Suicide: Consequences

Suicide: Consequences
Cost to Society
•The total lifetime cost of self-inflicted injuries occurring in 2000 was approximately $33 billion. This includes $1 billion for medical treatment and $32 billion for lost productivity (Corso et al. 2007).
Consequences
•Suicide is the 11th leading cause of death among Americans (CDC, 2006).
•Over 33,000 people kill themselves each year (CDC, 2006).
•Approximately 395,000 people with self-inflicted injuries are treated in emergency departments each year (CDC, 2007).
•Many people are exposed to another person's suicide which may affect them psychologically. One estimate was that approximately 7% of the US population knew someone who died of suicide during the past 12 months. (Crosby and Sacks, 2002).
References
Centers for Disease Control and Prevention. Web-based Injury Statistics Query and Reporting System (WISQARS). Atlanta, GA: National Center for Injury Prevention and Control. Available at: www.cdc.gov/ncipc/wisqars. Last modified 2008 August 26.

Crosby AE, Sacks JJ. Exposure to suicide: Incidence and association with suicidal ideation and behavior – United States, 1994. Suicide and Life-Threatening Behavior 2002; 32:321–328.

Corso PS, Mercy JA, Simon TR, Finkelstein EA, & Miller TR. Medical Costs and Productivity Losses Due to Interpersonal Violence and Self- Directed Violence. American Journal of Preventive Medicine 2007: 32(6): 474–482.

Family Psychoeducation

Family Psychoeducation
Workbook
Chapter 12: Readings and Other Resources
Essential Readings For Practitioners

The following four books are recommended references for those wanting to master this approach. The first includes key elements of the Anderson and Falloon approach and should be read first. The Miklowitz, et al., book is an important reference for those working with consumers with bipolar disorder.

McFarlane, W.R., Multifamily Groups in the Treatment of Severe Psychiatric Disorders, New York, NY, Guilford, 2002.

Anderson, C., Hogarty, G., Reiss, D., Schizophrenia and the Family, New York, NY, Guilford Press, 1986

Falloon, I., Boyd, J., McGill, C., Family Care of Schizophrenia, New York, NY, Guilford Press, 1984.

Miklowitz, D.J., Goldstein, M., Bipolar Disorder: A Family-focused Treatment Approach, New York, NY, Guilford Press, 1997

Additional Resources For Practitioners

Amenson, C., Schizophrenia: A Family Education Curriculum, Pacific Clinics, 1998.
Provides 150 slides with lecture notes for a class for families with a member with schizophrenia. Includes information about the illness, medication and psychosocial treatments and the role of the family in promoting recovery.


Amenson, C., Schizophrenia: Family Education Methods, Pacific Clinics, 1998.
Companion handbook to Schizophrenia: A Family Education Curriculum provides methods for forming a class, optimizing the learning of families, and dealing with typical problems that arise in conducting family classes.


Mueser K, Glynn S: Behavioral Family Therapy for Psychiatric Disorders. Oakland, New Harbinger Publications, 1999
A comprehensive model of single-Family Psychoeducation that includes a multifamily discussion/support group. The book contains individual educational handouts for various psychiatric diagnoses and handout for various related topic areas.
Psychopharmacology

The Essential Guide to Psychiatric Drugs by J. Gorman, St. Martin’s Press, 1995.
Written for a sophisticated consumer, it is the most accessible source of information about psychotropic medications. It distills the Physician’s Desk Reference into understandable language. It describes the individual “trees” (such as Prozac) in the forest of medicines. “The benzodiazepines: Are they really dangerous?” is a typical section heading.


Medicine and Mental Illness by M. Lickey and B. Gordon, Freeman, 1991.
A scholarly yet readable work written for professionals, it is best at teaching the principles of diagnosis, neurophysiology and psychopharmacological treatment of mental illness. It describes the “forest” of psychopharmacology, why it is there and how it works. “The blockade of dopamine receptors and antipsychotic potency” is a typical section heading. It does not discuss the profiles of individual medications.
Cultural Competence

The Cross-Cultural Practice of Clinical Case Management in Mental Health edited by Peter Manoleas, Haworth Press, 1996.
A collection of useful articles about the role of gender, ethnicity, and acculturation in treatment seeking and response. Provides guidelines for engaging and intervening with specific ethnic and diagnostic groups in varying treatment contexts.
Videotapes

Schizophrenia Explained by William R. McFarlane, M.D. Produced by, and order from, the author at Maine Medical Center, 22 Bramhall Street, Portland, ME 04102. (Phone 207-871-2091). mcfarw@mmc.org
This provides a full review in lay language of the psychobiology of schizophrenia, emphasizing the key concepts in Family Psychoeducation: stress reduction, optimal environments and interactions for recovery, and support for the family’s ability to contribute to recovery in many ways. It is often used in lieu of a psychiatrist during Family Education Workshops and for staffs of case management programs, community residences and employment programs to help them understand how to assist consumers with this disorder.


Exploring Schizophrenia by Christopher S. Amenson, Ph.D. Produced by the California Alliance for the Mentally Ill (Phone 916-567-0163).
This videotape uses everyday language to describe schizophrenia and give guidelines for coping with illness for consumers and their families.


Surviving and Thriving with a Mentally Ill Relative by Christopher Amenson, Ph.D., Third edition 1998.
Eighteen hours of good “home video quality” videotapes cover schizophrenia, bipolar disorder, major depressive disorder, medication, psychosocial rehabilitation, relapse prevention, motivation, and family skills. Order from Paul Burk, 1352 Hidden Springs Lane, Glendora, CA 91740. (Phone 626-335-1307).


Critical Connections: A Schizophrenia Awareness Video produced by the American Psychiatric Association, 1997.
This 30 minute video was designed by the APA to help consumers and families cope with the disabling effects of schizophrenia. It provides a hopeful, reassuring message about new medications and psychosocial treatments that assist with recovery.


Exploring Bipolar Disorder by Jerome V. Vaccaro, M.D., 1996
One hour professional quality videotape describes the illness, recovery, and the role of the family. Persons with the illness contribute valuable insights. Produced by and ordered from the California Alliance for the Mentally Ill, 1111 Howe Avenue, Suite 475, Sacramento, CA 95825. Phone 916-567-0163.
Periodicals

Schizophrenia Bulletin
Highly technical and difficult to read but it is the ultimate source for research findings. The fall 1995 issue summarizes “Treatment Outcomes Research”.


Psychiatric Services
Practical articles in all aspects of mental illness. Brief clinically relevant articles on medication and other treatments. The most useful periodical for clinical staff.


Psychosocial Rehabilitation
Practical psychosocial rehabilitation articles. Easy to read and understand. Provides “how to” details. Contains good consumer written articles.
Other Resources

There are a number of excellent books written for persons with a mental illness and their families to help them understand and deal with these illnesses. Many of these are helpful for professionals directly and all are important resources to which to refer patients and families. (See Reading List for Families.) Many of the professional and family books are offered at a discount by The National Alliance on Mental Illness, 200 N. Glebe Road, Suite 1015, Arlington, VA 22203-3754. Phone 703-524-7600.

Books on Mood Disorders (Bipolar and Unipolar Depressions)

A Brilliant Madness: Living with Manic Depressive Illness by Patty Duke and Gloria Hochman. (Bantam, 1992)
Combines personal experience with clinical information to describe manic depression in understandable terms and provide guidelines for coping with it.


Control Your Depression by Peter Lewinsohn, Ricardo Munoz, Mary Ann Youngren, and Antonette Zeiss.(Prentice Hall, Englewood Cliffs, New Jersey, 1979)
Self-help book which assesses contributors to depression and includes activities, relaxation techniques, thinking, social skills, self-control, and specific ideas and exercises for each problem area.


The Depression Workbook by Mary Ellen Copeland. (Harbinger, 1992)
Assists individuals in taking responsibility for wellness by using charts and techniques to track and control moods. The most complete and useful self help book for bipolar and unipolar depressions.


The Feeling Good Handbook by David Burns, (Penguin, New York, NY, 1989)
Self-help book presents rationale for cognitive therapy for depression. Gives specific ideas and exercises to help change thought patterns associated with depression and other problems.


Lithium and Manic Depression: A Guide by John Bohn and James Jefferson.
A very helpful guide for people with manic depression and their families regarding lithium treatment. Order from Lithium Information Center, Department of Psychiatry, University of Wisconsin, 600 Highland Ave., Madison, WI 53792.


Our Special Mom and Our Special Dad by Tootsie Sobkiewicz (Pittsburgh: Children of Mentally Ill Parents, 1994 and 1996)
Two interactive storybooks that allow primary school age children to understand and identify with the problems associated with having a mentally ill parent. Can be well utilized by a relative or therapist in individual or group work.


Overcoming Depression, Third Edition by D. & J. Papolos (Harper & Row, 1997).
A comprehensive book written for persons suffering from manic depression and major depression, as well as their families. It is the best source of information about these disorders. Does not offer coping strategies. This book and The Depression Workbook are the best two to read.


An Unquiet Mind by Kay Redfield Jamison
A compelling and emotional account of the author’s awareness, denial, and acceptance of her bipolar disorder. It offers hope and insight regarding recovery for anyone who reads it.
Books on Dual Diagnosis (Mental Illness and Substance Abuse)

Alcohol, Street Drugs, and Emotional Problems: What you need to know by B. Pepper and H. Ryglewicz.
These informative pamphlets come in versions for the client, for the family and for professionals. They can be ordered from TIE Lines, 20 Squadron Blvd. Suite 400, New York, NY 10956.


Lives at Risk: Understanding and Treating Young People with Dual Disorders by B. Pepper and H. Rygelwicz
Poignant description of the combination of schizophrenia, mood disorders, and/or personality disorders with substance abuse. Strong on empathy and understanding of the multiple problems. Provides little specific guidance.


Hazelden Publications (RW9 P.O. Box 176, Center City, MN 55012-0176 Phone 1-800-328-9000 or Website www.htbookplace.org
Publishes a large number of pamphlets and self-help books on substance abuse and dual diagnoses. Examples of titles include:
Preventing Relapse Workbook
Taking Care of Yourself: When a family member has a dual diagnosis
Twelve Steps and Dual Disorders
Understanding Schizophrenia and Addiction
Books About Children Who Have a Mental Illness

Children and Adolescents with Mental Illness: A Parents Guide by E. McElroy (Woodbine House, 1988)
Useful guide written by a psychologist who heads the NAMI Children’s and Adolescent network.


