions and offering opportunities for one-to-one instruction with teachers. Parental concern about drug treatment of ADHD and intensifying interest in alternative therapies were reported by Benedict Carey in "Focusing on the Mind: Interest Rises in Non-Drug Therapies for Attention Deficit in Children" (Los Angeles Times, September 15, 2003). The article cited increased interest in using restrictive diets and nutritional supplements, such as vitamins, iron, zinc, and fatty acids, as well as use of biofeedback (a technique that uses monitors to teach voluntary control of certain body functions such as heartbeat, blood pressure, muscle tension, and brainwave activity) to treat children and teens with ADHD.

Use of restrictive or elimination diets is based on the notion that food dyes, preservatives, and other additives found in processed foods may cause allergic reactions in susceptible children. Ohio University Emeritus Professor of Psychiatry L. Eugene Arnold estimated that between 5% and 10% of children with ADHD might benefit from restrictive diets. Other investigators feel there is no harm experimenting with this alternative therapy provided that parents consider other strategies if the diet fails to improve symptoms. They caution, however, that effective treatment should be actively pursued so that children do not suffer life-altering consequences of the disorder, such as dropping out of school or progressing to an even more disabling mental disorder.

Using electroencephalogram (EEG) technology, researchers have found that persons with ADHD have distinctive patterns of lower frequency wave patterns emanating from the frontal cortexes of their brains. Biofeedback uses EEG technology to teach affected individuals to sharpen their focus and enhance their concentration. Several small studies comparing the use of biofeedback to treatment with methylphenidate (Ritalin) revealed that weekly biofeedback improved symptoms of participants receiving drug treatment as well as those who were not taking drugs, but the results are not conclusive. Detractors question the variable and subjective measures used to assess the effectiveness of biofeedback and wonder whether study participants are simply benefiting from the placebo effect—responding favorably to the attention given them during the bio-feedback sessions.

Attention Deficit Hyperactivity Disorder in Adults

For many years it was thought that ADHD generally subsided before or during early adulthood. Beginning in the late 1970s, however, studies began to show that significant numbers of adults suffer from ADHD. L. B. Silver in "Attention-Deficit Hyperactivity Disorder in Adult Life" (Child and Adolescent Psychiatric Clinics of North America, 2000) estimated that anywhere from 30% to 70% of children with ADHD continue to exhibit symptoms as adults. For an adult to be diagnosed with ADHD, he or she must have symptoms of the disorder that first manifested during their childhood and have persisted into adulthood. Treatment for ADHD in adults is similar to treatment for the disorder in children.

DISRUPTIVE DISORDERS

Children and adolescents with disruptive disorders, which include oppositional defiant disorder and conduct disorder, display antisocial behaviors. Like separation anxiety, the diagnosis of a disruptive disorder largely depends on assessing whether behavior is age appropriate. For example, just as clinging may be considered normal for a toddler but abnormal behavior in an older child, toddlers and very young children often behave aggressively—grabbing toys and even biting one another. When, however, a child older than five displays such aggressive behavior, it may indicate an emerging oppositional defiant or conduct disorder.

It is important to distinguish isolated acts of aggression or the normal childhood and adolescent phases of testing limits from the pattern of ongoing, persistent defiance, hostility, and disobedience that is the hallmark of oppositional defiant disorder (ODD). Children with ODD are argumentative, lose their tempers, refuse to adhere to rules, blame others for their own mistakes, and are spiteful and vindictive. Their behaviors often alienate them from family and peers and cause problems at school.

Family strife, volatile marital relationships, frequently changing caregivers, and inconsistent child-rearing practices may increase risk for the disorder. Some practitioners consider oppositional defiant disorder a gateway condition to conduct disorder. According to the Surgeon General's report, estimates of the prevalence of ODD range from 1% to 6%, depending on the population and the way the disorder was evaluated. Prepubescent boys are diagnosed more often with ODD than girls of the same age, but after puberty the rates in both genders are equal.

