Dr. Sarah Reynolds, our guest speaker, is an expert on Dialectical Behavior Therapy (DBT), a type of psychotherapy used for reducing self-injury and suicidal behaviors.

David Roberts is the HealthyPlace.com moderator.

The people in blue are audience members.

David: Good Evening. I'm David Roberts. I'm the moderator for tonight's conference. I want to welcome everyone to HealthyPlace.com.

Our topic tonight is "Self-Injury: What it takes for you to stop self-injuring and DBT for treating self-injury." Our guest is Sarah Reynolds, Ph.D., who is a research coordinator at the Behavioral Research and Therapy Clinic (BRTC). The BRTC, directed by Dr. Marsha Linehan, is devoted to the study and treatment of self-injury and suicide. Dr. Reynolds has extensive training and experience with Dialectical Behavior Therapy (DBT), a well-known and scientifically based outpatient psychotherapy for reducing suicidal behaviors.

Good evening, Dr. Reynolds and welcome to HealthyPlace.com. We appreciate you being our guest tonight. Many people talk about wanting to quit self-injuring, yet they find it extremely difficult to accomplish that. Why is that?

Dr. Reynolds: People self-injure, usually to regulate extreme negative emotions. It is often their only way to cope. It is the only way that they have learned, and so they keep coming back to it. It is obviously ineffective for having a reasonable quality of life, but it can work in the short-term for reducing the emotional pain.

David: What skills, exactly, do they lack?

Dr. Reynolds: Well, first of all, they usually are quite emotionally vulnerable, that is, they have a lot of ups and downs in their moods. Thus, they have a lot of emotionalities to try to deal with, just because of their biology. Further, people who self injure, typically have a lot of difficulties tolerating their negative emotions without doing something impulsive to try to stop them, and they may have difficulty forming good relationships with others.

David: Is it possible for someone to learn to stop self-injuring on their own, without professional treatment?

Dr. Reynolds: It may be possible, depending on the severity of their self-harm, but it might be quite difficult.

David: And I want to get into the treatment aspect in a moment, but you mentioned that some people use self-injury to regulate their emotions. How does that work?

Dr. Reynolds: A lot of emotional regulation skill involves refocusing attention away from emotional pain, a skill that self-injurers often lack. So, self-injury can focus attention away from the original problem and onto the physical injury. It can also validate for the person their own sense (although it is false) that they are a bad person and deserve to be punished. So, in this way, it can be calming because it validates their sense of the world.

Finally, people sometimes self injure because it can take them out of a difficult situation that causes stress. This indirectly reduces negative emotions.

David: What is the most effective method of treatment for self-injury?

Dr. Reynolds: The only treatment that has been shown to be effective in a scientific study is Dialectical Behavior Therapy (DBT). Several studies have shown that DBT reduces self-injury (both self-mutilation and suicide attempts) for women diagnosed with borderline personality disorder (BPD). There may be other treatments out there that people consider "effective" but none have been researched. Unfortunately, not much research is done on this problem.

David: Can you please explain what Dialectic Behavior Therapy is and how it works?

Dr. Reynolds: DBT is an outpatient (out of hospital) psychotherapy that views self-injury as an ineffective attempt to solve problems. Therefore, the goal of DBT is to stop self-injury and figure out better solutions. It is a structured treatment that is cognitive-behavioral. It has a number of different parts, including individual therapy, and a skills group that teaches skills for tolerating distress, increasing awareness of surroundings (mindfulness), regulating emotions, and interacting effectively with others.

David: We have a lot of audience questions, Dr. Reynolds. Let's get to some of those and then we'll continue on with our discussion about the treatment of self-injury.

Fragil Heart: My neighbor Michele, a single mom of three, is a self-injurious person who cuts herself repeatedly. I know that she refused treatment for her drug addiction and the Department of Human Services is going to remove her children. She has no knowledge of this. My question is, after the kids are gone, her chances of cutting are great and she has begun to hide her cuts. How can I help her, if I can? I do support and listen to her.

Dr. Reynolds: Well, the best thing is to encourage her to get into treatment. I would also consider telling her that you think her kids will be removed from the home. Often times, it can take major consequences as a result of our behavior before we can change. I am sure that even your emotional support is a great comfort to her, as many people who cut are very socially isolated.

2nice: How common is self-injury in people with a depressive illness?

Dr. Reynolds: Self-injury is very often associated with a diagnosis of BPD (Borderline Personality Disorder), and very often with a mood disorder, such as depression. People who self-injure are often chronically miserable.

Keatherwood: I haven't done any self-injury for over five years. Because of some things that happened this past weekend, it is all I can think of. I'm taking extra medications, doing all the alternatives I know, talking with my therapist, etc., but I can't get the idea out of my mind. I feel like I'm going to explode if I don't do something. I thought I was past this. Any suggestions? The hospital has been suggested, but I'd like to avoid that.

Dr. Reynolds: Wow! It is fabulous that you have not self-harmed in so long. You clearly have a lot of good skills, if you have been able to resist previous urges to self-injure, which I bet you have done. How did you get through those rough patches before? Think about that.

Also, I would think about the pros and cons of doing it at this point. What are the bad things about doing it, and is it really likely to make you feel better? Think carefully about it, and my guess is that in your heart of hearts, you know it will ultimately make you feel worse. You've done wonderfully for this long. Stay committed to no more self-injury.

David: Is it unusual, or not unusual, for someone to suffer a relapse once they have "recovered"?

Dr. Reynolds: It is not at all unusual. Self-harm has an addiction-like quality. But the longer someone avoids it, the longer they will likely keep from doing so again. The trouble is that each time one self-injures, it teaches your brain that self-injury is the way to solve problems, and thus, blocks you from finding more effective solutions to what is really happening in your life.

secret*shame: I am sixteen, and I have been cutting for five years. Why can't I stop? I don't want to tell my mom because I don't want to hurt her. What can I do?

Dr. Reynolds: I am so sad to hear that you have been cutting since age eleven. From your name, it sounds like you have a lot of shame about who you are and your self-injury? The thing is, you probably should tell your mother or someone you can trust if not her. The point is, you have been doing this for a long time, and it is too big of a problem for you to get over it by yourself! I desperately hope that you talk to an adult who can help you out with this. That is the only way you can stop it right now. I want to emphasize, secret*shame, that your mother will be far more hurt if you do not tell her about this so that she can help you.

David: I want to add, secret*shame's situation is not unusual. Many teens are afraid to tell their parents about things like self-injury. How would you suggest they handle that, Dr. Reynolds? Because without their parent's help (insurance and support), they can't get the therapy they need. How, specifically, can they broach the subject with their parents?

Dr. Reynolds: Yes, that is true. If they don't want to acknowledge the self-injury itself, they could consider getting help simply due to depression and misery. Once in therapy, their responses will likely be confidential, or at least they can ask the therapist if it can be kept confidential. Certainly, for someone who is sixteen, the therapist is unlikely to talk to their parents without consent unless the adolescent is at risk of suicide. If not their parent, I would strongly urge them to try to find another adult that they can trust such as a teacher, an older sibling, etc.

David: That's a good suggestion.

here2help: I am a seventeen-year-old male student in England, UK and I have a seventeen-year-old female friend who does self-injury. She has been doing this for about two years, I think, but it has only recently become known to anyone but herself. I was the first person she told out of choice, but others found out either after she fainted or by finding blood on her. I want to know what I can do to help her. She is on anti-depressants, although she's not very good at taking them. She does have therapy and she also drinks.

Dr. Reynolds: She is in a relatively good situation given that she has treatment and friends. If you think that her self-injury is a bad thing, it might help to be honest with her about that. Communicate to her that you think it is a big problem. I think that would be helpful.

teatranna: Are the use of "ice cube" therapy (holding ice cubes in the hands to feel pain) or "line" therapy (the drawing of lines on one's body with a red marker) effective alternatives to self-injury, or are they dangerous substitutions that only perpetuate the urges?