Educational Rights of Children with Disorders: A Primer for Advocates by Center for Law and Education. (Cambridge 1991.)


Neurobiological Disorders in Children and Adolescents by E. Peschel, R. Peschel and C. Howe. (Oxford Press, 1992)
Biological mental illnesses among children are less common and less understood “family problems”. This book helps to define childhood neurobiological disorders and gives guidance for finding appropriate treatment.
Books on Special Topics

Planning for the Future and the Life Planning Workbook by L. Mark Russell and Arnold Grant (American Publishing Company, 1995)
This book and accompanying workbook are guides for parents seeking to provide for the future security and happiness of an adult child with a disability following the parents’ deaths.


A Parent’s Guide to Wills and Trusts by Don Silver. (Adams-Hall, 1992)
Information on how to protect a disabled child’s financial future, written by an attorney and NAMI member.


Schizophrenia and Genetic Risks by Irving Gottesman.
This pamphlet contains detailed information about this single topic. It may be ordered from NAMI.


A Street is Not a Home: Solving American’s Homeless Dilemma by Robert Coates. (Prometheus, 1990)
Analysis and guide to dealing with homelessness among persons suffering from mental illness.


Suicide Survivors: A Guide for Those Left Behind by Adina Wrobleski. (Afterwards, 1991.)
With an understanding attitude, the author explores and offers coping suggestions for the many issues that confront families who have had a member kill himself.


Reading List For Families With A Member Who Has A Mental Illness
(Annotations by Christopher S. Amenson, Ph.D.)

Books Which Offer Guidance To Families

Coping with Schizophrenia: A Guide for Families by Kim Mueser and Susan Gingerich. (New Harbinger, 1994)
Comprehensive guide to living with schizophrenia and the best source for practical advice on topics including medication, preventing relapse, communication, family rules, drug use, and planning for the future. Includes forms and worksheets for solving typical problems.


Schizophrenia: Straight Talk for Families and Friends by Maryellen Walsh. (Morrow & Co., 1985).
A parent who, as a professional writer, thoroughly researched the field writes this book. This book is emotional in ways that will touch you and deals with all the issues important to families of persons of schizophrenia. If you can read only one book, select this one if you want to feel understood; select Understanding Schizophrenia to access current research on causes and treatments; select Coping with Schizophrenia if you want concrete advice about coping with the illness.


Surviving Schizophrenia: A Family Manual, Third Edition by E. Fuller Torrey. (Harper & Row, 1995).
Beloved by the Alliance for the Mentally Ill because it was the first book in 1983 to support and educate families. Contains one of the best descriptions of “The Inner World of Madness”. Discusses the major topics in easy to read and very pro-family language.


Troubled Journey: Coming to Terms with the Mental Illness of a Sibling or Parent by Diane Marsh and Rex Dickens (Tarcher/Putnam, 1997)
The best book for siblings and adult children. Helps to recognize and resolve the impact of mental illness on childhood. Seeks to renew self-esteem and improve current family and other relationships.


Understanding Schizophrenia: A Guide to the New Research on Causes and Treatment by Richard Keefe and Philip Harvey. (The Free Press, 1994)
The best description of research on schizophrenia as of 1994. It provides more depth and detail than Surviving Schizophrenia and is a little more difficult to read. A must for families that want to understand the science of schizophrenia.


How to Live with a Mentally Ill Person: A Handbook of Day-to-Day Strategies by Christine Adamec. (John Wiley and Sons, 1996)
This comprehensive, easy-to-read book is written by a parent. It reviews methods for accepting the illness, dealing with life issues, developing coping strategies, negotiating the mental health system, and more.
Books Describing The Experience of Schizophrenia

Anguished Voices: Siblings and Adult Children of Persons with Psychiatric Disabilities by Rex Dickens and Diane Marsh (Center for Psychiatric Rehabilitation, 1994.)
Collection of 8 well-written articles which describe the impact of mental illness on siblings and children. A poignant statement of the issues across the life span that need to be addressed when a person grows up with mental illness in the family.


Crazy Quilt by Jocelyn Riley (William Morrow, 1984)
Fictional account of a 13-year-old girl whose mother has schizophrenia. Written for children and adolescents. Provides understanding for these forgotten victims.


Is There No Place on Earth for Me? by Susan Sheehan. (Houghton-Mifflin, 1982.)
A very realistic depiction of the experience of schizophrenic woman is interwoven with information about legal, funding, and treatment issues. Gives a good description of historical and political influences on the treatment of persons suffering from schizophrenia. Won the Pulitzer Prize.


Tell Me I’m Here: One Family’s Experience with Schizophrenia by Ann Devesch. (Penquin, 1992)
Written by a United Nations Media Peace Prize winner and founder of Schizophrenia Australia, this book describes their family’s experience.


The Quiet Room by Lori Schiller. (1994)
The life story of a person who had an almost full recovery from schizophrenia with clozapine. Great for its inspirational value.


The Skipping Stone: Ripple Effects of Mental Illness on the Family by Mona Wasow (Science and Behavior Books, 1995)
Describes the impact of mental illness on each member of the family in a “Tower of Babel”. Information is from in-depth interviews with family members and professionals.


The Girl with the Crazy Brother by Betty Hyland (Franklin Watts, 1986)
Written for adolescents by an Alliance for the Mentally Ill member. Describes in short novel form the experience of a teenage girl trying to understand the sudden deterioration of her older brother.
Website resources

Bipolar Disorder In Children: Why Are The Rates Rising?

Bipolar Disorder In Children: Why Are The Rates Rising?
By Michael F. Hogan, PhD, Commissioner, New York State Office of Mental Health; and
Lloyd I. Sederer, M.D., Medical Director, New York State Office of Mental Health

Recent media reports tell us that the diagnosis of bipolar disorder in children and adolescents (formerly called manic depressive disorder) is forty times more frequent than it was just ten years ago. Can the numbers of children and adolescents with this illness increase so rapidly? Are medications being over-prescribed?

The rapid increase in diagnoses in such a short period of time cannot be explained by changes in genetics, environment or families. In part it must be due to a broader definition of the illness, which now includes anger and hyperactivity.

But the signs and symptoms needed to make the diagnosis of bipolar disorder, according to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM IV) have not changed in recent years. Diagnoses are being made more liberally, perhaps to the benefit of some children but clearly also to the detriment of others.

For a reliable diagnosis to be made, symptoms common in this disorder such as mood swings, irritability and impulsive behavior must occur during a distinct period of a mood disturbance, a hallmark of this illness and the DSM IV definition. Many children are impulsive and irritable, but that in itself does not meet the criteria for this illness. These symptoms occur with other disorders found in children and adolescents, such as attention deficit hyperactivity disorder (ADHD), depression with agitation and irritability, conduct disorder, and substance use disorders.

A diagnosis of bipolar disorder in children and adolescents does not tell us if the childhood form of the illness will continue into adulthood. Many children with mood swings, depression, and irritability have been brought to physicians over many years. They have been diagnosed with various disorders, including ADHD, conduct disorder and depression, according to the trends at the time. Diagnoses made today may change for individual children as they age, and for children in the future as psychiatry matures.

What should psychiatrists do now? What should parents and caretakers expect in the treatment of their children? A heightened awareness of the existence of bipolar disorder in children may be beneficial if it helps us to recognize more cases of true bipolar disorder and institute treatment earlier. It can also cause confusion and concern in parents and psychiatrists around the use of the medications prescribed for bipolar disorder.

First, a child should be assessed directly by a child and adolescent psychiatrist with information obtained from parents, caregivers and sometimes teachers. Second, valid rating scales can help introduce some objectivity to what is still a professional judgement. The Mood Disorder Questionnaire and the Young Mania Rating Scale are specific to bipolar disorder. Scales such as the Conners’ (with parent and teacher rating forms) for hyperactivity and ADHD can help to differentiate these common conditions, even if many children and adolescents with bipolar disorder also have ADHD. The Beck Depression Inventory (children’s version) can help identify depression. Third, as noted earlier, a consultation or second opinion is another important way to confirm or refute a diagnosis made by one doctor. This is especially valuable in children whose behaviors stimulate desperate efforts to “do something.” Any doctor not open to a second opinion should be suspect.

The treatment of bipolar disorder in children and adolescents, or any mental disorder for that matter, begins with forming a trusting relationship with the child and parents. This means the physician should provide information and educate the family about mental illness, be open to questions and concerns, and share decision-making. Benefits, risks and side-effects of any treatment must be offered in a clear and understandable manner; if you as a parent or youth do not understand, say so and expect a good answer.

Medications are a primary treatment for bipolar disorder and many mental illnesses, and they can provide invaluable help. But medications are only one form of intervention, and not enough in themselves. Various forms of psychotherapy in association with medication may be helpful. In particular, “psycho-educational treatment” for the child and parents provides concrete information about the illness, its impact, and treatment options. Cognitive behavior therapy can be especially helpful in the depressive phase of bipolar disorder and is effective in reducing disruptive behaviors. Support groups for families of children and adolescents with bipolar disorder and other severe disorders also can be helpful.

In light of the rise in diagnosis of this disorder, doctors, families and youth have reason to be concerned that a diagnosis is accurate and the treatment it leads to is optimal. Families should insist on clear information, seek second opinions when unsure, and demand monitoring of care to see if the diagnosis “holds” over time. Parents and youth should expect careful observation of any prescribed medications, and recognize that medications may be a critical part of the treatment but they are not sufficient when it comes to the care of our children.

Disaster Reactions of Potential Risk Groups

Training Manual
for Mental Health and Human Service Workers
in Major Disasters
SECTION 3
Disaster Reactions of Potential Risk Groups

Although there are many feelings and reactions people share in common following a disaster, there are also expressions that are more specifically influenced by the survivor's age, cultural and ethnic background, socioeconomic status, pre-existing physical, and psychosocial vulnerabilities. Disaster mental health workers are better prepared to design effective interventions when they have an understanding of how demographic and health factors interact with disaster stress.