Children or adolescents with conduct disorder are aggressive. They may fight, sexually assault, or behave cruelly to people or animals. Because lying, stealing, vandalism, truancy, and substance abuse are common behaviors, adults, social service agencies, and the criminal justice system often view affected young people as "bad" rather than mentally ill. The American Academy of Child and Adolescent Psychiatry describes an array of generally antisocial behaviors that when exhibited by children or adolescents suggest a diagnosis of conduct disorder. These actions and behaviors include:

• bullies, threatens, or intimidates others
• often initiates physical fights
• uses a weapon such as a bat, brick, knife, or gun that could cause serious physical harm
• physically cruel to people or animals
• steals from a victim while confronting them
• engages in coercive or forced sexual activity
• deliberately sets fires with the intention to cause damage
• deliberately destroys others' property
• breaks into a building, house, or car
• lies to obtain goods or favors, or to avoid obligations
• steals items without confronting a victim
• often stays out at night despite parental objections
• runs away from home
• often truant from school

Conduct disorder severely compromises the lives of affected children and adolescents. Their schoolwork suffers, as do their relationships with adults and peers. The Surgeon General's report found that youths with conduct disorders have higher rates of injury and sexually transmitted diseases (STDs) and are likely to be expelled from school and have problems with the law. Rates of depression, suicidal thoughts, suicide attempts, and suicide are all higher in children and teens diagnosed with conduct disorders. Children in whom the disorder presents before age ten are predominantly male. Early onset places them at greater risk for adult antisocial personality disorder. More than one-quarter of severely antisocial children become antisocial adults.

The origins of conduct disorder have not been pinpointed, but, like other mental disorders, it is probably caused by some combination of biological and psychosocial factors. Psychosocial risk factors for conduct disorder include maternal rejection, separation from parents with no surrogate caregiver, early institutionalization, family neglect, abuse or violence, parental marital conflict, large family size, overcrowding, and poverty. In these circumstances children may lack feelings of attachment to their parents or families, and later, to the community. Eventually they express these feelings of alienation by behaving with disregard for societal rules and values. Some mental health practitioners describe affected individuals as appearing to lack a moral compass.

To date there are no medications that have proven effective in treating conduct disorder. While psychosocial interventions can reduce their antisocial behavior, living with a child or teen with a conduct disorder stresses the entire family. Support programs train parents how to positively reinforce appropriate behaviors and how to strengthen the emotional bonds between parent and child. Identifying and intervening with high-risk children to enhance their social interaction and prevent academic failure can mitigate some of the potentially harmful long-term consequences of conduct disorder.

EATING DISORDERS

American society is preoccupied with body image. Americans are bombarded with images of very thin, beautiful young women and lean, muscular men in magazines, on television, on billboards, and in the movies. The advertisers of many products suggest that to be thin and beautiful is to be happy. Many prominent weight-loss programs reinforce this suggestion. A well-balanced, low-fat food plan, combined with exercise, can help most overweight people achieve a healthier weight and lifestyle. Dieting to achieve a healthy weight is quite different from dieting obsessively to become "model" thin, which can have consequences ranging from mildly harmful to life threatening. The NIMH observes that eating disorders frequently coexist with other mental disorders, including depression, substance abuse, and anxiety disorders.

Preteens, teens, and college-age women are at special risk for eating disorders. In fact, most of those who develop an eating disorder are young women. However, between 5% and 15% of people with anorexia or bulimia and about 35% of those with binge-eating disorder are male, according to the NIMH. No one knows exactly how many men and teenage boys are afflicted. Until recently, there has been a lack of awareness that eating disorders can be a problem for males, perhaps because men are more likely to mask the symptoms of eating disorders with excuses and rationales such as preventing heart disease or diabetes or trying to build a more muscular physique. Studies suggest that for every ten women with an eating disorder, one male is afflicted.