Dr. Reynolds: I think this is a much better alternative than actual tissue damage (breaking the skin). It is qualitatively different from inflicting tissue damage and is a great way to work on stopping self-injury.

David: Here are some more questions:

scarlet47: My therapist is sending me for four DBT sessions. Can that amount help with success. I refuse to attend more. It was unnatural and brainwashing to me, and I don't have patience and won't attend any group sessions. I committed to him to attend, but I am not open to it. He wants to see the impact. I believe you can take the horse to the well, but you can't make him drink.

Dr. Reynolds: Four sessions of Dialectical Behavior Therapy will not help. However, a year of DBT can help you to bring about incredible changes in your life. You must have some reasons for going to even four sessions? Think about the advantages and disadvantages of going. But you are right, you must be absolutely committed to ending self-injury. Otherwise, the treatment won't work. I hope you change your mind. Good luck.

ill_fated: What is the difference between DBT and CBT (Cognitive-Behavioral Therapy)?

Dr. Reynolds: DBT is specifically designed to treat people who have problems with self-injury, and who have severe personality disorders, like Borderline Personality Disorder. It is actually a form of cognitive-behavioral therapy, but the other types of CBT that are currently available are only for anxiety, depression, and eating disorders. Also, one piece of DBT that is relatively unique, is that it emphasizes validating the patient. This is important because self-injurers often do not trust themselves, their emotional reactions, or their experiences as valid and meaningful. DBT helps the client to learn to trust and validate themselves.

Crazy02: Dr. Reynolds, I am in the Philadelphia area and the mother of a nineteen-year-old self-injurer. I hear what you are saying, but what can I do to help my daughter?

Dr. Reynolds: Have you tried to get her into therapy?

David: That would be the first thing. What else can a parent do to help? And also, a lot of parents feel guilty, thinking they are the cause of their child's self-injury behavior.

Dr. Reynolds: Well, I realize that you may not be able to interact with me and answer my question. Basically, I think that is the central piece. If she refuses to go, then, providing the emotional support that you do is no doubt helpful. Beyond that, it is essentially impossible to control a nineteen-year-old's behavior. I know this must be very frustrating, but your hands are somewhat tied.

For parents in general, there are some good self-help books that they might consider reading, such as "Eclipses" by Melissa Ford Thornton. Another book I want to mention that can be helpful for friends and family of self-injurers is "Stop Walking On Eggshells."

I also emphasize that it is not reasonable for any parent to think that it is their "fault" that their children are engaging in self-injury. Things are not that simple.

hippiemommy3: Other than cutting and forms of self-mutilation, is taking overdoses a form of self-injury? At least once a week I seem to take 20 Darvocet and I want to stop. I am in a day treatment program and have a good therapist. I have medication management, but whenever I get my hands on my pills, I just take too many. Is this self-injury, or something else?

Dr. Reynolds: Taking overdoses can be a form of self-injury. In your case, I would want to know your intent. It sounds like your problem is more likely drug addiction.

David: Someone asked a question about the books Dr. Reynolds mentioned. You can find some in our online bookstore.

xXpapercut_pixieXx: Can DBT also be used to bring a person back from a sense of numbness or blankness?

Dr. Reynolds: This sense of numbness is not uncommon in people who have BPD and who self-injure. The answer is yes, DBT can be very helpful for addressing this problem as it so often coexists with BPD and self-injury.

arryanna: Is there any specific medication you have found to help reduce the amount of self-injury?

Dr. Reynolds: No, the few studies that have been done, indicate that no medications are effective in the long-term.

Filly: What if part of the problem is not learning the proper skills. I made it fine through the teens, twenties and most of the thirties with only a few thoughts of self-injury and now, suddenly, after the break up of a long relationship, added with high stress from work, I started to self-injure? By the way, I am in the DBT of Portland, and I do believe it will work.

Dr. Reynolds: It is not uncommon that people may "fall apart" and self-injure in instances of extreme stress. It sounds like that's what happened to you. But, you have an excellent prognosis for getting past this, since it started late and you are already in a good treatment program. Good luck.

megs5: I have heard that self-injury is most common among people who have been abused or raped. Why would someone like me cut? I have not been through anything?

Dr. Reynolds: Many people who self-injure or attempt suicide have a history of abuse. However, many do not. The etiology of this behavior is not exactly known. What I believe, is that a person is born biologically with a predisposition to be very emotional. Then, they have an environment that does not meet their needs.

angelight789: Is self-injury related to one's menstrual cycle or hormone level? I am taking a drug called Lupron that induces menopause and I have been cutting more. I have severe endometriosis and a lot of female-related problems. Could this impact my self-injury problem?

Dr. Reynolds: I am not sure whether it could directly affect your cutting. A medical doctor would be better able to answer that. What I can say, is that having health problems increases stress, which certainly increases the likelihood of self-injury.

dazd_and_confusd: I was hospitalized for an attempted suicide last year for 8 and 1/2 months. I'm still suicidal and I self-injure. I'm in therapy, but nothing helps. I'm afraid of going back to the hospital because I don't think it will help, but that seems like the only option. I'm afraid. I hate the way I am and how my life is, and I don't know what else to do.

Dr. Reynolds: You sound really desperate. The thing to do at a time like this is to try to generate some hope that things will get better and that this will pass.

As for the hospital, I am not an advocate of hospitalization for suicide attempts, because there is absolutely no evidence that it helps. In fact, I think in some cases it can harm because it does not teach you to cope in your everyday environment. So, I agree that the hospital is probably not the answer. Please remember when you are acutely miserable, things will get better. No emotion lasts for a long time. It always peaks and then dissipates like a wave. Hang in there.

bleedingpink: I started cutting last year. It got really bad to the point where I was cutting thirty times a night. I was able to stop for seven months. Then, one day I found out my best friend was cutting again, and it made me start cutting again. Why is that?

Dr. Reynolds: It is very common that talking to another who cuts, or talking about cutting, is a trigger for people to cut. I would urge you to not talk to her about this, and be sure that you have friends who cope in more adaptive ways.

betty654: I have been in DBT for almost a year now and have not cut. The thoughts are worse than ever and I feel worse than before. Will the thoughts ever go away and for how long?

Dr. Reynolds: It is wonderful that you have not cut! You're obviously working hard toward building a life worth living. It is no surprise that the thoughts are still there. I assume that you mean thoughts or urges to cut and misery? The bad news is, that the misery and urges take longer to go away than just the cutting itself. The good news is that you will get there, it just takes a lot of work and some radical acceptance that you may not be the kind of person that will ever be light-hearted and happy-go-lucky. Good luck betty654.

David: Dr. Reynolds, referring back to your earlier comment regarding hospitalization, you mentioned that you didn't think it was particularly helpful for those who are suicidal. One of our audience members thought that hospitalization would stop the person from following through, at least for a while. Can you respond to that?

Dr. Reynolds: Yes, people assume that the best treatment is to be very restrictive to those who are suicidal, but no one has ever done a study on that. This is a good point, because it may stop them for twenty-four hours, and I would never say that hospitalization is always bad, but what is to be done after that short period of time is up? Also, any short-term gain is offset by the long-term disadvantage of what they have learned: that when they fall apart and can't cope on their own, they are taken to the hospital and taught that they cannot care for themselves.

Also, they cannot live in the hospital forever, and they need to learn how to control their emotions in everyday life. Studies have shown that learning needs to take place in the environment in which it will be used, which means a person's daily life.

dianna_mcheck: Can practicing sado-masochism relate to self-injury? When I am in a sexual relationship where S&M is present, I don't self-injure, but when it is not, I do. Is it just a fluke, or is it connected?

Dr. Reynolds: It could be connected, particularly if you are masochistic. But self-injury is typically not done to cause sexual arousal.