This section describes groups commonly found within communities following a disaster and provides suggestions for disaster mental health interventions. Common issues, concerns, and reactions are also briefly presented in this section.

Common Needs and Reactions

First is a review of some thoughts, feelings, and behaviors common to all who experience a disaster:

Concern for basic survival

Grief over loss of loved ones and loss of valued and meaningful possessions

Fear and anxiety about personal safety and the physical safety of loved ones

Sleep disturbances, often including nightmares and imagery from the disaster

Concerns about relocation and related isolation or crowded living conditions

Need to talk about events and feelings associated with the disaster, often repeatedly

Need to feel one is a part of the community and its disaster recovery efforts
Potential Risk Groups

Each disaster-affected community has its own demographic composition, prior history with disasters or other traumatic events, and cultural representation. When disaster program planners review the groups impacted by a disaster in their community, consideration should be given to the following, as well as additional groups unique to the locale:

Age groups

Cultural and ethnic groups

Socioeconomic groups

People with serious and persistent mental illness

Human service and disaster relief workers
The majority of survivors are resilient and with time can integrate their disaster experiences and losses and move on. However, survivors who have significant concurrent psychosocial, health, or financial problems are at greater risk for depression, anxiety, post-traumatic stress symptoms or an exacerbation of their pre-existing condition. When survivors have personally sustained severe disaster losses (e.g., death of a loved one, devastation of home and community), their reactions are more intensely expressed and over a longer period of time (Solomon & Green, 1992). This section includes a brief overview for each group. The disaster reactions described normally resolve over time with sufficient support and physical recovery. References for more detailed information are provided.

Age Groups

Each stage of life is accompanied by special challenges in coping with the aftermath of a disaster and age-related vulnerabilities to disaster stress. For children, their age and development determine their capacity cognitively to understand what is occurring around them and to regulate their emotional reactions. Children are more vulnerable to difficulty when they have experienced other life stresses in the year preceding the disaster, such as a divorce, a move, or the death of a family member or pet (Vogel & Vernberg, 1993). For adults, stress associated with family and home disruption, financial setbacks, and work overload predominate. For older adults, concerns regarding health, financial stability, and living independently become primary.

The age groups considered in this section are:

Preschool (ages 1-5)

Childhood (ages 6-11)

Pre-adolescence and Adolescence (ages 12-18)

Adults

Older Adults
Reactions and problems vary depending upon the phase of the post-disaster period. Some of the problems discussed appear immediately; many appear months later.

Preschool (ages 1-5)

Small children view their world from the perspectives of predictability, stability, and the availability of dependable caretakers. Disruption in any of these domains causes distress. Preschool age children often feel powerlessness and fear in the face of a disaster, especially if they are separated from parents. Because of their age and small size, they are unable to protect themselves or others. As a result, they may feel considerable anxiety and insecurity.

In the preschool years, children generally lack the verbal and conceptual skills necessary to understand and cope effectively with sudden unexpected stress. They typically look to parents and older siblings as behavior models, as well as for comfort and stability. Research has shown that children's reactions are more related to how their family or caregiver is coping than the actual objective characteristics of the disaster itself (Green et al., 1991).

Children who have lost one or both parents are especially in need. Loss of a relative, a playmate, or a pet is also a disturbing event for children. They will need opportunities to express their grief. One of the major fears of childhood is abandonment, so children need frequent reassurance they will be cared for.

Preschoolers express their upset through regressive behaviors such as thumb sucking, bed-wetting, clinging to their parents, a return of fear of the dark, or not wanting to sleep alone. They often have sleep problems and frightening dreams. These problems are best understood as normal expressions of anxiety about the disruption of their familiar routines and previously secure worlds.

In the natural course of events, small children will try to resolve traumatic experiences by reliving them in their play activities. They may reenact the earthquake, flood, or tornado repeatedly. Children should be encouraged to verbalize their questions, feelings, and misunderstandings about the disaster so that adults can listen and explain. Relief of disaster fears and anxiety is attained through reestablishing the child's sense of security. Frequent verbal reassurance, physical comforting, more frequent attention, comforting bedtime rituals, and mealtime routines are helpful. As much as possible, young children should stay with people with whom they feel most familiar.

Childhood (ages 6 - 11)

School age children are developing the cognitive capacity to understand the dangers to family and environment inherent in disasters. They are more able to understand the disaster event and the mitigating role of disaster preparedness. This awareness can also contribute to preoccupation with weather and disasters, and fears about family members being killed or injured. School age children have a great need to understand what has happened and the concrete steps that they can take for protection and preparedness in the future.

Children often have special bonds with playmates or pets. When the disaster causes loss of significant others due to death or relocation, the child may grieve deeply. They experience the full range of human emotions, but may not have the words or means to express their internal experience. Adults can assist children to express these powerful emotions through talking, play, art, and age-appropriate recovery or preparedness activities.

School age children also manifest their anxiety through regressive behavior. Returning to behavior appropriate for a younger age is trying for parents, but serves an initially functional purpose for the child. These behaviors include: irritability, whining, clinging, fighting with friends and siblings, competing with younger siblings for parents' attention, or refusing to go to school. Bedtime and sleep problems are common due to nightmares and fearfulness about sleeping alone or in the dark.

Sometimes children's behavior can be "super good" at home, because they are afraid of further burdening their parents or causing more family disruption. They may show disaster stress at school through concentration problems, a decline in academic performance, aggression toward classmates, or withdrawal from social interactions. Some children may have somatic reactions and seek attention from the school nurse for stomach aches, headaches, nausea, or other complaints.

Pre-adolescence and Adolescence (ages 12 - 18)

This age group has a great need to appear competent to the world around them, especially to their family and friends. They struggle with the conflicts inherent in moving toward independence from parents on the one hand and the desire to maintain the dependence of childhood on the other. Approval and acceptance from friends are of paramount importance. Adolescents need to feel that their anxieties and fears are both appropriate and shared by their peers.

Disaster stress may be internalized and expressed through psychosomatic symptoms such as, gastrointestinal distress, headaches, skin problems, or vague aches and pains. Sleep problems such as insomnia, night terrors, or sleeping excessively may signal internal upset. Adolescents may turn to alcohol or drugs to cope with their anxiety and loss.

Social or school problems may also occur. Acting out or rebellious behavior may involve fighting with others, stealing, or power struggles with parents. Other adolescents may express their distress through withdrawal from friends and family and avoidance of previously enjoyed activities. School performance may decline. When the disaster causes major destruction of home and community, an older adolescent may postpone the developmental step of moving away from home.

Adults

Adults are focused on family, home, jobs, and financial security. Many are involved with caring for elderly parents as well. Pre-disaster life often involves maintaining a precarious balance between competing demands. Following a disaster, this balance is lost with the introduction of the enormous time, financial, physical, and emotional demands of recovery. Children in the family are in special need of attention and familiar routines, yet parents do not have enough hours in the day to accomplish all that is before them.

Over time, this stress overload can be manifested through physical symptoms of headaches, increased blood pressure, ulcers, gastrointestinal problems, and sleep disorders. Somatic reactions are especially present in those who are less able to experience and express their emotions directly. Cultural, gender-based, or psychological factors may interfere with emotional expression and seeking social support.

Emotional reactions often oscillate between numbness and intense expression. Anxiety and depression are common, as adults grapple with both anxiety about future threats and grief about the loss of home, lifestyle, or community. Anger and frustration about relief efforts abound, sometimes reflecting a displacement of the "less rational" anger that the disaster happened to them and was out of their control.

Older Adults

In the normal course of life, older adults typically have coped with losses prior to the disaster. They may have successfully adjusted to losses of employment, family, home, loved ones, or physical capabilities. For some, coping with these prior losses has strengthened resilience. For others, the prior losses may have worn down the individual's reserves and the disaster is an overwhelming blow (Norris et al., 1994). As a result of the disaster, irreplaceable possessions such as photographs or mementos passed on through generations may be destroyed. Pets or gardens developed over years may be lost. Mental health workers must recognize the special meaning of these losses, if they are to assist with grieving.

Older adults living on limited incomes tend to reside in dwellings that are susceptible to disaster hazards due to the location and age of the buildings. Because of financial limitations and age, they may not be able to afford the repairs to their homes. Leaving familiar surroundings is especially difficult for those who experience deficits in hearing, vision, or memory, because they rely on known environmental cues to continue living independently.

Many older adults fear that if their diminished physical or cognitive abilities are revealed, they risk loss of independence or being institutionalized. As a result, they may under report the full extent of their problems and needs. They may continue living in damaged or unsanitary conditions, because they do not have the physical strength, stamina, or cognitive organizational ability to undertake disaster clean up. Disaster mental health workers must carefully assess the range and full extent of problems in living faced by the older survivor. Often, concrete practical assistance for recovery, stabilization, and engagement with appropriate resources allows the older adult to continue living independently.

A larger proportion of older persons, as compared with younger age groups, have chronic illnesses that may worsen with the stress of a disaster, particularly when recovery extends over months. They are more likely to be taking medications that need to be replaced quickly following a disaster. While older adults may be in more need of multiple services for recovery, they are often especially reluctant to accept help and what they perceive as "handouts." Disaster mental health programs can more quickly gain acceptance when they work closely with known, trusted organizations and employ older adults as outreach workers.