Anorexia Nervosa

Anorexia nervosa involves severe weight loss—a minimum of 15% below normal body weight. People with anorexia literally starve themselves, although they may be very hungry. For reasons that researchers do not yet fully understand, people with anorexia become terrified of gaining weight. Both food and weight become obsessions. They often develop strange eating habits, refuse to eat with other people, and exercise strenuously to burn calories and prevent weight gain. Individuals with anorexia continue to believe they are overweight even when they are dangerously thin.

The medical complications of anorexia are similar to starvation. When the body attempts to protect its most vital organs—the heart and the brain—it goes into "slow gear." Monthly menstrual periods stop, and breathing, pulse, blood pressure, and thyroid function slow down. The nails and hair become brittle, and the skin dries. Water imbalance causes constipation, and the lack of body fat causes an inability to withstand cold temperatures. Depression, weakness, and a constant obsession with food are also symptoms of the disease. In addition, personality changes may occur. The person suffering from anorexia may have outbursts of anger and hostility or may withdraw socially. In the most serious cases, death can result.

Bulimia

The person who has bulimia eats compulsively and then purges (gets rid of the food) through self-induced vomiting; use of laxatives, diuretics, strict diets, fasts, or exercise; or a combination of several of these compensatory behaviors. In 2002 the NIMH reported that based on community surveys, between 2% and 5% of Americans engage in binge eating, and about half of those with anorexia will turn to bulimia. Bulimia often begins when a young person is disgusted with the excessive amount of "bad" food consumed and vomits to rid the body of the calories.

Many people with bulimia are at a normal body weight or higher because of their frequent binge-purge behavior, which can occur from once or twice a week to several times a day. Those people with bulimia who maintain normal weights may manage to keep their eating disorders secret for years. As with anorexia, binge-eating disorder usually begins during adolescence, but many people with bulimia do not seek help until they are in their thirties or forties.

Binge eating and purging is dangerous. In rare cases, bingeing can cause stomach ruptures, and purging can result in heart failure because the body loses vital minerals. The acid in vomit wears down tooth enamel and the stomach lining and can cause scarring on the hands when fingers are pushed down the throat to induce vomiting. The esophagus may become inflamed, and glands in the neck may become swollen.

People with bulimia often talk of being "hooked" on certain foods and needing to feed their "habits." This addictive behavior carries over into other areas of their lives, including substance (alcohol and drug) abuse. Many people with bulimia suffer from comorbidities such as severe depression, which increases their risk for suicide.

Causes of Eating Disorders

Evidence suggests a genetic component to susceptibility to eating disorders. For example, in the general population the chance of developing anorexia is about one in two hundred, but when a family member has the disorder, the risk increases to one in thirty. Twin studies demonstrate that when one twin is affected there is about a 50% chance the other will develop anorexia (Arline Kaplan, "Exploring the Gene-Environment Nexus in Anorexia, Bulimia," Psychiatric Times, vol. 29, no. 9, August 2004).

People with bulimia and anorexia seem to have different personalities. Those with bulimia are likely to be impulsive (acting without considering the consequences) and are more likely to abuse alcohol and drugs. People with anorexia tend to be perfectionists, good students, and competitive athletes. They usually keep their feelings to themselves and rarely disobey their parents. People with bulimia and anorexia share certain traits: they lack self-esteem, have feelings of helplessness, and fear gaining weight. In both disorders, the eating problems appear to develop as a way of handling stress and anxiety.

The person with bulimia consumes huge amounts of food (often junk food) in a search for comfort and stress relief. Yet the bingeing brings only guilt and depression. However, persons with anorexia restrict food to gain a sense of control and mastery over some aspect of their lives. Controlling their body weight seems to offer two advantages—the victims can take control of their bodies and can gain approval from others.

Demographics and Prevalence of Eating Disorders

Individuals with eating disorders usually come from white, middle- or upper-class families. The NIMH noted that while eating disorders have increased substantially in industrialized countries during the past twenty years, they are almost unheard of in developing countries. Thinness is not necessarily admired among all people throughout the world, especially in countries where hunger is not a matter of choice.