Jayfer: At the moment, I am trying really hard. I am seeing a therapist but finding it really hard to stop at the moment. I quite often rely on the thought of, "Well if I can't cope, I can always self-injure." Would you say that this thought is natural and healthy? If not what can I do to change this thought?

Dr. Reynolds: That thought is understandable given that you have been doing this for a long time, but it is definitely not healthy or natural. That thought is really your mortal enemy because it is "keeping the door open" to self-harm, and therefore, not really teaching you new ways to cope. What you should do is commit that there will absolutely be no more self-harm. SLAM the door, as if you were a drug addict.

tracyancrew: Do you think a day treatment program like partial hospitalization helps someone who self injures?

Dr. Reynolds: An intensive treatment like partial hospitalization can be great. It is not the same as an inpatient hospitalization because you do go home at night, and also typically have assignments at home, etc. So, beyond that, I would have to know what type of treatment it is.

There are a number of DBT partial hospitalization programs, for example, the one I know of for certain is Cornell Medical Center in New York. For those interested in finding DBT providers in their area, you can check at this website: www.behavioraltech.com. This is the website of the Behavioral Technology Transfer Group. It is a company that specializes in empirically supported treatments such as DBT. So, they have a resource list on their website.

earthangelgrl: OK, when does self-injury come to the point where it is dangerous and you should seek help for cutting? I have had days where I have done nearly 500 cuts.

Dr. Reynolds: Clearly, you have reached the point of "dangerous" in the sense that the quality of your life is probably nil. It does not matter that your cutting is not medically serious, I strongly advise you to get professional treatment as soon as possible! I wish you well.

smilewmn: I see a therapist for abuse related issues. She knows I cut, but doesn't tell me it's wrong., so I feel like it's okay to do. Why wouldn't she tell me it's wrong?

Dr. Reynolds: There are a number of treatment providers who may say that it is "okay" to cut while you work on the underlying problems related to the cutting. My treatment approach, DBT, takes a very different approach that you cannot have a good life when you are intentionally harming yourself. Each time that happens you teach yourself that it is the only solution, and perhaps also that you are a bad person deserving of pain. It just depends on your treatment goals: if you want a better life, you have to commit to stopping any cutting or suicide attempts.

Tigirl: I have been cutting, burning, and breaking bones for about two years and I have been anorexic for fourteen years. What are my chances of getting better? (Find information about anorexia)

Dr. Reynolds: You have good chances of leading a good life, if you get help. You seem to be looking for help, and if so, that is definitely on your side because people who don't ask for help have a lot less chance of getting better. Good luck, Tigirl.

Nerak: I have not self-injured in thirty-two days, but I feel the urges coming back, and am so afraid that one day I will not be able to stop. Any suggestions on what to do to not get to that point?

Dr. Reynolds: Try to identify things that you have done before that help. For example, some people know they will not cut when around others. Also, consider the ideas earlier such as holding an ice cube. I would also make out a list of pros and cons for self-harming so that you can look at it when you begin to get dysregulated. Finally, you have to remember that even when you have an urge, it will peak and then go down. So, you just have to get through it.

David: Thank you, Dr. Reynolds, for being our guest tonight and for sharing this information with us. And to those in the audience, thank you for coming and participating. I hope you found it helpful. Also, if you found our site beneficial, I hope you'll pass our URL http://www.healthyplace.com around to your friends, mail list buddies, and others.

Dr. Reynolds: Thank you very much for having me. I have enjoyed it.

David: And again, Dr. Reynolds, thank you for staying so late and answering questions. We appreciate it.

Dr. Reynolds: Good luck to everyone, and take care.

David: Good night, everyone.

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

How should a child be diagnosed for ADHD? Here's a step-by-step guide your child's doctor or therapist should be following to evaluate your child for ADHD.

Ideally, the diagnosis of ADHD should be made by a professional in your area with training in ADHD or in the diagnosis of mental disorders. Child psychiatrists and psychologists, developmental/behavioral pediatricians, or behavioral neurologists are those most often trained in differential diagnosis. Clinical social workers may also have such training.

The family can start by talking with the child's pediatrician or their family doctor. Some pediatricians may do the assessment themselves, but often they refer the family to an appropriate mental health specialist they know and trust.

Whatever the specialist's expertise, his or her first task is to gather information that will rule out other possible reasons for the child's behavior. In ruling out other causes, the specialist checks the child's school and medical records. The specialist tries to sense whether the home and classroom environments are stressful or chaotic, and how the child's parents and teachers deal with the child. They may have a doctor look for such problems as emotional disorders, undetectable (petit mal) seizures, and poor vision or hearing. Most schools automatically screen for vision and hearing, so this information is often already on record. A doctor may also look for allergies or nutrition problems like chronic "caffeine highs" that might make the child seem overly active.

Next the specialist gathers information on the child's ongoing behavior in order to compare these behaviors to the symptoms and diagnostic criteria for ADHD listed in the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders). This involves talking with the child and if possible, observing the child in class and in other settings.

The child's teachers, past and present, are asked to rate their observations of the child's behavior on standardized evaluation forms to compare the child's behaviors to those of other children the same age. Of course, rating scales are subjective--they only capture the teacher's personal perception of the child. Even so, because teachers get to know so many children, their judgment of how a child compares to others is usually accurate.

The specialist interviews the child's teachers, parents, and other people who know the child well, such as school staff and baby-sitters. Parents are asked to describe their child's behavior in a variety of situations. They may also fill out a rating scale to indicate how severe and frequent the behaviors seem to be.

In some cases, the child may be checked for social adjustment and mental health. Tests of intelligence and learning achievement may be given to see if the child has a learning disability and whether the disabilities are in all or only certain parts of the school curriculum.

In looking at the data, the specialist pays special attention to the child's behavior during noisy or unstructured situations, like parties, or during tasks that require sustained attention, like reading, working math problems, or playing a board game. Behavior during free play or while getting individual attention is given less importance in the evaluation. In such situations, most children with ADHD are able to control their behavior and perform well.

The specialist then pieces together a profile of the child's behavior. Which ADHD-like behaviors listed in the DSM does the child show? How often? In what situations? How long has the child been doing them? How old was the child when the problem started? Are the behaviors seriously interfering with the child's friendships, school activities, or home life? Does the child have any other related problems? The answers to these questions help identify whether the child's hyperactivity, impulsivity, and inattention are significant and long-standing. If so, the child may be diagnosed with ADHD.

Sources:

• Attention Deficit Hyperactivity Disorder, publication by NIMH, June 2006.

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next: 3D Medical Animation~ adhd library articles~ all add/adhd articles

Some of us will experience intense, prolonged feelings of anxiety and fear just from watching the Virginia Tech shooting on tv news

Following a nationally publicized traumatic incident like the shootings at Virginia Tech, it is common for those actually involved in the shooting, or those closest to them, to experience a wide range of emotions; from severe helplessness, hopelessness and horror, to anger, and for some, even guilt of having survived the ordeal. But even those of us who only experience the events as spectators from afar (through news reports) may be dismayed, confused or frightened by the emotions we experience.

Some spectators will experience some of the emotions listed above. Many may be bothered by symptoms of fearfulness or depression. Others may be confused that they are not experiencing any unusual emotions and may wonder why they are "unmoved by the incident."  Still others may experience anger or frustration at the "shooter"  or his family, the people in charge for not responding sooner, the laws regarding gun possession, the mental health system for failing to prevent the tragedy, or society itself for creating the conditions the shooter experienced. All of these thoughts and feelings, as well as a multitude of others not mentioned, are understandable. They appear on top of the underlying layer of thoughts of disbelief, frustration, fear, and of sadness and grief.

Who is susceptible to long-term fear from a tragic event?