Disaster Reactions and Intervention Suggestions
Age Groups
Behavioral Symptoms
Physical Symptoms
Emotional Symptoms
Intervention Options

PRESCHOOL
(1 - 5)

Resumption of bed-wetting, thumb sucking
Clinging to parents
Fears of the dark
Avoidance of sleeping alone
Increased crying


Loss of appetite
Stomach aches
Nausea
Sleep problems, nightmares
Speech difficulties
Tics


Anxiety
Fear
Irritability
Angry outbursts
Sadness
Withdrawal


Give verbal assurance and physical comfort
Provide comforting bedtime routines
Avoid unnecessary separations
Permit child to sleep in parents' room temporarily
Encourage expression regarding losses (i.e., deaths, pets, toys)
Monitor media exposure to disaster trauma
Encourage expression through play activities
CHILDHOOD
(6 - 11)

Decline in school performance
Aggressive behavior at home or school
Hyperactive or silly behavior
Whining, clinging, acting like a younger child
Increased competition with younger siblings for parents' attention


Change in appetite
Headaches
Stomach aches
Sleep disturbances, nightmares


School avoidance
Withdrawal from friends, familiar activities
Angry outbursts
Obsessive preoccupation with disaster, safety


Give additional attention and consideration
Relax expectations of performance at home and at school temporarily
Set gentle but firm limits for acting out behavior
Provide structured but undemanding home chores and rehabilitation activities
Encourage verbal and play expression of thoughts and feelings
Listen to the child's repeated retelling of disaster event
Involve the child in preparation of family emergency kit, home drills
Rehearse safety measures for future disasters
Develop school disaster program for peer support, expressive activities, education on disasters, preparedness planning, identifying at-risk children
Disaster Reactions and Intervention Suggestions (Continued)
Age Groups
Behavioral Symptoms
Physical Symptoms
Emotional Symptoms
Emotional Symptoms

PRE-ADOLESCENCE AND ADOLESCENCE
(12 - 18)

Decline in academic performance
Rebellion at home or school
Decline in previous responsible behavior
Agitation or decrease in energy level, apathy
Delinquent behavior
Social withdrawal


Appetite changes
Headaches
Gastrointestinal problems
Skin eruptions
Complaints of vague aches and pains
Sleep disorders


Loss of interest in peer social activities, hobbies, recreation
Sadness or depression
Resistance to authority
Feelings of inadequacy and helplessness


Give additional attention and consideration
Relax expectations of performance at home and school temporarily
Encourage discussion of disaster experiences with peers, significant adults
Avoid insistence on discussion of feelings with parents
Encourage physical activities
Rehearse family safety measures for future disasters
Encourage resumption of social activities, athletics, clubs, etc.
Encourage participation in community rehabilitation and reclamation work
Develop school programs for peer support and debriefing, preparedness planning, volunteer community recovery, identifying at-risk teens
ADULTS

Sleep problems
Avoidance of reminders
Excessive activity level
Crying easily
Increased conflicts with family
Hypervigilance
Isolation, withdrawal


Fatigue, exhaustion
Gastrointestinal distress
Appetite change
Somatic complaints
Worsening of chronic conditions


Depression, sadness
Irritability, anger
Anxiety, fear
Despair, hopelessness
Guilt, self doubt
Mood swings


Provide supportive listening and opportunity to talk in detail about disaster experiences
Assist with prioritizing and problem-solving
Offer assistance for family members to facilitate communication and effective functioning
Assess and refer when indicated
Provide information on disaster stress and coping, children's reactions and families
Provide information on referral resources
Disaster Reactions and Intervention Suggestions (Continued)
Age Groups
Behavioral Symptoms
Physical Symptoms
Emotional Symptoms
Intervention Options

OLDER ADULTS

Withdrawal and isolation
Reluctance to leave home
Mobility limitations
Relocation adjustment problems


Worsening of chronic illnesses
Sleep disorders
Memory problems
Somatic symptoms
More susceptible to hypo- and hyperthermia
Physical and sensory limitations (sight, hearing) interfere with recovery


Depression
Despair about losses
Apathy
Confusion, disorientation
Suspicion
Agitation, anger
Fears of institutionalization
Anxiety with unfamiliar surroundings
Embarrassment about receiving "hand outs"


Provide strong and persistent verbal reassurance
Provide orienting information
Use multiple assessment methods as problems may be under reported (e.g., repeat observations, geriatric screening questions, discussion with family)
Provide assistance with recovery of possessions
Assist in obtaining medical and financial assistance
Assist in reestablishing familial and social contacts
Give special attention to suitable residential relocation
Encourage discussion of disaster losses and expression of emotions
Provide and facilitate referrals for disaster assistance
Engage providers of transportation, chore services, meals programs, home health, and home visits as needed
Cultural and Ethnic Groups

Disaster mental health programs must respond specifically and sensitively to the various cultural groups affected by a disaster. In many disasters, ethnic and racial minority groups may be especially hard hit because of socioeconomic conditions that force the community to live in housing that is particularly vulnerable. Language barriers, suspicion of governmental programs due to prior experiences, rejection of outside interference or assistance, and differing cultural values often contribute to disaster outreach programs' difficulty in establishing access and acceptance. Communities that take pride in their self-reliance are reluctant to seek or accept help, especially from mental health workers.

Cultural sensitivity is conveyed when disaster information and application procedures are translated into primary spoken languages and available in non-written forms. Intense emotions are typically experienced and expressed in a person's language of origin, so outreach teams that include bilingual, bicultural staff, and translators are able to interact more effectively with disaster survivors. Whenever possible, it is preferable to work with trained translators rather than family members, especially children, because of privacy concerns regarding mental health issues and the importance of preserving family roles.

Cultural groups have considerable variation regarding views on loss, death, home, spiritual practices, use of particular words, grieving, celebrating, mental health, and helping. The role of the family, who is included in the family, and who makes decisions also varies. Elders and extended family play a significant role in some cultures, whereas isolated nuclear families are the decision-makers in others.

It is essential that disaster mental health workers learn about the cultural norms, traditions, local history, and community politics from leaders and social service workers indigenous to the groups they are serving. Program outreach workers and mental health staff are most effective when they are bilingual and bicultural. During the program development phase, establishing working relationships with trusted organizations, service providers, and community leaders is helpful. Being respectful, nonjudgmental, well informed, and following through on stated plans dependably are especially important for outreach workers.

Socioeconomic Groups

Many affluent, middle to upper middle class people live with a sense of security and see themselves as invulnerable to the devastation and tragedy associated with disasters. Because of their financial resources and life situations, they may have been protected from crises in the past, and have purchased insurance for "protection" in the future. They are more accustomed to planning and controlling life events, rather than unexpected overwhelming events controlling them. Shock, disbelief, self blame, and anger predominate in the hours and days following a major disaster, as the reality of losses, danger, and the work that lies ahead begins to sink in.

Higher income families may never have received assistance from social service agencies before. Accepting clothing, food, money, or shelter can be difficult and sobering. While they may need emergency assistance initially, they often do have social, financial, family, or other resources that engage quickly and buffer the disaster's impact.

Affluent families typically rely on known professionals for their support-their family physician, minister, or psychotherapist. Disaster mental health programs focus on educating local health care professionals and religious leaders about disaster stress, because these providers are most likely to encounter upper class survivors in need. Psychosocial Issues for Children and Families in Disaster: A Guide for the Primary Care Physician (CMHS, 1995) is an informative resource for training. Recovery programs can also coordinate disaster mental health counseling and support groups through these known and trusted entities.

In contrast, low-income survivors have fewer resources and greater pre-existing vulnerability when disaster strikes. While they may have developed more crisis survival skills than the more protected upper class individuals, they often lack the availability of support and housing from family and friends and do not have insurance coverage or monetary savings. Without these, the recovery process is even more arduous and prolonged, and sometimes impossible. Federal and State disaster assistance programs are designed to meet serious and urgent needs. The intent of these programs is not to replace all losses. Uninsured, poor families may have unmet needs and should be referred to non-profit disaster relief organizations and unmet needs committees. If they are renters, they may be faced with unaffordable increases in rent after landlords have invested money to repair their properties. They may be dislocated to temporary disaster housing that is undesirable and removed from their social supports. Relocation may make transportation and getting to appointments more difficult.

Faced with these multiple challenges and assistance that falls short of solving the problems before them, low-income disaster survivors can feel overwhelmed. For those with limited reading and writing abilities, obtaining accurate information and completing forms is difficult. Disaster mental health workers are most effective when they provide concrete problem-solving assistance that facilitates addressing priority needs. Workers must be knowledgeable about the full range of community resources available to people of limited economic means and actively engage this resource network with those in need.

People With Serious and Persistent Mental Illness

Clinical field experience has shown that disaster survivors with mental illness function fairly well following a disaster, if essential services have not been interrupted. People with mental illness have the same capacity to "rise to the occasion" and perform heroically as the general population during the immediate aftermath of the disaster. Many demonstrate an increased ability to handle this stress without an exacerbation of their mental illness, especially when they are able to maintain their medication regimens.

However, some survivors with mental illness have achieved only a tenuous balance before the disaster. The added stress of the disaster disrupts this balance; for some, additional mental health support services, medications, or hospitalization may be necessary to regain stability. For individuals diagnosed with Post Traumatic Stress Disorder (PTSD), disaster stimuli (e.g., helicopters, sirens) may trigger an exacerbation due to associations with prior traumatic events.

Many people with mental illness are vulnerable to sudden changes in their environment and routines. Orienting to new organizations and systems for disaster relief assistance can be difficult. Program planners need to be aware of how disaster services are being perceived and build bridges that facilitate access and referrals where necessary. Disaster mental health services designed for the general population are equally beneficial for those with mental illness; disaster stress affects all groups. In addition, when case managers and community mental health counselors have a solid understanding of disaster mental health issues, they are able to better provide services to this population following a disaster. Responding to the Needs of People with Serious and Persistent Mental Illness in Times of Major Disaster provides a comprehensive discussion of planning, preparedness, and options for service delivery with this population (CMHS, 1996).

Human Service and Disaster Relief Workers

Workers in all phases of disaster relief, whether in law enforcement, local government, emergency response, or victim support, experience considerable demands to meet the needs of the survivors and the community. Typically, disaster workers are altruistic, compassionate, and dedicated people who occasionally have difficulty knowing when it is time to take a break from the operation. For many, the disaster response takes precedence over all other responsibilities and activities. The brochure, Prevention and Control of Stress Among Emergency Workers-A Pamphlet for Workers, is an excellent resource for both disaster relief workers and mental health providers (NIMH, 1987). This brochure highlights the importance of having a personal emergency preparedness plan, so that workers are assured that their families are safe while they devote themselves to disaster relief for the community.

Relief workers may witness human tragedy and serious physical injuries, depending on the nature of the disaster and their role. This contributes to the psychological impact of their work. In disasters in which there is a high level of exposure to human suffering, injuries, and fatalities, providing psychological support and interventions for workers is especially necessary. In addition, relief workers and first responders should be considered a target group for ongoing services during the course of the disaster mental health recovery program.