Estimates of the prevalence of eating disorders vary in part because secretiveness and shame prevent many cases from being reported. The NIMH in "Eating Disorders: Facts about Eating Disorders and the Search for Solutions" (2001, http://www.nimh.nih.gov/Publicat/eatingdisorders.cfm) estimates that throughout their lifetimes, from .5% to 3.7% of females suffer from anorexia and from 1.1% to 4.2% suffer from bulimia. The lifetime prevalence of binge eating was estimated as 2-5% for males and females. The National Women's Health Information Center names eating disorders as a key health issue affecting from 1% to 4% of young women in the United States. The center also observes that eating disorders often coexist with other high-risk health behaviors such as tobacco, alcohol and drug use, delinquency, unprotected sexual activity, and suicide attempts.

Dean D. Krahn et al in "Pathological Dieting and Alcohol Use in College Women—A Continuum of Behaviors" (Eating Behaviors, January 2005) examined the relationship between dieting, binge eating disorder, and alcohol use in female college students. The University of Wisconsin researchers found a relationship between dieting and bingeing severity and the frequency, intensity, and negative consequences of alcohol use in the students. In fact, dieting and bingeing was more closely associated with alcohol use than depression, the subjects' parents' drinking history, or their ages when they had their first alcoholic drinks. Further, the severity of the disordered eating behavior was linked to the occurrence of negative consequences of alcohol use such as blackouts and unintended sexual activity. The researchers concluded that destructive eating behaviors are often associated with harmful alcohol use.

According to the National Eating Disorders Association, conservative estimates of the prevalence of eating disorders in the United States project that as many as ten million women and one million men are affected. An estimated 35% of normal dieters progress to the dangerous extreme dieting that is a precursor of eating disorders. The Eating Disorders Coalition for Research, Policy, and Action reports that the incidence of eating disorders has doubled since the 1960s and that mortality attributable to eating disorders is as high as 20%—the highest mortality rate of any mental illness.

Treatment of Eating Disorders

Generally a physician treats the medical complications of the disorder, while a nutritionist advises the affected individual about specific diet and eating plans. To help the person with an eating disorder face his or her underlying problems and emotional issues, psychotherapy is usually necessary. Persons with eating disorders, whether they are normal weight, overweight, or obese, should seek help from a mental health professional such as a psychiatrist, psychologist, or clinical social worker for their eating behavior. Sometimes the challenge is to convince people with eating disorders to seek and obtain treatment; other times it is difficult to gain their adherence to treatment. Many anorexics deny their illness, and getting and keeping anorexic patients in treatment can be difficult. Treating bulimia is similarly difficult. Many bulimics are easily frustrated and want to leave treatment if their symptoms are not quickly relieved.

Several approaches are used to treat eating disorders. Cognitive behavioral therapy (CBT) teaches people how to monitor their eating and change unhealthy eating habits. It also teaches them how to change the way they respond in stressful situations. CBT is based on the premise that thinking influences emotions and behavior—that feelings and actions originate with thoughts. CBT posits that it is possible to change the way people feel and act even if their circumstances do not change. It teaches the advantages of feeling calm when faced with undesirable situations. CBT clients learn that they will confront undesirable events and circumstances whether they become troubled about them or not. When they are troubled about events or circumstances, they have two problems—the troubling event or circumstance, and the troubling feelings about the event or circumstance. Clients learn that when they do not become troubled about trying events and circumstances they can reduce the number of problems they face by half.

Interpersonal psychotherapy (IPT) helps people look at their relationships with friends and family and make changes to resolve problems. Interpersonal psychotherapy is short-term therapy that has demonstrated effectiveness for the treatment of depression. According to the International Society for Interpersonal Psychotherapy, IPT does not assume that mental illness arises exclusively from problematical interpersonal relationships. It does emphasize, however, that mental health and emotional problems occur within an interpersonal context. For this reason, the therapy aims to intervene specifically in social functioning to relieve symptoms.

Like other forms of psychotherapy, IPT may be used in conjunction with medications. Because eating disorders frequently recur, it is recommended that successful short-term treatment be combined with ongoing maintenance therapy, such as monthly sessions following completion of the short-term phase.