For most of us, time will dampen and ultimately remove the most intense of these feelings, but for some people, the feelings of fear become prolonged. The most vulnerable amongst these long-term sufferers are those with pre-existing mental illness; especially those with one of the various anxiety disorders and those with substance abuse problems.

Anxiety is explained to be inappropriate or overdone feelings of fear, apprehension and worry. I explain to my patients that anxiety is best thought of as a severe case of the "what ifs."  What if this? What if that? What if, what if, what if??? It is an ongoing and unrealistic state of concern for future events.

If you're experiencing an anxiety disorder, you may find it difficult to control the worrisome thoughts and feelings, and the anxiety is accompanied by behavioral symptoms:

• restless, feeling keyed up or on edge, often with trouble getting restful sleep
• withdrawal and isolation

physiological symptoms:

• heart racing
• trouble breathing
• stomach problems

emotional symptoms:

• irritability,
• crying easily
• sadness
• fear of disease or death

To be a disorder, these symptoms must bother the person significantly (cause distress) and/or interfere with their ability to function on an everyday basis. There are a variety of anxiety disorders like phobias, obsessive compulsive disorder, generalized anxiety disorder, social anxiety disorder and post traumatic stress disorder, but the hallmark symptom of an anxiety disorder is inappropriate or overdone fear, worry and apprehension.

What if you have realistic fears?

For most people suffering from anxiety disorders, the underlying precipitating cause is unclear or unknown (except perhaps for PTSD where the stressor is clear and overwhelming). Despite being unaware of the cause, the person with an anxiety disorder continues to suffer from the fear and worry, although they realize it is overdone.

With a tragedy like to one at Virginia Tech, however, a person with a pre-existing anxiety disorder now has an obvious "reason"  to be anxious---after all, what happened at the university could happen anywhere, and to anyone---even to them. Although possible, a similar event is unlikely. Even though school shootings are covered "wall-to-wall"  by the media they are, thankfully, unusual and, in fact, rare events. After all, that's what makes them newsworthy.

Although it is understandable to experience worry and concern over such horrific tragedies, if the anxiety resulting from such concern is overwhelming, impairing or prolonged, it may indicate a need for the sufferer to get help.

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So, how do you know if you have prolonged anxiety that is problematic?

If you begin to experience ongoing symptoms such as:

• Fearfulness that is uncontrollable and incapacitating
• Trouble with sleep impairing daytime functioning
• Withdrawal from usual activities
• Failure to take care of ones daily needs (like eating, resting,etc)
• Onset of depression
• Difficulty concentrating or functioning day to day
• Marked worsening of underlying emotional disorder
• Turning to non-prescribed chemicals or alcohol to control worry

Although these symptoms may not represent a true disorder, they can be the warning signs that alert you to the need for more help; especially if they are prolonged in duration.

Self-help techniques for coping with anxiety include:

1. Take a break from the news
2. Re-establish a regular day-to-day routine
3. Re-connect with a support system such as family or friends and talk to them about your thoughts, feelings and behavior
4. Pamper yourself with activities you enjoy
5. Engage in relaxation techniques (massage, meditation, yoga, exercise, positive self-talk and relaxation techniques)
6. Avoid self-medication (alcohol, drugs)
7. Begin to question your own irrational thoughts and feelings 8. Get good information from places like HealthyPlace.com

If these self-help activities do not significantly relieve your anxiety, a visit with a mental health professional might be in order.

Detailed information on Anxiety Disorders can be found here.

By Harry Croft, MD
Medical Director of HealthyPlace.com

back to: Dr. Harry Croft's News Index

http://www.healthyplace.com/news_2007/croft/croft_va_tech_shootings_anxiety.asp

Dr. Michael B. Schachter, our guest tonight, is a board-certified psychiatrist and author of the book: What Your Doctor May NOT Tell You About Depression: The Breakthrough Integrative Approach for Effective Treatment.

Natalie is the HealthyPlace.com moderator.

The people in blue are audience members

Natalie: Good evening. I'm Natalie, your moderator for tonight's Depression chat conference. I want to welcome everyone to the HealthyPlace.com website. Here's the link to the HealthyPlace.com Depression Community. You can click on this link and sign up for the mail list at the top of the page so you can keep up with events like this. There's a lot of info there on depression (visit the Depression Community Center) and antidepressant medications (see complete list of articles on antidepressants).

Tonight, we are going to discuss how to fight depression safely and effectively.

Dr. Michael B. Schachter, our guest tonight, is a board-certified psychiatrist and author of the book: What Your Doctor May NOT Tell You About Depression: The Breakthrough Integrative Approach for Effective Treatment. Dr. Schachter graduated magna cum laude from Columbia College and received his medical degree from Columbia in 1965. He has been involved with alternative and complementary medicine since 1974 and is a recognized leader in orthomolecular psychiatry and nutritional medicine.

Dr. Schachter maintains that you can effectively deal with depression through healthy living and eating habits as well as by using supplements, vitamins, minerals and other non-prescription treatments (see: Natural Antidepressants: An Alternative to Antidepressants).

Good evening, Dr. Schachter and thank you for joining us. What is it that your doctor may NOT tell you about depression?

Dr. Schachter: Many factors may contribute to a person's depressed state and many of them are not considered by conventional physicians or psychiatrists (See: Causes of Depression: What Causes Depression?). Among these factors are: one's diet, toxic factors (such as artificial sweeteners), suboptimal levels of vitamins and minerals like the B complex, magnesium and zinc, hormonal imbalances, deficiency of various neurotransmitters (such as serotonin or dopamine), lack of activity and exercise, adverse effects of many medications (such as blood pressure medications and even antidepressants) and diseases (such as Lyme disease). All of these things should be considered when evaluating a depressed patient, but the typical response of most conventional physicians and psychiatrists is to write a prescription for an antidepressant medication.

Natalie: I think many people believe that depression really results from two things: 1) a bad situation the person may be in, or 2) something is wrong with their neurotransmitters. Are you saying there's more to depression than that?

Dr. Schachter: Yes, many other factors need to be considered, such as hormone imbalances, diet, nutritional deficiencies, toxicity etc..

Natalie: A lot of people, medical professionals and patients alike, maintain that alternative or complementary medicine, things like nutritional supplements, vitamins and diet regulation, are a lot of bunk and just don't work when it comes to treating something as serious as depression. Using these natural methods of treatment, what results have you seen?

Dr. Schachter: Our results in treating depressed patients are excellent. It is almost like solving a jig saw puzzle trying to figure out which of the many factors mentioned previously are playing a significant role in this particular patient's depression. Once you get the right combination, patient's improve without the significant potential side effects of medication.

Natalie: So what does a typical exam for a patient presenting with depression look like when they come to your office?

Dr. Schachter: In our practice, we occasionally prescribe antidepressant medication, but generally as a last resort, rather than a first option. We usually will try various natural treatment first. If these are not sufficient, we will usually add an antidepressant to the program, using as low a dosage as possible to try to avoid adverse effects. Frequently, when using various non-drug adjuncts, the dosage of antidepressant can be much lower.

Natalie: How do you determine what is causing depression in a person?

Dr. Schachter: We recommend a thorough evaluation with a full medical and psychological history, including what medications have been taken recently, a dietary evaluation, a variety of tests that may include: various vitamin levels (like vitamin D and B12 and others), a search for mineral toxicity (such as mercury), and mineral deficiencies, a urine test to measure neurotransmitters (like serotonin and dopamine), a saliva test to measure various hormones (such as DHEA, cortisol, sex.) From this assessment, the treatment evolves. However, we have some general rules about avoiding sugar, caffeine, alcohol and tobacco and do give each patient a list of things to avoid and other things that are desirable.

Natalie: I noticed that you mentioned earlier that you do give patients antidepressants on occasion. Do you believe they are effective in treating depression and in what instances would you recommend a patient take them?