As some order returns to the community, many workers, particularly volunteers, return to their regular jobs. However, they may attempt to continue with their disaster work. Over time, the result of this overwork can be the "burn-out" syndrome. This state of exhaustion, irritability, and fatigue creeps up unrecognized and can markedly decrease the individual's effectiveness and capability. These workers may be avoiding problems at home by working constantly. Disaster mental health workers should be on the lookout for workers whose coping resources have eroded due to their personal vulnerabilities and seemingly unrelenting workload. The next section in this manual, "Stress Prevention and Management," offers suggestions for identifying, educating, and intervening with those who may be having stress reactions and difficulty coping.

References and Recommended Reading

Bolin, R. & Bolton, P. Race, Religion and Ethnicity in Disaster Recovery. Colorado: University of Colorado Institute of Behavioral Science, 1986.

Center for Mental Health Services. Manual for Child Health Workers in Major Disasters. Washington, D.C.: U.S. Department of Health and Human Services; Publication No. (ADM) 86-1070. (Rev. ed. in press.)

Center for Mental Health Services. Responding to the Needs of People with Serious and Persistent Mental Illness in Times of Major Disaster. Washington, D.C.: U.S. Department of Health and Human Services; Publication No. (SMA) 96-3077, 1996.

Center for Mental Health Services. Psychosocial Issues for Children and Families in Disasters: A Guide for the Primary Care Physician. Washington, D.C.: US Department of Health and Human Services; Publication No. (SMA) 95-3022, 1995.

Gerrity, E. T. & Steinglass, P. Relocation stress following natural disasters. In: Ursano, R. J., McCaughey, B. G., & Fullerton, C. S. (Eds.). Individual and Community Responses to Trauma and Disaster: The Structure of Human Chaos. Great Britain: Cambridge University Press, 1994.

Gist, R. & Lubin, B. (Eds.). Psychological Aspects of Disaster. New York: John Wiley & Sons, 1989.

Green, B. L., Korol, M., Grace, M. C., Vary, M. G., Leonard, A. C., Gleser, G. C. & Smitson-Cohen, S. Children and disaster: Age, gender, and parental effects on PTSD symptoms. Journal of the American Academy of Child and Adolescent Psychiatry, 30, 945-951, 1991.

Green, B. L. & Solomon, S. D. The mental health impact of natural and technological disasters. In Freedy, J. R. & Hobfoll (Eds.). Traumatic Stress: From Theory to Practice. New York: Plenum, 1995.

LaGreca, A. M., Vernberg, E. M., Silverman, W. K., Vogel, A. L. & Prinstein, M. J. Helping Children Prepare for and Cope with Natural Disasters: A Manual for Professionals Working with Elementary School Children. BellSouth Corporation, 1995. (To obtain copies: Contact Dr. La Greca, Department of Psychology, University of Miami, P.O. Box 248185, Coral Gables, FL 33124.)

Mitchell, J. & Bray, G. Emergency Services Stress: Guidelines for Preserving the Health and Careers of Emergency Services Personnel. New Jersey: Prentice-Hall, 1990.

National Institute of Mental Health. Prevention and Control of Stress Among Emergency Workers: A Pamphlet for Workers. Washington, D.C.: U. S. Department of Health and Human Services; Publication No. (ADM) 90-1497, 1987.

Norris, F. H., Phifer, J. F. & Kaniasty, K. Individual and community reactions to the Kentucky floods: Findings from a longitudinal study of older adults. In: Ursano, R. J., McCaughey, B. G., & Fullerton, C. S. (Eds.). Individual and Community Responses to Trauma and Disaster: The Structure of Human Chaos. Great Britain: Cambridge University Press, 1994.

Saylor, C. F. (Ed.). Children and Disasters. New York: Plenum Press, 1993.

Solomon, S. D. & Green, B. L. Mental health effects of natural and human-made disasters. PTSD Research Quarterly, 3 (1), 1-8, 1992.

Sue, D. W. & Sue, D. Counseling the Culturally Different: Theory and Practice. New York: Wiley, 1990.

Ursano, R. J., McCaughey, B. G., & Fullerton, C. S. (Eds.). Individual and Community Responses to Trauma and Disaster: The Structure of Human Chaos. Great Britain: Cambridge University Press, 1994.

U. S. Department of Health and Human Services. Action Plan of the Administration on Aging to Strengthen the Disaster Response Capacity to Serve Older People. Rockville, MD, 1994. Vogel, J. M. & Vernberg, E. M. Children's psychological responses to disasters. Journal of Clinical Child Psychology, 22(4), 464-484, 1993.

Specific Treatments for Episodes of Depression and Mania

Specific Treatments for Episodes of Depression and Mania
This section describes specific types of pharmacotherapies and psychosocial therapies for episodes of depression and mania. Treatment generally targets symptom patterns rather than specific disorders. Differences in the treatment strategy for unipolar and bipolar depression are described where relevant.

Treatment of Major Depressive Episodes

Pharmacotherapies
Antidepressant medications are effective across the full range of severity of major depressive episodes in major depressive disorder and bipolar disorder (American Psychiatric Association, 1993; Depression Guideline Panel, 1993; Frank et al., 1993). The degree of effectiveness, however, varies according to the intensity of the depressive episode. With mild depressive episodes, the overall response rate is about 70 percent, including a placebo rate of about 60 percent (Thase & Howland, 1995). With severe depressive episodes, the overall response rate is much lower, as is the placebo rate. For example, with psychotic depression, the overall response rate to any one drug is only about 20 to 40 percent (Spiker, 1985), including a placebo response rate of less than 10 percent (Spiker & Kupfer, 1988; Schatzberg & Rothschild, 1992). Psychotic depression is treated with either an antidepressant/antipsychotic combination or ECT (Spiker, 1985; Schatzberg & Rothschild, 1992).

There are four major classes of antidepressant medications. The tricyclic and heterocyclic antidepressants (TCAs and HCAs) are named for their chemical structure. The MAOIs and SSRIs are classified by their initial neurochemical effects. In general, MAOIs and SSRIs increase the level of a target neurotransmitter by two distinct mechanisms. But, as discussed below, these classes of medications have many other effects. They also have some differential effects depending on the race or ethnicity of the patient.

The mode of action of antidepressants is complex and only partly understood. Put simply, most antidepressants are designed to heighten the level of a target neurotransmitter at the neuronal synapse. This can be accomplished by one or more of the following therapeutic actions: boosting the neurotransmitter’s synthesis, blocking its degradation, preventing its reuptake from the synapse into the presynaptic neuron, or mimicking its binding to postsynaptic receptors. To make matters more complicated, many antidepressant drugs affect more than one neurotransmitter. Explaining how any one drug alleviates depression probably entails multiple therapeutic actions, direct and indirect, on more than one neurotransmitter system (Feighner, 1999).

Selection of a particular antidepressant for a particular patient depends upon the patient’s past treatment history, the likelihood of side effects, safety in overdose, and expense (Depression Guideline Panel, 1993). A vast majority of U.S. psychiatrists favor the SSRIs as“first-line” medications (Olfson & Klerman, 1993). These agents are viewed more favorably than the TCAs because of their ease of use, more manageable side effects, and safety in overdose (Kapur et al., 1992; Preskorn & Burke, 1992). Perhaps the major drawback of the SSRIs is their expense: they are only available as name brands (until 2002 when they begin to come off patent). At minimum, SSRI therapy costs about $80 per month (Burke et al., 1994), and patients taking higher doses face proportionally greater costs.

Four SSRIs have been approved by the FDA for treatment of depression: fluoxetine, sertraline, paroxetine, and citalopram. A fifth SSRI, fluvoxamine, is approved for treatment of obsessive-compulsive disorder, yet is used off-label for depression.11 There are few compelling reasons to pick one SSRI over another for treatment of uncomplicated major depression, because they are more similar than different (Aguglia et al., 1993; Schone & Ludwig, 1993; Tignol, 1993; Preskorn, 1995). There are, however, several distinguishing pharmacokinetic differences between SSRIs, including elimination half-life (the time it takes for the plasma level of the drug to decrease 50 percent from steady-state), propensity for drug-drug interactions (e.g., via inhibition of hepatic enzymes), and antidepressant activity of metabolite(s) (DeVane, 1992). In general, SSRIs are more likely to be metabolized more slowly by African Americans and Asians, resulting in higher blood levels (Lin et al., 1997).

The SSRIs as a class of drugs have their own class-specific side effects, including nausea, diarrhea, headache, tremor, daytime sedation, failure to achieve orgasm, nervousness, and insomnia. Attrition from acute phase therapy because of side effects is typically 10 to 20 percent (Preskorn & Burke, 1992). The incidence of treatment-related suicidal thoughts for the SSRIs is low and comparable to the rate observed for other antidepressants (Beasley et al., 1991; Fava & Rosenbaum, 1991), despite reports to the contrary (Breggin & Breggin, 1994).

Some concern persists that the SSRIs are less effective than the TCAs for treatment of severe depressions, including melancholic and psychotic subtypes (Potter et al., 1991; Nelson, 1994). Yet there is no definitive answer (Danish University Anti-depressant Group, 1986, 1990; Pande & Sayler, 1993; Roose et al., 1994; Stuppaeck et al., 1994).

Side effects and potential lethality in overdose are the major drawbacks of the TCAs. An overdose of as little as 7-day supply of a TCA can result in potentially fatal cardiac arrhythmias (Kapur et al., 1992). TCA treatment is typically initiated at lower dosages and titrated upward with careful attention to response and side effects. Doses for African Americans and Asians should be monitored more closely, because their slower metabolism of TCAs can lead to higher blood concentrations (Lin et al., 1997). Similarly, studies also suggest that there may be gender differences in drug metabolism and that plasma levels may change over the course of the menstrual cycle (Blumenthal, 1994b).

In addition to the four major classes of antidepressants are bupropion, which is discussed below, and three newer FDA-approved antidepressants that have mixed or compound synaptic effects. Venlafaxine, the first of these newer antidepressants, inhibits reuptake of both serotonin and, at higher doses, norepinephrine. In contrast to the TCAs, venlafaxine has somewhat milder side effects (Bolden-Watson & Richelson, 1993), which are like those of the SSRIs. Venlafaxine also has a low risk of cardiotoxicity and, although experience is limited, it appears to be less toxic than the others in overdose. Venlafaxine has shown promise in treatment of severe (Guelfi et al., 1995) or refractory (Nierenberg et al., 1994) depressive states and is superior to fluoxetine in one inpatient study (Clerc et al., 1994). Venlafaxine also occasionally causes increased blood pressure, and this can be a particular concern at higher doses (Thase, 1998).