Group therapy has been found helpful for bulimics, who are relieved to find that they are not alone or unique in their binge-eating behaviors. A combination of behavioral therapy and family systems therapy is often the most effective with anorexics. Family systems therapy considers the family as the unit of treatment and focuses on relationships and communication patterns within the family rather than the personality traits or symptoms displayed by individual family members. Family systems therapy considers the family as an entity that is more than the sum of its individual members and uses "systems theory" to determine family members' roles within the system as a whole. Problems are addressed by modifying the system rather than trying to change an individual family member. Persons with eating disorders who also suffer from depression may benefit from antidepressant and antianxiety medications to help relieve coexisting mental health problems.

A long-term study (approximately 11.5 years) of 173 young women diagnosed with bulimia reiterated the strong hold eating disorders have on their victims (P. K. Keel et al, "Long-Term Outcome of Bulimia Nervosa," Archives of General Psychiatry, vol. 56, January 1999). At the final follow-up, 30% of the patients still showed symptoms of eating disorders. Eighteen percent were diagnosed with an "eating disorder not otherwise specified," 11% with bulimia, and .6% with anorexia nervosa.

Of the 70% in remission, one-third had achieved only partial remission. Patients who had longer periods of symptoms before beginning treatment and those who had a history of substance abuse were less likely to be successful. The results of this study underscore the observation that the earlier the eating disorder is diagnosed and treated, the more likely the patient will recover to a healthy weight.

Recovery from eating disorders is uneven. The Eating Disorders Coalition for Research, Policy, and Action characterized recovery as a process that frequently entails multiple rehospitalizations, limited ability to work or attend school, and limited capacity for interpersonal relationships. About one-third of sufferers recover after an initial episode and treatment, another third fluctuate between recovery and relapse, and the remaining one-third suffer chronic decline and deterioration.

In part, eating disorders are difficult to treat effectively because many sufferers resist entering treatment and/or fail to complete treatment programs. Katherine Halmi et al. in "Predictors of Treatment Acceptance and Completion in Anorexia Nervosa: Implications for Future Study Designs" (Archives of Psychiatry, July 2005) examined the factors leading to nonacceptance and noncompletion (dropping out) of treatment of a specific treatment plan—cognitive behavioral therapy, fluoxetine hydro-chloride, or their combination for one year to treat anorexia nervosa. Of the 122 subjects with diagnosed anorexia nervosa, almost half (46%) dropped out of treatment. More than two-thirds (68%) of those who dropped out cited "dissatisfaction with some aspect of the treatment" as their reason for noncompletion. While the researchers did not pinpoint the reasons for nonacceptance and noncompletion, their study offered some clues and direction for further investigation. For example, the study found that subjects with high self-esteem were more likely than those with low self-esteem to complete treatment. As a result, the researchers opined that remedies must be identified to "improve acceptance of treatment and reduce dropout in those patients with low obsessive preoccupation and low self-esteem."

Robin Sysko et al in "Eating Behavior among Women with Anorexia Nervosa" (American Journal of Clinical Nutrition, August 2005) reconfirmed the finding that while hospital treatment of persons with anorexia is often successful, 30% to 70% of patients suffer relapses when they are discharged back into the community. The researchers wanted to find out whether current treatment for anorexia successfully addresses severe caloric restriction and other characteristic features of anorexia nervosa. To do this, they scrutinized eating behavior among persons with anorexia nervosa before and immediately after treatment that restored their weight and compared these behaviors to those of control subjects.

They observed twelve anorexic patients and twelve individuals without eating disorders who were asked to consume a strawberry yogurt shake, which they were told would be their lunch for the day. They were also told to consume as much as they wanted. The yogurt shake was in an opaque container and was drunk with a straw so that the subjects could not see the shake. They were also not told the contents of the shake or how many calories it contained. The anorexic patients were tested when they were admitted for treatment, and re-tested after they had reached 90% of their ideal body weight.