Dr. Schachter: In our practice, we occasionally prescribe antidepressant medication, but generally as a last resort, rather than a first option. We usually will try various natural treatment first. If these are not sufficient, we will usually add an antidepressant to the program, using as low a dosage as possible to try to avoid adverse effects. Frequently, when using various non-drug adjuncts, the dosage of antidepressant can be much lower. Also, in some very serious depressions, we might start the medication right away along with other measures we might use.

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Natalie: Are there different depression treatments for the different symptoms of depression?

Dr. Schachter: Yes. The symptoms often give clues as to what a person needs. For example, a person who is lethargic, has dry skin, has gained weight and is constipated, may be suffering from an essential fatty acid deficiency as well as a low functioning thyroid gland. One who is anxious and agitated as well as depressed (see: Relationships between Anxiety and Depression), may have excessive neuroexcitatory neurotransmitters along with a deficiency of serotonin. These need to be corrected starting with trying to correct the excitatory symptoms first (see: Depression and Anxiety Treatment).

Natalie: One of the things you focus on in the book is eating the proper foods. Why is that important?

Dr. Schachter: Proper eating is important to treat depression and any other chronic conditions. Within our body, we have trillions of cells and an almost infinite number of biochemical reactions occurring each minute. In order for these biochemical reactions to work properly, the building blocks must be present. These building blocks come from our food. For example, our neurotransmitters (the messages that are transmitted from one nerve cell to another) are made from certain amino acids (like tryptophan or tyrosine). These amino acids come from protein. If a person has insufficient protein in his diet, he may become depleted of serotonin or dopamine and thus become depressed. Other examples may include deficiencies of the essential fatty acids necessary to build the membranes of our nerve cells. A person that eats and drinks primarily a junk food diet will be deficient in vitamins, minerals and other important nutrients. The importance of a good diet cannot be overemphasized.

Natalie: Will a poor diet eventually lead to depression or rather is it a symptom of depression?

Dr. Schachter: A poor diet may certainly contribute to depression in many people. But, a person who is depressed may tend to gravitate to a poor diet for many reasons. For example, a depressed person will frequently want sugary foods or caffeine to get a quick fix. Unfortunately this may lead to stress on the adrenal glands and an overall worsening of the condition.

Natalie: You break foods down into 2 lists: "Positive Foods" and "Foods to Avoid." Can you please briefly outline some in each category?

Dr. Schachter: We suggest whole foods (as opposed to processed highly refined foods). Use organic foods as much as possible. Eat lots of vegetables, legumes, some fruits, good protein (including meat, fish and poultry), healthy organic nuts and seeds, organic whole grain grains and pure water. Organic dairy products are fine for some people, but the diet must be individualized somewhat. Stay away from or greatly limit sugary foods, fried foods, cakes, candies, ice cream, white breads, bagels, white pastas and refined carbohydrates in general.

SMD84:How do you correct an imbalance in the neurotransmitters?

Dr. Schachter: Neurotransmitters are made from amino acids. For example, tryptophan or 5 HTP is converted to serotonin in the body. The amino acids Phenyl alanine and tyrosine are converted to dopamine and norepinephrine. By ingesting the amino acid of the neurotransmitter that is low, you can reestablish balance. (visit HealthyPlace Alternative Treatments for Mental Health for more information on these supplements and more.)

There are basically 2 classes of neurotransmitters. They are either excitatory or inhibitory. An excess or deficiency of either class can cause problems. There are also a variety of substances that can modulate both the inhibitory and excitatory. The major inhibitory neurotransmitter is GABA, while the major excitatory neurotransmitter is glutamate. Serotonin usually enhances GABA activity, while norepinephrine tends to be involved with enhancing excitatory activity.

When treating depression, it is usually best to first enhance inhibitory activity to quiet the system down. After a few weeks, we focus on enhancing neuroexcitatory activity.

cocoa 1: David Burns suggests there is no clear indication that serotonin causes depression. He says there is not one study in the world that convinces him of that and that is his area of expertise. what convinces you that it does?

Natalie: David Burns is the author of "When Panic Attacks"

Dr. Schachter: Well, I'm not sure exactly what he means, but our experience in doing urine neurotransmitters is that when serotonin is low (compared to a norm for healthy non-depressed people, there frequently is depression. When we administer 5HTP which stimulates serotonin, the person frequently improves and the serotonin in the urine increases. We have hundreds of cases to show this and the lab that does this testing, has thousands of case histories and lab results to support this. I wouldn't say that "serotonin causes depression", but a deficiency in it seems to contribute to depression in many cases.

jdiamond: Do you have any recommendations about which natural health products have had effective results? Any types which are not an appropriate product used to manage depressive symptoms? (ex. vitamins, or prepared homeopathic remedies)

Dr. Schachter: There are many so-called natural products that are beneficial. These may include: targeted amino acids, essential fatty acids, certain herbs like rhodiola and St.John's Wort, minerals like Magnesium Taurate, essential fatty acids as contained in fish oil, flaxseed oil and evening primrose oil. Also, a variety of homeopathic remedies may be useful. When dealing with depression, the homeopath needs to be well trained and be aware of the dangers of aggravation that may occur. We have chapters on each of these areas in our book "What Your Doctor May Not Tell You About Depression." Regarding supplements to avoid, I would stay away from supplements that contain artificial coloring or flavoring (which some people react to) and be aware if he fact that it is possible to create imbalances with natural substance also.

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Natalie: One of the things I'm gathering from our conversation and your book is that treating depression EFFECTIVELY is more than just taking an antidepressant or even vitamins or supplements. It's really an entire lifestyle issue too.

Dr. Schachter: Yes. I believe this is correct. For example, exercise is extremely important. Some studies show exercise to be more effective and longer lasting than antidepressants. Fresh air and sunshine also appear to be important. Looking at one's eating habits, exercise patterns, supplements, exposure to sunlight and fresh air all are important in an overall approach to managing depression.

karenblibra:How does a person find a trained professional like yourself who can treat depression naturally / holistically?

Dr. Schachter: Our book has an appendix which lists some resources. Many well trained naturopathic physicians and integrative physicians use the approach we discuss in our book. We also mention some websites that list practitioners who try to practice using these principles. One organization that I have been involved with for more than 30 years is the American College for Advancement in Medicine (ACAM). You can go to their website at: http://www.acam.org/, click on find a physician and put in your zip code. Various physicians will come up and there will be codes indicating the kind of work they do.

Natalie: Dr. Schachter, what about people who have been on antidepressants for many years, 5+ years. Can they possibly be taken off the antidepressant and put on your regimen and have it be effective?

Dr. Schachter: This is an excellent question. Whether or not there may be some permanent and irreversible changes in the brain when someone is on an antidepressant for many years is controversial. What often happens when a person is on an antidepressant for a long period of time, is that they may develop severe deficiencies of certain neurotransmitters. These can generally be improved by giving the neurotransmitter precursors (certain amino acids) to build up these neurotransmitters. Sometimes when the antidepressants stop working, building the neurotransmitters will help them to work again. Whenever someone tries to go off an antidepressant after many years, it is crucial that this is done very slowly with nutritional support at the same time. Otherwise, severe withdrawal effects may occur in some cases. In almost all cases, the antidepressant medication dosage can be lowered. In some cases, it may be stopped completely; but, in other cases a low maintenance dose will be necessary.

Natalie: Dr. -- one audience member wanted to know if your book also talks about the causes of depression as well as the treatment recommendations?