Nefazodone, the second newer antidepressant, is unique in terms of both structure and neurochemical effects (Taylor et al., 1995). In contrast to the SSRIs, nefazodone improves sleep efficiency (Armitage et al., 1994). Its side effect profile is comparable to the other newer antidepressants, but it has the advantage of a lower rate of sexual side effects (Preskorn, 1995). The more recently FDA-approved antidepressant, mirtazapine, blocks two types of serotonin receptors, the 5-HT2 and 5-HT3 receptors (Feighner, 1999). Mirtazapine is also a potent antihistamine and tends to be more sedating than most other newer antidepressants. Weight gain can be another troublesome side effect.

Figure 4-2 presents summary findings on newer pharmacotherapies from a recent review of the treatment of depression by the Agency for Health Care Policy and Research (AHCPR, 1999). There have been few studies of gender differences in clinical response to treatments for depression. A recent report (Kornstein et al., in press) found women with chronic depression to respond better to a SSRI than a tricyclic, yet the opposite for men. This effect was primarily in premenopausal women. The AHCPR report (1999) also noted that there were almost no data to address the efficacy of pharmacotherapies in post partum or pregnant women.

Alternate Pharmacotherapies
Regardless of the initial choice of pharmacotherapy, about 30 to 50 percent of patients do not respond to the initial medication. It has not been established firmly whether patients who respond poorly to one class of antidepressants should be switched automatically to an alternate class (Thase & Rush, 1997). Several studies have examined the efficacy of the TCAs and SSRIs when used in sequence (Peselow et al., 1989; Beasley et al., 1990). Approximately 30 to 50 percent of those not responsive to one class will respond to the other (Thase & Rush, 1997).

Among other types of antidepressants, the MAOIs and bupropion are important alternatives for SSRI and TCA nonresponders (Thase & Rush, 1995). These agents also may be relatively more effective than TCAs or SSRIs for treatment of depressions characterized by atypical or reversed vegetative symptoms (Goodnick & Extein, 1989; Quitkin et al., 1993b; Thase et al., 1995). Bupropion and the MAOIs also are good choices to treat bipolar depression (Himmelhoch et al., 1991; Thase et al., 1992; Sachs et al., 1994). Bupropion also has the advantage of a low rate of sexual side effects (Gardner & Johnston, 1985; Walker et al., 1993).

Bupropion’s efficacy and overall side effect profile might justify its first-line use for all types of depression (e.g., Kiev et al., 1994). Furthermore, bupropion has a novel neurochemical profile in terms of effects on dopamine and norepinephrine (Ascher et al., 1995). However, worries about an increased risk of seizures delayed bupropion’s introduction to the U.S. market by more than 5 years (Davidson, 1989). Although clearly effective for a broad range of depressions, use of the MAOIs has been limited for decades by concerns that when taken with certain foods containing the chemical tyramine (for example, some aged cheeses and red wines); these medications may cause a potentially lethal hypertensive reaction (Thase et al., 1995). There has been continued interest in development of safer, selective and reversible MAOIs.

Hypericum (St. John's Wort). The widespread publicity and use of the botanical product from the yellow-flowering Hypericum perforatum plant with or without medical supervision is well ahead of the science database supporting the effectiveness of this putative antidepressant. Controlled trials, mainly in Germany, have been positive in mild-to-moderate depression, with only mild gastrointestinal side effects reported (Linde et al., 1996). However, most of those studies were methodologically flawed, in areas including diagnosis (more similar to adjustment disorder with depressed mood than major depression), length of trial (often an inadequate 4 weeks), and either lack of placebo control or unusually low or high placebo response rates (Salzman, 1998).

Post-marketing surveillance in Germany, which found few adverse effects of Hypericum, depended upon spontaneous reporting of side effects by patients, an approach that would not be considered acceptable in this country (Deltito & Beyer, 1998). In clinical use, the most commonly encountered adverse effect noted appears to be sensitivity to sunlight.

Figure 4-2. Treatment of depression-newer pharmacotherapies: Summary findings
Newer antidepressant drugs* are effective treatments for major depression and dysthymia.


They are efficacious in primary care and specialty mental health care settings:


–Major depression:
50 percent response to active agent
32 percent response to placebo


–Dysthymia (fluoxetine, sertraline, and amisulpride):
59 percent response to active agent
37 percent response to placebo


Both older and newer antidepressants demonstrate similar efficacy.


Drop-out rates due to all causes combined are similar for newer and older agents:


Drop-out rates due to adverse effects are slightly higher for older agents.


Newer agents are often easier to use because of single daily dosing and less titration.


--------------------------------------------------------------------------------
*SSRIs and all other antidepressants marketed subsequently. Source: AHCPR, 1999.


Basic questions about mechanism of action and even the optimal formulation of a pharmaceutical product from the plant remain; dosage in the randomized German trials varied by sixfold (Linde et al., 1996). Several pharmacologically active components of St. John's wort, including hypericin, have been identified (Nathan, 1999); although their long half-lives in theory should permit once daily dosing, in practice a schedule of 300 mg three times a day is most commonly used. While initial speculation about significant MAO-inhibiting properties of hypericum have been largely discounted, possible serotonergic mechanisms suggest that combining this agent with an SSRI or other serotonergic antidepressant should be approached with caution. However, data regarding safety of hypericum in preclinical models or clinical samples are few (Nathan, 1999). At least two placebo-controlled trials in the United States are under way to compare the efficacy of Hypericum with that of an SSRI.

Augmentation Strategies
The transition from one antidepressant to another is time consuming, and patients sometimes feel worse in the process (Thase & Rush, 1997). Many clinicians bypass these problems by using a second medication to augment an ineffective antidepressant. The best studied strategies of this type are lithium augmentation, thyroid augmentation, and TCA-SSRI combinations (Nierenberg & White, 1990; Thase & Rush, 1997; Crismon et al., 1999).

Increasingly, clinicians are adding a noradrenergic TCA to an ineffective SSRI or vice versa. In an earlier era, such polypharmacy (the prescription of multiple drugs at the same time) was frowned upon. Thus far, the evidence supporting TCA-SSRI combinations is not conclusive (Thase & Rush, 1995). Caution is needed when using these agents in combination because SSRIs inhibit metabolism of several TCAs, resulting in a substantial increase in blood levels and toxicity or other adverse side effects from TCAs (Preskorn & Burke, 1992).

Psychotherapy and Counseling
Many people prefer psychotherapy or counseling over medication for treatment of depression (Roper, 1986; Seligman, 1995). Research conducted in the past two decades has helped to establish at least several newer forms of time-limited psychotherapy as being as effective as antidepressant pharmacotherapy in mild-to-moderate depressions (DiMascio et al., 1979; Elkin et al., 1989; Hollon et al., 1992; Depression Guideline Panel, 1993; Thase, 1995; Persons et al., 1996). The newer depression-specific therapies include cognitive-behavioral therapy (Beck et al., 1979) and interpersonal psychotherapy (Klerman et al., 1984). These approaches use a time-limited approach, a present tense (“here-and-now”) focus, and emphasize patient education and active collaboration. Interpersonal psychotherapy centers around four common problem areas: role disputes, role transitions, unresolved grief, and social deficits. Cognitive-behavioral therapy takes a more structured approach by emphasizing the interactive nature of thoughts, emotions, and behavior. It also helps the depressed patient to learn how to improve coping and lessen symptom distress.

There is no evidence that cognitive-behavioral therapy and interpersonal psychotherapy are differentially effective (Elkin et al., 1989; Thase, 1995). As reported earlier, both therapies appear to have some relapse prevention effects, although they are much less studied than the pharmacotherapies. Other more traditional forms of counseling and psychotherapy have not been extensively studied using a randomized clinical trial design (Depression Guideline Panel, 1993). It is important to determine if these more traditional treatments, as commonly practiced, are as effective as interpersonal psychotherapy or cognitive-behavioral therapy.

The brevity of this section reflects the succinctness of the findings on the effectiveness of these interventions as well as the lack of differential responses and“side effects.” It does not reflect a preference or superiority of medication except in conditions such as psychotic depression where psychotherapies are not effective.

Bipolar Depression
Treatment of bipolar depression12 has received surprisingly little study (Zornberg & Pope, 1993). Most psychiatrists prescribe the same antidepressants for treatment of bipolar depression as for major depressive disorder, although evidence is lacking to support this practice. It also is not certain that the same strategies should be used for treatment of depression in bipolar II (i.e., major depression plus a history of hypomania) and bipolar I (i.e., major depression with a history of at least one prior manic episode) (DSM-IV).

Pharmacotherapy of bipolar depression typically begins with lithium or an alternate mood stabilizer (DSM-IV; Frances et al., 1996). Mood stabilizers reduce the risk of cycling and have modest antidepressant effects; response rates of 30 to 50 percent are typical (DSM-IV; Zornberg & Pope, 1993). For bipolar depressions refractory to mood stabilizers, an antidepressant is typically added. Bipolar depression may be more responsive to nonsedating antidepressants, including the MAOIs, SSRIs, and bupropion (Cohn et al., 1989; Haykal & Akiskal, 1990; Himmelhoch et al., 1991; Peet, 1994; Sachs et al., 1994). The optimal length of continuation phase pharmacotherapy of bipolar depression has not been established empirically (DSM-IV). During the continuation phase, the risk of depressive relapse must be counterbalanced against the risk of inducing mania or rapid cycling (Kukopulos et al., 1980; Wehr & Goodwin, 1987; Solomon et al., 1995). Although not all studies are in agreement, antidepressants may increase mood cycling in a vulnerable subgroup, such as women with bipolar II disorder (Coryell et al., 1992; Bauer et al., 1994). Lithium is associated with increased risk of congenital anomalies when taken during the first trimester of pregnancy, and the anticonvulsants are contraindicated (see Cohen et al., 1994, for a review). This is problematic in view of the high risk of recurrence in pregnant bipolar women (Viguera & Cohen 1998).