Before treatment, anorexic patients consumed an average 103.97 grams of the shake, which increased to an average of 178.03 grams after treatment. However, in both instances, control subjects consumed significantly more than anorexic patients, at an average of 489.58 grams. The researchers observed that subjects with anorexia found the experiment difficult and anxiety provoking because they were unable to see the shake and control their calorie intake. This was despite the fact that subjects treated for anorexia displayed significant decreases in psychological and eating-disordered symptoms after they had regained weight. The researchers felt their findings underscored the need for interventions for people with anorexia once they leave an intensive treatment program. They hope to devise strategies to help normalize patients' eating behavior outside the hospital, for example by helping reduce their anxiety and fear about eating unknown quantities of food.

PRESCRIBING PSYCHOACTIVE MEDICATION TO CHILDREN

The NIMH released Treatment of Children with Mental Disorders (2004, http://www.nimh.nih.gov/publicat/childqa.cfm#readNow), a publication aimed at parents of children with a range of mental disorders. The NIMH acknowledged public concern that psychotropic medication is being prescribed to very young children and that the safety and efficacy of most psychotropic medications have not yet been established. Several widely used drugs have not received FDA approval for use in young children simply because there are not enough data to support their use.

The data are lacking because historically there were ethical concerns about involving children in clinical trials to determine not only the most effective treatments but also proper dosage, potential side effects, and the long-term effects of drug use on learning and development. Policies about research involving children affect the FDA approval process and recommendations for use. For example, methylphenidate is approved for use in children age six and older, but its use was not evaluated in children younger than age six. In contrast, dextromethamphetamine received approval for use in children as young as three because by the time approval was sought, study guidelines permitted participation of younger children. Table 8.6 lists the brand and generic names of medications in four major classes of drugs used to treat mental disorders in children and adolescents and indicates the ages at which drug use is approved.

Because the FDA approval process often requires years of research to demonstrate safety and efficacy, and practitioners are eager to provide symptom relief for severely troubled children, many recommend off-label use of medications. Off-label treatment may involve use of a medication that has not yet received official FDA approval for use in children or the use of a drug the FDA has approved for children to treat a specific condition for which its use has not been approved. The HHS in Report of the Surgeon General's Conference on Children's Mental Health: National Action Agenda (updated April 2004, http://www.hhs.gov/surgeongeneral/topics/cmh/childreport.htm) found that the majority of all drugs approved by the FDA for adult use have not been approved for use in children. As such, they are prescribed off-label when used in pediatric and adolescent medicine. The NIMH observes that some off-label use is supported by data from well-controlled studies but cautions that other off-label prescribing, particularly to very young children whose responses to these drugs have not been scrutinized, should be performed prudently.

The Surgeon General's report found strong support for the safety and efficacy of several classes of agents for several conditions, specifically SSRIs for childhood/ adolescent obsessive-compulsive disorder and psychostimulants for ADHD. The report lamented the lack of information about the safety and efficacy of other psychotropics and urged researchers to produce data for SSRIs, mood stabilizers, and new antipsychotics, because these medications appear to be high on the growing list of psychotropic medications used to treat children and adolescents. Table 8.7 offers letter grades that rate the short-and long-term safety and efficacy of eight classes of drugs used to treat specific mental disorders in children.

SUICIDE

Suicide may be the ultimate expression or consequence of depression or other serious mental disorders. Not all people who suffer from depression contemplate suicide, nor do all those who attempt suicide suffer from depressive or other mental illnesses. However, with the exception of certain desperate medical situations, suicide in the United States generally is considered an unacceptable act, the product of irrationality. It often is referred to as a "long-term solution to a short-term problem."

Since 1970 the death rate for suicide has decreased from 13.1 suicides per one hundred thousand resident population to 10.9 deaths per one hundred thousand in 2002. (See Table 8.8.) In 2002 suicide ranked as the eighth-leading cause of death among males in the United States. (See Table 1.9 in Chapter 1.)