Dr. Schachter: That is the subtitle. The full title is: What Your Doctor May NOT Tell You About Depression: The Breakthrough Integrative Approach for Effective Treatment (Warner Books). The book is all about the possible causes and how to evaluate them. It begins with a few chapters where questionnaires are used to help determine what causes may be present. It is important to think about depression in a multidimensional way. Is it related to fatty acid deficiency? Could a low functioning thyroid (even with normal thyroid function tests be involved? Is the adrenal gland weak and stressed leading to depression? Could the toxic mineral mercury either from dental fillings or too much sushi playing a role in the depression? The book tries to address all of these factors and helps the reader to recognize what factors may be important

Natalie: Our time is up tonight. Thank you, Dr. Schachter, for being our guest, for sharing this information on safely and effectively treating depression and for answering audience questions. We appreciate you being here.

Dr. Schachter: Thank you.

Natalie: Here's the link to the HealthyPlace.com Depression Community. There's a lot of info there on depression and antidepressant medications.

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

Thank you again Dr. Schachter and good night everyone.

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

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13. Management of Patient's Post-ECT Course

13.1. Continuation therapy is traditionally defined as the provision of somatic treatment over the 6 month period following, the onset of remission in an index episode of mental illness (National Institute of Mental Health Consensus Development Panel 1985; Prien & Kupfer 1986; Fava & Kaji 1994). However, individuals referred for ECT are particularly likely to be medication resistant and to display psychotic ideation during the index episode of 'illness, and the risk of relapse remains high (50-95%) throughout the first year following completion of the ECT course (Spiker et al. 1985; Aronson et al 1987; Sackeim et al 1990a,b, 1993; Stoudemire et al. 1994; Grunhaus et al. 1995). For this reason, we will operationally define the continuation interval as the 12 month period following successful treatment with ECT.

Regardless of its definition, continuation treatment has become the rule in contemporary psychiatric practice (American Psychiatric Association 1993, 1994, 1997). Following completion of the index ECT course, an aggressive program of continuation therapy should be instituted as soon as possible. Occasional exceptions include patients intolerant to such treatment and possibly those with a history of extremely long periods of remission (although compelling evidence, for the latter is lacking).

13.2. Continuation pharmacotherapy. A course of ECT is usually completed over a 2- to 4-week period. Traditional practice, based in part on earlier studies (Seager and Bird 1962; Imlah et all. 1965; Kay et al. 1970) and in part on clinical experience, has suggested continuation treatment of patients with unipolar depression with antidepressant agents (and possibly antipsychotic agents in the presence of psychotic symptoms), patients with bipolar depression with antidepressant and/or mood stabilizer medications; patients with mania with mood stabilizer and possibly antipsychotic agents, and patients with schizophrenia with antipsychotic medications (Sackeim 1994). However, some recent evidence suggests that a combination of antidepressant and mood stabilizer pharmacotherapy might improve the effectiveness of continuation therapy for patients with unipolar depression (Sackeim 1994). It may also be beneficial to discontinue antidepressant medications during the continuation phase of treatment for patients with bipolar depression (Sachs 1996). For patients with major depression episodes, medication dosages during continuation treatment are maintained at the clinically effective dose range for acute treatment, with adjustment up or down depending upon response (American Psychiatric Association 1993). For patients with bipolar disorder or schizophrenia, a somewhat less aggressive approach is utilized (American Psychiatric Association 1994, 1997). Still, the role of continuation therapy with psychotropic drugs after a course of ECT continues to undergo assessment (Sackeim 1994). In particular, disappointingly high relapse rates, especially in patients with psychotic depression and in those who are medication resistant during the index episode (Sackeim et al. 1990a: Meyers 1992; Shapira et al. 1995; Flint & Rifat 1998), compel reevaluation of present practice, and suggest consideration of novel medication strategies or continuation ECT.

13.3. Continuation ECT. While psychotropic continuation therapy is the prevailing practice, few studies document the efficacy of such use after a course of ECT. Some recent studies report high relapse rates even in patients complying with such regimens (Spiker et al. 1985, Aronson et al. 1987; Sackeim, et al. 1990, 1993); Stoudemire et al. 1994). These high relapse rates have led some practitioners to recommend continuation ECT for selected cases (Decina et al. 1987; Kramer 1987b; Jaffe et al. 1990b; McCall et al. 1992). Recent reviews have tended to report surprisingly low relapse rates among patients so treated (Monroe 1991; Escande et al. 1992; Jarvis et al. 1992; Stephens et al. 1993; Favia & Kaji 1994; Sackeim 1994; Fox 1996; Abrams 1997a; Rabheru & Persad 1997). Continuation ECT has also been described as a viable option in contemporary guidelines for long-term management of patients with major depression (American Psychiatric Association 1993), bipolar disorder (American Psychiatric Association 1994), and schizophrenia (American Psychiatric Association 1997).

Recent data on continuation ECT have primarily consisted of retrospective series in patients with major depression (Decina et al. 1987; Loo et al. 1988; Matzen et al. 1988; Clarke et al. 1989; Ezion et al. 1990; Grunhaus et al. 1990; Kramer 1990; Thienhaus et al. 1990; Thornton et al. 1990; Dubin et al. 1992; Puri et al. 1992; Petrides et al. 1994; Vanelle et al. 1994; Swartz et al. 1995; Beale et al. 1996), mania (Abrams 1990; Kellner et al. 1990; Jaffe et al. 1991; Husain et al. 1993; Vanelle et al. 1994; Godemann & Hellweg 1997), schizophrenia (Sajatovik & Neltzer 1993; Lohr et al. 1994; Hoflich et al. 1995; Ucok & Ucok 1996; Chanpattaria 1998), and Parkinson's Disease (Zervas & Fink 1991; Friedman & Gordon 1992; Jeanneau 1993; Hoflich et al. 1995; Aarsland et al. 1997; Wengel et al. 1998). While some of these investigations have included comparison groups not receiving continuation ECT or have compared use of mental health resources before and after implementation of continuation ECT, controlled studies involving random assignment are not vet available. Still, suggestive evidence that continuation ECT is cost-effective, in spite of the cost per treatment, is particularly promising (Vanelle et al. 1994; Schwartz et al. 1995; Steffens et al. 1995; Bonds et al. 1998). In addition, an NIMH-funded, prospective multi-site study comparing continuation ECT with continuation pharmacotherapy with the combination of nortriptyline and lithium is presently underway (Kellner - personal communication).

Because continuation ECT appears to represent a viable form of continuation management of patients following completion of a successful course of ECT, facilities should offer this modality as a treatment option. Patients referred for continuation ECT should meet the following indications: 1) history of illness that is responsive to ECT; 2) either resistance or intolerance to pharmacotherapy alone or a patient preference for continuation ECT; and 3) the ability and willingness of the patient to receive continuation ECT, provide informed consent, and comply with the overall treatment plan, including the behavioral restrictions that may be necessary.

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Since continuation ECT is administered to patients who are in clinical remission, and because long inter-treatment intervals are used, it is typically administered on an ambulatory basis (see Section 11.1). The specific timing of continuation ECT treatments has been the subject of considerable discussion (Kramer 1987b; Fink 1990; Monroe 1991; Scott et al. 1991; Sackeim 1994; Petrides & Fink 1994: Fink et al. 1996; Abrams 1997; Rabheru & Persad 1997; Petrides 1998), but evidence supporting any set regimen is lacking. In many cases, treatments are started on a weekly basis with the interval between treatments gradually extended to a month, depending upon the patient's response. Such a plan is designed to counteract the high likelihood of early relapse noted previously. In general, the greater the likelihood of early relapse, the more intensive the regimen should be. The use of psychotropic agents during a series of continuation ECT remains an unresolved issue (Jarvis et al. 1990; Thornton et al. 1990; Fink et al. 1996; Petrides 1998). Given the resistant nature of many such cases, some practitioners supplement continuation ECT with such medication in selected cases, particularly in those who have limited benefit from continuation ECT alone. In addition, some practitioners believe that the onset of symptoms of impending relapse in ECT responsive patients undergoing continuation pharmacotherapy alone may represent an indication for a short series of ECT treatments for a combination of therapeutic and prophylactic purposes (Grunhaus et al. 1990), although controlled studies are not yet available to substantiate this practice.