Pharmacotherapy, Psychosocial Therapy, and Multimodal Therapy
The relative efficacy of pharmacotherapy and the newer forms of psychosocial treatment, such as interpersonal psychotherapy and the cognitive-behavioral therapies, is a controversial topic (Meterissian & Bradwejn, 1989; Klein & Ross, 1993; Munoz et al., 1994; Persons et al., 1996). For major depressive episodes of mild to moderate severity, meta-analyses of randomized clinical trials document the relative equivalence of these treatments (Dobson, 1989; Depression Guideline Panel, 1993). Yet for patients with bipolar and psychotic depression, who were excluded from these studies, pharmacotherapy is required: there is no evidence that these types of depressive episodes can be effectively treated with psychotherapy alone (Depression Guideline Panel, 1993; Thase, 1995). Current standards of practice suggest that therapists who withhold somatic treatments (i.e., pharmacotherapy or ECT) from such patients risk malpractice (DSM-IV; Klerman, 1990; American Psychiatric Association, 1993; Depression Guideline Panel, 1993).

For patients hospitalized with depression, somatic therapies also are considered the standard of care (American Psychiatric Association, 1993). Again, there is little evidence for the efficacy of psychosocial treatments alone when used instead of pharmacotherapy, although several studies suggest that carefully selected inpatients may respond to intensive cognitive-behavioral therapy (DeJong et al., 1986; Thase et al., 1991). However, in an era in which inpatient stays are measured in days, rather than in weeks, this option is seldom feasible. Combined therapies emphasizing both pharmacologic and intensive psychosocial treatments hold greater promise to improve the outcome of hospitalized patients, particularly if inpatient care is followed by ambulatory treatment (Miller et al., 1990; Scott, 1992).

Combined therapies—also called multimodal treatments—are especially valuable for outpatients with severe forms of depression. According to a recent meta-analysis of six studies, combined therapy (cognitive or interpersonal psychotherapy plus pharmacotherapy) was significantly more effective than psychotherapy alone for more severe recurrent depression. In milder depressions, psychotherapy alone was nearly as effective as combined therapy (Thase et al., 1997b). This meta-analysis was unable to compare combined therapy with pharmacotherapy alone or placebo due to an insufficient number of patients.

In summary, the DSM-IV definition of major depressive disorder spans a heterogenous group of conditions that benefit from psychosocial and/or pharmacological therapies. People with mild to moderate depression respond to psychotherapy or pharmacotherapy alone. People with severe depression require pharmacotherapy or ECT and they may also benefit from the addition of psychosocial therapy.

Preventing Relapse of Major Depressive Episodes

Recurrent Depression. Maintenance pharmacotherapy is the best-studied means to reduce the risk of recurrent depression (Prien & Kocsis, 1995; Thase & Sullivan, 1995). The magnitude of effectiveness in prevention of recurrent depressive episodes depends on the dose of the active agent used, the inherent risk of the population (i.e., chronicity, age, and number of prior episodes), the length of time being considered, and the patient’s adherence to the treatment regimen (Thase, 1993). Early studies, which tended to use lower dosages of medications, generally documented a twofold advantage relative to placebo (e.g., 60 vs. 30 percent) (Prien & Kocsis, 1995). In a more recent study of recurrent unipolar depression, the drug-placebo difference was nearly fivefold (Frank et al., 1990; Kupfer et al., 1992). This trial, in contrast to earlier randomized clinical trials, used a much higher dosage of imipramine, suggesting that full-dose maintenance pharmacotherapy may improve prophylaxis. Indeed, this was subsequently confirmed in a randomized clinical trial comparing full- and half-dose maintenance strategies (Frank et al., 1993).

There are few published studies on the prophylactic benefits of long-term pharmacotherapy with SSRIs, bupropion, nefazodone, or venlafaxine. However, available studies uniformly document 1-year efficacy rates of 80 to 90 percent in preventing recurrence of depression (Montgomery et al., 1988; Doogan & Caillard, 1992; Claghorn & Feighner, 1993; Duboff, 1993; Shrivastava et al., 1994; Franchini et al., 1997; Stewart et al., 1998). Thus, maintenance therapy with the newer agents is likely to yield outcomes comparable to the TCAs (Thase & Sullivan, 1995).

How does maintenance pharmacotherapy compare with psychotherapy? In one study of recurrent depression, monthly sessions of maintenance interpersonal psychotherapy had a 3-year success rate of about 35 percent (i.e., a rate falling between those for active and placebo pharmacotherapy) (Frank et al., 1990). Subsequent studies found maintenance interpersonal psychotherapy to be either a powerful or ineffective prophylactic therapy, depending on the patient/treatment match (Kupfer et al., 1990; Frank et al., 1991a; Spanier et al., 1996).

Bipolar Depression. No recent randomized clinical trials have examined prophylaxis against recurrent depression in bipolar disorder. In one older, well-controlled study, recurrence rates of more than 60 percent were observed despite maintenance treatment with lithium, either alone or in combination with imipramine (Shapiro et al., 1989).

Treatment of Mania
Acute Phase Efficacy
Success rates of 80 to 90 percent were once expected with lithium for the acute phase treatment of mania (e.g., Schou, 1989); however, lithium response rates of only 40 to 50 percent are now commonplace (Frances et al., 1996). Most recent studies thus underscore the limitations of lithium in mania (e.g., Gelenberg et al., 1989; Small et al., 1991; Freeman et al., 1992; Bowden et al., 1994). The apparent decline in lithium responsiveness may be partly due to sampling bias (i.e., university hospitals treat more refractory patients), but could also be attributable to factors such as younger age of onset, increased drug abuse comorbidity, or shorter therapeutic trials necessitated by briefer hospital stay (Solomon et al., 1995). The effectiveness of acute phase lithium treatment also is partially dependent on the clinical characteristics of the manic episode: dysphoric/mixed, psychotic, and rapid cycling episodes are less responsive to lithium alone (DSM-IV; Solomon et al., 1995).

A number of other medications initially developed for other indications are increasingly used for lithium-refractory or lithium-intolerant mania. The efficacy of two medications, the anticonvulsants carbamazepine and divalproex sodium, has been documented in randomized clinical trials (e.g., Small et al., 1991; Freeman et al., 1992; Bowden et al., 1994; Keller et al., 1992). Divalproex sodium has received FDA approval for the treatment of mania. The specific mechanisms of action for these agents have not been established, although they may stabilize neuronal membrane systems, including the cyclic adenosine monophosphate second messenger system (Post, 1990). The anticonvulsant medications under investigation for their effectiveness in mania include lamotrigine and gabapentin.

Another newer treatment, verapamil, is a calcium channel blocker initially approved by the FDA for treatment of cardiac arrhythmias and hypertension. Since the mid-1980s, clinical reports and evidence from small randomized clinical trials suggest that the calcium channel blockers may have antimanic effects (Dubovsky et al., 1986; Garza-Trevino et al., 1992; Janicak et al., 1992, 1998). Like lithium and the anticonvulsants, the mechanism of action of verapamil has not been established. There is evidence of abnormalities of intracellular calcium levels in bipolar disorder (Dubovsky et al., 1992), and calcium’s role in modulating second messenger systems (Wachtel, 1990) has spurred continued interest in this class of medication. If effective, verapamil does have the additional advantage of having a lower potential for causing birth defects than does lithium, divalproex, or carbamazepine.

Adjunctive neuroleptics and high-potency benzodiazepines are used often in combination with mood stabilizers to treat mania. The very real risk of tardive dyskinesia has led to a shift in favor of adjunctive use of benzodiazepines instead of neuroleptics for acute stabilization of mania (Chouinard, 1988; Lenox et al., 1992). The novel antipsychotic clozapine has shown promise in otherwise refractory manic states (Suppes et al., 1992), although such treatment requires careful monitoring to help protect against development of agranulocytosis, a potentially lethal bone marrow toxicity. Other newer antipsychotic medications, including risperidone and olanzapine, have safer side effect profiles than clozapine and are now being studied in mania. For manic patients who are not responsive to or tolerant of pharmacotherapy, ECT is a viable alternative (Black et al., 1987; Mukherjee et al., 1994). Further discussion of antipsychotic drugs and their side effects is found in the section on schizophrenia.

Maintenance Treatment to Prevent Recurrences of Mania
The efficacy of lithium for prevention of mania also appears to be significantly lower now than in previous decades; recurrence rates of 40 to 60 percent are now typical despite ongoing lithium therapy (Prien et al., 1984; Gelenberg et al., 1989; Winokur et al., 1993). Still, more than 20 studies document the effectiveness of lithium in preventing suicide (Goodwin & Jamison, 1990). Medication noncompliance almost certainly plays a role in the failure of longer term lithium maintenance therapy (Aagaard et al., 1988). Indeed, abrupt discontinuation of lithium has been shown to accelerate the risk of relapse (Suppes et al., 1993). Medication“holidays” may similarly induce a lithium-refractory state (Post, 1992), although data are conflicting (Coryell et al., 1998). As noted earlier, antidepressant cotherapy also may accelerate cycle frequency or induce lithium-resistant rapid cycling (Kukopulos et al., 1980; Wehr & Goodwin, 1987).

With increasing recognition of the limitations of lithium prophylaxis, the anticonvulsants are used increasingly for maintenance therapy of bipolar disorder. Several randomized clinical trials have demonstrated the prophylactic efficacy of carbamazepine (Placidi et al., 1986; Lerer et al., 1987; Coxhead et al., 1992), whereas the value of divalproex preventive therapy is only supported by uncontrolled studies (Calabrese & Delucchi, 1990; McElroy et al., 1992; Post, 1990). Because of increased teratogenic risk associated with these agents, there is a need to obtain and evaluate information on alternative interventions for women with bipolar disorder of childbearing age.