Who Commits Suicide?

Suicide occurs among all age, sex, racial, occupational, religious, and social groups. Table 8.8 lists the suicide death rates by age, sex, and race/ethnicity from 1950 to 2002. In 2002 suicide was the third-leading cause of death among people age fifteen to twenty-four; more teens and young adults died from suicide than from HIV disease, cancer, birth defects, chronic lung disease, heart disease, pneumonia, influenza, and diabetes combined. (See Table 1.12 in Chapter 1.)

The number of completed suicides does not give a complete picture of the problem, because for every completed suicide there are many unsuccessful suicide attempts. For example, during the 1990s death rates for suicide declined, but in some age groups the rate of suicide attempts actually increased. Usually suicide attempts outnumber completed suicides by about eight to one. Among teens, however, the ratio is twenty-five to thirty attempts for every successful suicide. According to the NIMH, approximately one million teens go through "suicide crises" each year. Depression, substance abuse, physical abuse, and sexual abuse are risk factors for attempted suicide by adolescents.

The NIMH states that approximately four times as many men die by suicide than women do. This is despite the fact that women attempt suicide three times as often as men. Men make up about three-fourths of total suicides, and white males account for most of that number. Men use more deadly weapons than women—more than half shoot themselves (80% percent of all suicide deaths by firearm are white males), but gun use is increasing rapidly among people of both genders. In the younger age brackets for women (ages fifteen to twenty-four), more than half of those who completed a suicide used a gun.

In 2002 the suicide rate for white non-Hispanic males in the "all ages" category (21.4 per one hundred thousand population) was higher than the rate for males of other races and ethnicities in that age category. It was more than double the rate of African-American males (9.8 per one hundred thousand). American Indian/Alaska Native males had a suicide rate almost as high as that of white males (16.4 per one hundred thousand). This reflects the high suicide rate (27.9 per one hundred thousand) among the youngest (ages fifteen to twenty-four) and young to middle-aged (twenty-five to forty-four years) American Indian/Alaska Native males (26.8 per one hundred thousand). Although still relatively high, the suicide rate among the youngest American Indian/Alaska Native males (ages fifteen to twenty-four) has decreased by almost half from its peak of 49.1 per one hundred thousand in 1990. Between 1950 and 2002, suicide rates among young (fifteen to twenty-four years old) white and African-American men increased dramatically—from 4.9 to 11.3 per one hundred thousand population for African-American males. (See Table 8.8.)

Among older white males, the suicide rate in 2002 was far higher than for any other racial group. Non-Hispanic white males age sixty-five and older had death rates from suicide (35.1 per one hundred thousand) three times higher than the rates for African-American males (11.7 per one hundred thousand). (See Table 8.8.)

For white and African-American women, the suicide rates were far lower than those for men in all age groups.

The death rate from suicide for non-Hispanic white women was 5.1 per one hundred thousand in 2002, and for African-American women the rate was less than a third that at 1.6 per one hundred thousand. Young non-Hispanic white women ages fifteen to twenty-four had a suicide rate (3.4 per one hundred thousand) about one-sixth the rate for non-Hispanic white men (19.3 per one hundred thousand) in the same age group. For African-American women of all ages, the rate (1.6 per one hundred thousand) was about one-sixth the African-American male rate (9.8 per one hundred thousand). (See Table 8.8.)

Female suicide rates do not change as drastically as men's do as they age. African-American women age sixty-five years and older had a suicide rate in 2002 of 1.1 per one hundred thousand, compared with 11.7 per one hundred thousand African-American men. For non-Hispanic white women age sixty-five and older, the rate was 4.5 per one hundred thousand in 2002, compared with the non-Hispanic white male rate of 35.1 per one hundred thousand. (See Table 8.8.) One widely held theory about the high rates among white men older than age sixty-five years is that these men, who traditionally have been in positions of power, have great difficulty adjusting to lives they may consider useless or diminished.