Before each continuation ECT treatment, the attending physician should 1) assess clinical status and current medications, 2) make a determination as to whether the treatment is indicated, and decide the timing of the next treatment. A monthly assessment may be used if continuation treatments are occurring at least twice monthly and the patient has been clinically stable for at least 1 month. In any case, the overall treatment plan, including the role of ECT, should be updated at least quarterly. Informed consent should be renewed no less frequently than every 6 months (see Chapter 8). To provide an ongoing assessment of risk factors, an interval medical history, focusing on specific systems at risk with ECT, and vital signs should be done prior to each treatment, with further assessment as clinically indicated. In many settings, this brief evaluation is accomplished by the ECT psychiatrist or anesthetist on the day of the treatment. A full anesthesia pre-operative exam (see Section 6) should be repeated at least every 6 months, and laboratory tests at least annually. Although cognitive effects appear to be less severe with continuation ECT than with the more frequent treatments that are administered during an ECT course (Ezion et al. 1990; Grunhaus et al. 1990; Theinhaus et al. 1990; Thornton et al. 1990; Barnes et al. 1997), monitoring of cognitive function should be done at least every 3 treatments. As discussed in Chapter 12, this may consist of simple bedside assessment of memory function.

13.4. Continuation psychotherapy. For some patients, individual or group psychotherapy may be useful in dealing with underlying psychodynamic issues, in facilitating better ways to cope with stressors that might otherwise precipitate a clinical relapse, in assisting the patient to re-organize his/her social and vocational activities, and in encouraging a return to normal life.

Maintenance therapy. Maintenance therapy is empirically defined herein as the prophylactic use of psychotropics or ECT longer than 12 months past the onset of remission in the index episode. Maintenance treatment is indicated when attempts to stop continuation therapy have been associated with symptom recurrence, when continuation therapy has been only partially successful, or when a strong history of recurrent illness is present (Loo et al. 1990; Thienhaus et al. 1990; Thornton et al. 1990; Vanelle et al. 1994; Stiebel 1995). The specific criteria for maintenance ECT, as opposed to maintenance psychotropic therapy, are the same as those described above for continuation ECT. The frequency of maintenance ECT treatments should be kept to the minimum compatible with sustained remission, with re-evaluation of the need for extension in the treatment series and repeated application of informed consent procedures performed at the intervals listed above for continuation ECT.

RECOMMENDATIONS

13.1. General Considerations

a) Continuation therapy, typically consisting of psychotropic medication or ECT, is indicated for virtually all patients. The rationale behind decisions not to recommend continuation therapy should documented.

b) Continuation therapy should begin as soon as possible after termination of the ECT course, except when presence of adverse ECT effects, e.g., delirium, necessitates a delay.

c) Unless countervened by adverse effects, continuation therapy should be maintained for at least 12 months. Patients with a high risk of recurrence or residual symptomatology will generally require longer-term maintenance therapy.

d) The aim of maintenance therapy is to prevent recurrence of new episodes of the index disorder. It is typically defined as treatment continuing longer than 12 months following completion of the most recent ECT course. Maintenance therapy is indicated when therapeutic response has been incomplete, when a recurrence of clinical symptoms or signs has occurred, or where a history of early relapse is present.

13.2. Continuation/Maintenance Pharmacotherapy

The choice of agent should be determined by the type of underlying illness, a consideration of adverse effects, and response history. In this regard, when clinically feasible, practitioners should consider a class of pharmacologic agents for which the patient did not manifest resistance during the treatment of the acute episode.

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13.3. Continuation/Maintenance ECT

13.3.1. General

a) Continuation/Maintenance ECT should be available in programs administering ECT.

b) Continuation/maintenance ECT may be given on either an inpatient or outpatient basis. In the latter case, the recommendations presented in Section 11.1 apply.

13.3.2. Indications for Continuation ECT

a) history of recurring episodic illness which has been responsive to ECT; and

b) either 1) pharmacotherapy alone has not proved effective in preventing relapse or cannot be safely administered for such a purpose; or 2) patient preference; and

c) the patient is agreeable to receive continuation ECT, and is capable, with the assistance of others, of complying with the treatment plan.

13.3.3. Delivery of Treatments

a) Various formats exist for delivering continuation ECT. The timing of treatments should be individualized for each patient, and should be adjusted as necessary with consideration of both beneficial and adverse effects.

b) The duration of continuation ECT should be guided by the factors described in 13.1(b) and 13.1(c).

13.3.4. Maintenance ECT

a) Maintenance ECT is indicated when a need for maintenance treatment (Section 13.1(d)) exists in patients already receiving continuation ECT (Section 13.3.2).

b) Maintenance ECT treatments should be administered at the minimum frequency compatible with sustained remission.

c) The continued need for maintenance ECT should be reassessed at least every three months. This assessment should include consideration of both beneficial and adverse effects.

13.3.5. Pre-ECT Evaluation for Continuation/Maintenance ECT

Each facility using continuation/maintenance ECT should devise procedures for pre-ECT evaluation in such cases. The following recommendations are suggested, with the understanding that additions to or increased frequency of evaluative procedures should be included whenever clinically indicated.

a) Prior to each treatment:

1) interval psychiatric evaluation (this evaluation may be done monthly if treatments are at an interval of 2 weeks or less AND the patient has been clinically stable for at least 1 month)

2) interval medical history and vital signs (this exam may be done by the ECT psychiatrist or anesthetist at the time of the treatment session), with additional examination as clinically indicated

b) Updating of overall clinical treatment plan at least every three months.

c) Assessment of cognitive function at least every three treatments.

d) At least every six months:

1) consent for ECT

anesthesia preoperative examination

e) Laboratory tests at least yearly.

13.4 Continuation/Maintenance Psychotherapy

Psychotherapy, whether on an individual, group, or family basis, represents a useful component of the clinical management plan for some patients following an index ECT course.

next: Chapter 2: 2.1. - Indications for Use of ECT
~ all Shocked! ECT articles
~ depression library articles
~ all articles on depression

LONDON - New "landmark" research finds that alcohol and tobacco are more dangerous than some illegal drugs like marijuana or Ecstasy and should be classified as such in legal systems, according to a new British study.

In research published Friday in The Lancet magazine, Professor David Nutt of Britain's Bristol University and colleagues proposed a new framework for the classification of harmful substances, based on the actual risks posed to society. Their ranking listed alcohol and tobacco among the top 10 most dangerous substances.

Nutt and colleagues used three factors to determine the harm associated with any drug: the physical harm to the user, the drug's potential for addiction, and the impact on society of drug use. The researchers asked two groups of experts - psychiatrists specializing in addiction and legal or police officials with scientific or medical expertise - to assign scores to 20 different drugs, including heroin, cocaine, Ecstasy, amphetamines, and LSD.

Nutt and his colleagues then calculated the drugs' overall rankings. In the end, the experts agreed with each other - but not with the existing British classification of dangerous substances.

Heroin and cocaine were ranked most dangerous, followed by barbiturates and street methadone. Alcohol was the fifth-most harmful drug and tobacco the ninth most harmful. Cannabis came in 11th, and near the bottom of the list was Ecstasy.

According to existing British and U.S. drug policy, alcohol and tobacco are legal, while cannabis and Ecstasy are both illegal. Previous reports, including a study from a parliamentary committee last year, have questioned the scientific rationale for Britain's drug classification system.

"The current drug system is ill thought-out and arbitrary," said Nutt, referring to the United Kingdom's practice of assigning drugs to three distinct divisions, ostensibly based on the drugs' potential for harm. "The exclusion of alcohol and tobacco from the Misuse of Drugs Act is, from a scientific perspective, arbitrary," write Nutt and his colleagues in The Lancet.