Service Delivery for Mood Disorders
The mood disorders are associated with significant suffering and high social costs, as explained above (Broadhead et al., 1990; Greenberg et al., 1993; Wells et al., 1989; Wells et al., 1996). Many treatments are efficacious, yet in the case of depression, significant numbers of individuals either receive no care or inappropriate care (Katon et al., 1992; Narrow et al., 1993; Wells et al., 1994; Thase, 1996). Limitations in insurance benefits or in the management strategies employed in managed care arrangements may make it impossible to deliver recommended treatments. In addition, treatment outcome in real-world practice is not as effective as that demonstrated in clinical trials, a problem known as the gap between efficacy and effectiveness (see Chapter 2). The gap is greatest in the primary care setting, although it also is observed in specialty mental health practice. There is a need to develop case identification approaches for women in obstetrics/gynecology settings due to the high risk of recurrence in childbearing women with bipolar disorder. Little attention also has been paid to screening and mental health services for women in obstetrics/gynecology settings despite their high risk of depression (Miranda et al., 1998).

Primary care practice has been studied extensively, revealing low rates of both recognition and appropriate treatment of depression. Approximately one-third to one-half of patients with major depression go unrecognized in primary care settings (Gerber et al., 1989; Simon & Von Korff, 1995). Poor recognition leads to unnecessary and expensive diagnostic procedures, particularly in response to patients’ vague somatic complaints (Callahan et al., 1996). Fewer than one-half receive antidepressant medication according to Agency for Health Care Policy Research recommendations for dosage and duration (Simon et al., 1993; Rost et al., 1994; Katon 1995, 1996; Schulberg et al., 1995; Simon & Von Korff, 1995). About 40 percent discontinue their medication on their own during the first 4 to 6 weeks of treatment, and fewer still continue their medication for the recommended period of 6 months (Simon et al., 1993). Although drug treatment is the most common strategy for treating depression in primary care practice (Olfson & Klerman, 1992; Williams et al., 1999), about one-half of primary care physicians express a preference to include counseling or therapy as a component of treatment (Meredith et al., 1994, 1996). Few primary care practitioners, however, have formal training in psychotherapy, nor do they have the time (Meredith et al., 1994, 1996). A variety of strategies have been developed to improve the management of depression in primary care settings (cited in Katon et al., 1997). These are discussed in more detail in Chapter 5 because of the special problem of recognizing and treating depression among older adults.

Another major service delivery issue focuses on the substantial number of individuals with mood disorders who go on to develop a chronic and disabling course. Their needs for a wide array of services are similar to those of individuals with schizophrenia. Many of the service delivery issues relevant to individuals with severe and persistent mood disorders are presented in the final sections of this chapter.



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10 Nonadherence is defined as lack of adherence to prescribed activities such as keeping appointments, taking medication, and completing assignments.

11 Technically, FDA approves drugs for a selected indication (a disorder in a certain population). However, once the drug is marketed, doctors are at liberty to prescribe it for unapproved (off-label) indications.

12 Bipolar depression refers to episodes with symptoms of depression in patients diagnosed with bipolar disorder.

Evidence-Based Practices: Shaping Mental Health Services Toward Recovery

Evidence-Based Practices: Shaping Mental Health Services Toward Recovery
Illness Management and Recovery Workbook
Chapter 9
Practitioner Guidelines for Handout #8:
Coping with Problems and Symptoms
Introduction

Coping with problems effectively can help people reduce stress and their susceptibility to relapses. This module helps people to identify problems they may be experiencing, including symptoms that are distressing. Two general approaches to dealing with problems are taught:

A step-by-step method for solving problems and achieving goals
Coping strategies for dealing with specific symptoms or problems.
People can choose strategies that seem most likely to address their problems. Practicing problem-solving and using coping strategies both in the sessions and as part of homework can help people learn how to reduce their stress and discomfort.

Goals

Convey confidence that people can deal with problems and symptoms effectively.
Help people identify problems and symptoms that they experience.
Introduce a step-by-step method of solving problems and achieving goals.
Help people select and practice strategies for coping with specific problems and symptoms.
Encourage people to include family members and other supportive people in their plans for coping with problems and symptoms.
Number and pacing of sessions

“Coping with Problems and Symptoms” can usually be covered in two to four sessions. Within each session, most people find that covering one or two topics and completing a questionnaire is a comfortable amount.

Structure of sessions

Informal socializing and identification of any major problems.
Review the previous session.
Discuss the homework from the previous session. Praise all efforts and problem-solve obstacles.
Follow-up on goals.
Set the agenda for the current session.
Teach new material (or review material from the previous session if necessary).
Summarize the progress made in the current session.
Agree on homework to be completed before the next session.
Strategies to be used in each session

Motivational strategies

Most people are motivated to solve and/or cope with problems and symptoms that cause them distress. In this module, the practitioner focuses on helping the person develop effective strategies for dealing with specific problems and symptoms that he or she is experiencing. For example, if someone is troubled by persistent auditory hallucinations, the practitioner could focus on identifying and practicing strategies for dealing with hearing voices. If someone has problems related to drug or alcohol use and is interested in reducing his or her substance use, the practitioner could focus on helping the person learn strategies for achieving this goal

The following suggestions may be helpful:

“The “Common Problem Checklist” helps people identify the specific areas in which they experience problems. The practitioner can then focus on the sections of the handout that provide strategies for dealing with these problems.
Practitioners should keep in mind the goals identified by people in previous sessions. Being able to solve problems (or cope with them more effectively) can help people overcome some of the obstacles they may have experienced in achieving some of their goals. For example, when someone has a goal of taking a class, having difficulty concentrating may interfere with his ability to study, which presents an obstacle to his goal of succeeding in school. Using the strategies of minimizing distractions and breaking down tasks into smaller parts might help him improve his concentration and ability to study for tests.
Practitioners can help people to make plans to achieve goals, using the Step-By-Step Problem-Solving and Goal Achievement worksheet.
Educational strategies

Educational strategies for this module focus on increasing people’s knowledge about two general approaches to dealing with problems: a step-by-step method for solving problems and achieving goals, and coping strategies for dealing with specific symptoms or problems.

The following educational strategies were discussed in detail in the Practitioner Guidelines for Educational Handout #1:

Review the contents of the handout by summarizing or taking turns reading paragraphs.
Pause at the end of each topic to check for understanding and to learn more about the person’s point-of-view.
Allow plenty of time for questions and interaction.
Pause to allow the person to complete the checklists and questionnaires.
Break down the content into manageable “pieces.”
Find a pace that is comfortable to the person.
Cognitive-behavioral strategies

Cognitive-behavioral strategies focus on helping people learn more effective strategies for solving and coping with problems.

During the sessions, practitioners can help people learn how to use the strategies of their choice by modeling and role-playing the skills.

The following examples may be helpful:

If someone who has problems with depression wanted to learn the strategy of scheduling something pleasant to do each day, the practitioner could help her set up a calendar of a week’s worth of pleasant activities. If one of the pleasant activities was going bowling with a friend, the practitioner could help her decide whom to invite and role-play a conversation making the invitation.
The practitioner should help people make plans for implementing the strategies and help them practice any aspect of the plan with which they feel uncomfortable. For example, if someone is having a problem getting along with a roommate who plays loud music late at night, he might decide to use the strategy of asking the roommate to use head phones after 11 PM. The practitioner could help him role-play how he might make the request.
Homework

Homework focuses on helping people put into action what they are learning about coping with problems and symptoms. During the session, people identify coping strategies that they would like to use in their own lives. The homework assignments follow up on this by making specific plans for people to try out the strategies on their own.

Practitioners should follow up on homework assignments in the next session by asking how it went. They should reinforce completed homework or the effort people have made to complete homework. If people are not able to complete the assignment, practitioners can explore the obstacles they encountered and help them come up with a solution for following through on the homework.

The following examples of homework may be helpful:

Working on solving a problem using the “Step-By-Step Problem-Solving and Goal Achievement” method. The person may benefit from asking family members or other supportive people to participate in helping to solve the problem.
Working on planning how to achieve a goal using the “Step-By-Step Problem-Solving and Goal Achievement” method.
Reviewing what helped and what did not help in dealing with specific problems in the past.
Using a particular coping strategy and evaluating its effectiveness. For example, someone could practice using reading to distract himself from voices.
Asking family members, friends and other supporters to participate in a coping strategy. For example, if someone plans to attend Alcoholics Anonymous (AA) as a strategy for stopping alcohol abuse, she could ask for a ride to a local AA meeting as part of a homework assignment.
Modifying coping strategies that are not effective and trying them again. For example, if someone was unsuccessful in using reading to distract himself from voices, he might try something else, like listening to music. If listening to music is not effective, he could try humming to himself to distract himself from voices.
Locating resources for implementing a coping strategy. For example, if someone wants to attend a support group as part of coping with the problem of isolation, she could call the local mental health center or look on the Internet for information about the location and times of local support groups.
Tips for common problems

People may prefer not to talk about problems.
The practitioner can help the person re-frame problems as goals, which sounds more positive. For example, “sleep problems” could be defined as “getting a good night’s sleep”; “depression” could be defined as “being in a more optimistic mood”; “lack of interest” could be defined as “developing more interests.”
The goals that were established previous sessions can also be worked on in this module. The Step-By-Step Problem-Solving and Goal Achievement method is helpful in this process.
People may find it difficult to identify a coping strategy that they want to try to deal with a problem.
Particularly when people are depressed or experience the negative symptoms of schizophrenia, they may find it hard to imagine that a coping strategy may be helpful. In such situations, the practitioner can encourage the person to keep an open mind and to “give it a try” to see what happens. For example, some people find it hard to believe that exercise can help to improve one’s mood. The practitioner can encourage someone to try a 10 to 15 minute walk, rating his mood before and after the walk.
Practitioners can also suggest that the person ask someone to join him or her in using a coping strategy. For example, as part of a coping strategy for developing interests, someone could ask a friend or relative to join her on a trip to the art museum.
Review Questions

At the end of this module, the practitioner can use either open-ended questions or multiple-choice questions to assess how well the person understands the main points.

Open-ended questions

What are some of the important steps in solving a problem?
What is a problem that you experience?
What strategy could you use to cope with the problem you identified in question #2?
Multiple choice and true/false questions

In solving problems, it is important to consider more than one possible solution. True or False

Which two of the following items are examples of common problems?

Feeling anxious

Trouble concentrating

Having too much money
Which of the following is an effective strategy for sleeping better?

Going to bed at different times every night

Doing something relaxing in the evening

Napping during the day
Which of the following is an effective strategy for coping with depression?

Set goals for daily activities

Keep your feelings inside

Remind yourself of your faults