Other minority groups showed similar disparities between the suicide rates of women and men in 2002. American Indian/Alaska Native males (16.4 per one hundred thousand) had a suicide rate four times that of American Indian/Alaska Native females (4.1 per one hundred thousand). The suicide rate for Asian/Pacific Islander men was eight per one hundred thousand, whereas the rate for Asian/Pacific Islander women was three per one hundred thousand. Hispanic males had a rate of 9.9 per one hundred thousand. Hispanic females (1.8 per one hundred thousand) and African-American females (1.6 per one hundred thousand) had the lowest suicide rates. (See Table 8.8.)

Why Do People Commit Suicide?

People commit suicide for various reasons. Notes left by people who have killed themselves usually tell of life crises that they believed were unbearable. Many describe enduring chronic pain, losing loved ones, being unable to pay bills, or finding themselves incapable of living independently. Other commonly cited reasons are as follows:

• To punish loved ones
• To gain attention
• To join a deceased loved one
• To avoid punishment
• To express love

Some suicides are committed on an irrational, impulsive whim. Researchers observe that even among those most determined to commit suicide, the desire is not as much to die as it is to escape the lives they are leading and to end the pain they are suffering. Whatever the cause of their despair, they are desperately crying out for help.

Follow-up studies on suicide survivors reveal their intense ambivalence about actually dying. Not all survivors are glad to be alive, but for most, the attempted suicide marked a definite turning point. It was an urgent and dramatic signal that their problems demanded serious and immediate attention. Most of the survivors said that what they really wanted was to change their lives.

Suicide among the Terminally Ill

Not all suicides are categorized as the acts of people who are mentally ill. Some people consider suicides committed by people who are terminally ill as rational choices. They argue that a person who is terminally ill has the right to die, that is, the right to control the manner of their death. Until the late 1990s, people with cancer and AIDS were, of the terminally ill, the most likely to commit suicide. Patients with terminal diseases often worry that they will suffer long and painful deaths and that they stand a good chance of losing everything—health, independence, jobs, insurance, homes, and contact with loved ones and friends.

Researchers have found that factors with significant impact on the quality of life include security, family, love, pleasurable activity, and freedom from pain and suffering. Sufferers of debilitating disease may lose all of these. For some, suicide is a last recourse to relieve pain, suffering, insecurity, dependence, or hopelessness.

Suicide's Warning Signs

Researchers believe that most suicidal people convey their intentions to someone among their friends and family, either openly or indirectly. The people they signal are those who know them well and are in the best position to recognize the signs and give help. Comments such as "You'd be better off without me," "No one will have to worry about me much longer," or even a casual "I've had it" may be signals of upcoming attempts. Some people who are suicidal put their affairs in order. They draw up wills, give away prized possessions, or act as if they are preparing for a long trip. They may even talk about going away.

Often the indicator is a distinct change in personality or behavior. A normally happy person may become increasingly depressed. A regular churchgoer may stop attending services, or an avid runner may quit exercising. These types of changes, if added to expressions of worthlessness or hopelessness, can indicate not only that the person is seriously depressed but also that he or she may have decided on trying suicide. Although the vast majority of people who are depressed are not suicidal, most of the suicide-prone are depressed. Researchers and health care practitioners caution that suicide threats and attempts should not be discounted as harmless bids for attention. Anyone thinking, talking about, or planning suicide should receive immediate professional evaluation and treatment.

People who have a record of previous suicide attempts are at the highest risk of actually killing them-selves—more than six hundred times likelier than the general population. Between 20% and 50% of those who complete suicide have tried it before (Institute of Medicine, Reducing Suicide: A National Imperative, Washington, DC: National Academies Press, 2002).

The National Center for Injury Prevention and Control (NCIPC) of the CDC sponsors initiatives to raise public awareness of suicide and institutes strategies to reduce suicide deaths. Along with support for research about risk factors for suicide in the general population, NCIPC also addresses high-risk populations with programs such as the American Indian/Alaska Native Community Suicide Prevention Center and the Surgeon General's Call to Action—a blueprint for addressing suicide.