Tobacco causes 40 percent of all hospital illnesses, while alcohol is blamed for more than half of all visits to hospital emergency rooms. The substances also harm society in other ways, damaging families and occupying police services.

Nutt hopes that the research will provoke debate within the UK and beyond about how drugs - including socially acceptable drugs such as alcohol - should be regulated. While different countries use different markers to classify dangerous drugs, none use a system like the one proposed by Nutt's study, which he hopes could serve as a framework for international authorities.

"This is a landmark paper," said Dr. Leslie Iversen, professor of pharmacology at Oxford University. Iversen was not connected to the research. "It is the first real step towards an evidence-based classification of drugs." He added that based on the paper's results, alcohol and tobacco could not reasonably be excluded.

"The rankings also suggest the need for better regulation of the more harmful drugs that are currently legal, i.e. tobacco and alcohol," wrote Wayne Hall, of the University of Queensland in Brisbane, Australia, in an accompanying Lancet commentary. Hall was not involved with Nutt's paper.

While experts agreed that criminalizing alcohol and tobacco would be challenging, they said that governments should review the penalties imposed for drug abuse and try to make them more reflective of the actual risks and damages involved.

Nutt called for more education so that people were aware of the risks of various drugs. "All drugs are dangerous," he said. "Even the ones people know and love and use every day."

Source: Associated Press

next: Sexual Addiction, Online Conference Transcript
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~ all addictions articles

Medication changes and what can happen when you try and change your bipolar medication on your own. Read my story.

I'm Bipolar? - October 23, Year One 17 Months After Diagnosis

Do Not Do This!

Everything seemed to be going okay, except that my insurance company was refusing to precertify anymore visits until my psychiatrist filled out and submitted a treatment plan. We had just changed my medication balance, boosting Serzone from 300 to 400 mg per day, and cutting Celexa from 10 to 5 mg. That was on September 7.

A week later, on September 14, I lost it. When an internet friend of mine found herself in what I believed to be a situation filled with injustice, I threw myself passionately into defending her - and found myself crying uncontrollably, off and on, all afternoon and evening and into the night. By bedtime, I had scared myself. I hadn't had one of these crying jags in a long time - in fact, near as I can tell, not since the day I was diagnosed bipolar. I decided that an extra 100 Serzone was not enough to compensate for cutting Celexa down to 5. So I did the dumb, dumb thing: I boosted Serzone, on my own, from 400 to 500 mg per day.

Too Much, Too Fast

Spread out between morning and night doses, the increase was just 50 mg at a time, but even so the effects of going from 150 per dose to 250 per dose within 7 days showed up immediately. The next morning I was seeing motion trails off my hands and arms as I moved. I was heavy-headed, and not until after I took a 2-hour nap in the afternoon did my head finally clear.

I attributed all this, that day, to the prolonged crying spells of the day before. But two days later I was complaining of extremely swollen and painful breasts - to the point that just having clothing touch them hurt. I thought it was PMS ... but it wasn't.

On the 19th I got up and crashed into the nearest wall, unable to walk straight at first, and remained woozy. That day I finally used our own resource - the Side Effects Library - to look up Serzone. Sure enough: blurred vision/changes in vision, breast tenderness and dizziness were all there.

The dizziness didn't go away. That afternoon I drove (very cautiously) to my chiropractic appointment, skipped all therapies except the adjustment (because it hurt so much to lie on my chest!), and told the doctor what was going on. He was horrified and insisted that I call my psychiatrist immediately when I got home - which I did.

Dr. Meyer confirmed that Serzone was the likely culprit and advised cutting it back. I went down to 400 per day again.

The breast pain went away soon, but not the dizziness or the motion trails. Over the next week, I cut Serzone back to 350, then to 300. I called the Dr. Meyer's office again to find out what was happening with the insurance company. They had finally received the huge form, filled it in, and mailed it back, but had received no reply. I ran out of Celexa and figured well, we were trying to get me off that anyway, so did not ask for more. ANOTHER mistake.

CRASH!

The side effects - motion trails and lightheadedness - had never completely gone away, and now depression was getting strong. On October 6 I called the doctor again. Still no reply from the insurance company, but by now I didn't care any more, and made the first possible appointment, four days away. Then I called the insurance company to find out what the hell was going on. After speaking to three or four different people, I found out that (a) they couldn't find the form from my doctor, and (b) I could go to see him anytime I wanted to, and when they received the form, they would backdate the treatment plan to cover my visit. I wanted to scream! I would have gone to see the doctor much sooner if I had known I could get it covered by insurance!

The next few days were horrible. I couldn't work. I cried a lot. As once before in a serious depression, I came perilously close to buying a pack of cigarettes; instead I turned to the Quit Smoking Support Forum where I got enough help to get me through till my Tuesday appointment.

Finally October 10th came. After I went over everything with Dr. Meyer, he put me back to the meds mix from late July: 20 mg Celexa, 200 Serzone (100 morning and night), and 25 Trazodone for sleep. He also gave me a low dose of Lorazepam (Ativan) because I had been experiencing muscle spasms from tension/anxiety and my fibromyalgia was in full flare. Finally, he told me to take half a Celexa as soon as I got home.

The dizziness cleared up quickly, the depression lifted just as fast. Amazing! Since then, I've taken Lorazepam as needed and have been able to cope with several household emergencies - something I couldn't possibly have done before getting the meds adjusted. Back pain has eased significantly as well.

And the moral of the story is ...

DON'T MESS WITH YOUR MEDS. If things are not going the way you think they should, call your doctor immediately! I put myself through three-and-a-half weeks of needless misery and pain by changing dosages on my own, and not reporting to the doctor when I should have. I've learned my lesson. I hope you, too, can learn from my mistakes.

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It is difficult to determine which begins first -- depression or sexual dysfunction. Some studies suggest there are high rates of sexual dysfunction in those who have mood disorders. Types of dysfunction associated with depression include low desire and orgasmic disorder. The use of antidepressants makes the situation more complicated because of their sexual side effects. Some studies show that the incidence of sexual function side effects is as high as 50% while other studies show no difference in sexual function between those who are taking antidepressants and those who are not

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Treatment for Depression:

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For the most comprehensive information about Depression, visit our Depression Community Center here, at HealthyPlace.com.

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

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

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

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

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Dysfunctions and Prevalence

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

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

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

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

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

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

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

Comprehensive Assessments

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Treatment Considerations

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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SOURCES:

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

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

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

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

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

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

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

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

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

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

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MUST HAVE books for people with sexual dysfunctions, rape, sex after 50, sexually transmitted diseases and other sexuality issues.

buy the book $16

Cybersex Exposed: Simple Fantasy or Obsession? by: Jennifer Schneider; Robert Weiss Robert Weiss LCSW, CSAT-S is Founding Director of The Sexual Recovery Institute - Los Angeles, an outpatient sexual addiction treatment center. Mr. Weiss was a guest on the HealthyPlace Mental Health TV Show and he talked about the realities of sexual addiction.

 

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Intimacy With Impotence: The Couple's Guide to Better Sex After Prostate Disease By: Ralph Alterowitz, Barbara Alterowitz buy the book $11 Reader Comment: " Intimacy CAN be achieved with impotence, but NOT without love and understanding. This is well covered in the first half of the book."	The First Year--HIV: An Essential Guide for the Newly Diagnosed By Brett Grodeck, Daniel S. Berger buy the book $11 Reader Comment: "This is an accessible, nonjudgmental guide for people dealing with an HIV diagnosis, regardless of sexual orientation, gender, or needle/drug use status."	You Can Be Your Own Sex Therapist: A Systematized Behavioral Approach to Enhancing Your Sensual Pleasures, Improving Your Sexual Enjoyment By: Carole Altman, Ph.D. buy the book $14 Reader Comment: "This wonderful 'how to' guide is 'a must' for everyone's bedroom."