Bipolar disorder symptoms are similar in females and males, but they may affect women differently. Although bipolar disorder occurs in similar frequency across both genders, studies suggest that there are certain aspects of the condition that affect men and women uniquely. For example, female hormones, along with pregnancy and childbirth, may influence symptoms and treatments, while late-onset bipolar disorder is often associated with menopause. Let’s explore how bipolar disorder symptoms affect women and why there is such variation between the sexes when it comes to this condition.

Bipolar Disorder Symptoms in Females: How Are Women Affected?

Bipolar disorder symptoms in females can differ greatly from the symptoms of bipolar experienced by males. Alongside environmental factors, there are simple biological differences that influence the way the condition manifests and is treated. While it’s easy to think that men and women are in the same boat when it comes to mental health, there is extensive evidence that a woman’s experience with bipolar disorder can be entirely different from a man’s.

Research suggests that in women, hormones play a substantial role in the development and severity of bipolar disorder. Here are some of the ways in which bipolar disorder symptoms are different in women:

• Women with bipolar I disorder are at very high risk for postpartum mania and psychosis, so careful monitoring is required
• Women are more likely to have symptoms of depression than mania
• Women are also more likely to have rapid cycling, which is defined as having four or more episodes of mania or depression per year
• Women with mood disorders experience more severe symptoms of premenstrual syndrome (PMS)
• Women may need to alter medical treatment for bipolar disorder if they are pregnant or trying to conceive. Very few bipolar medications have been tested on pregnant women, for obvious reasons, so the safety of some drugs is still unknown. If you are concerned about becoming pregnant while taking medication for bipolar disorder, ask your doctor for advice. Never stop taking your medication abruptly.

Treatment for Bipolar Disorder Symptoms in Women

Treatment for bipolar disorder symptoms in women depends on the type and severity of symptoms. Women in full bipolar I mania may require hospitalization, for example, while women who experience cyclothymic disorder or bipolar type II (characterized by depression and “hypomania” – a milder form of mania) may find their moods are stabilized by regular bipolar medication. In most cases, long-term treatment is required to manage bipolar symptoms.

Treatment for all types of bipolar disorder usually consists of medication and therapy. Common medications for bipolar disorder symptoms in women include:

• Antipsychotics, such as quetiapine (Seroquel), lurasidone (Latuda), aripiprazole (Abilify), olanzapine (Zyprexa), ziprasidone (Geodon) and risperidone (Risperdal). These medications help with symptoms of mania and are used to prevent psychosis.
• Mood stabilizers, including lithium and lamotrigine. These are used to prevent or delay episodes of mania or hypomania and treat symptoms of depression.

If bipolar disorder symptoms worsen at particular times in your cycle, or during pregnancy or menopause, your doctor may recommend complementary treatment to help you manage the effects of hormonal fluctuations.

Use of Bipolar Medications During Pregnancy

Some medications may not be safe for use in pregnancy, or else your dose may need to be adjusted. It’s important to talk to your doctor if you are currently pregnant or trying to conceive and taking bipolar medications ("Mood Stabilizers in Pregnancy: Are They Safe?").

Doctors usually recommend that treatment be continued during pregnancy but risks to the baby’s health and development are strongly considered.

Generally speaking, doctors prefer prescribing older drugs such as haloperidol (Haldol) and lithium, as well as antidepressants, to manage bipolar symptoms during pregnancy. These drugs not only have a proven track record and but they have more safety data than the newer medications for bipolar disorder.

Some of the newer atypical antipsychotic medications have been studied during pregnancy and at this time have demonstrated no known risks for birth defects or developmental abnormalities. Whereas, some drugs, such as valproic acid (Depakote) and carbamazepine (Tegretol), have been shown to be harmful to babies and contribute to birth defects. If a woman taking valproic acid discovers she is pregnant, the doctor may change her medication or adjust the dosage and prescribe folic acid to help prevent birth defects affecting the development of the baby's brain and spinal cord.

When it comes to carbamazepine during pregnancy, most doctors will not recommend it unless there are no other options. Carbamazepine poses risks to the unborn baby. In addition, it can cause liver failure and a blood disorder in the mother, especially if started after conception.

One other important point to be aware of. Some bipolar medications taken in late pregnancy may cause the baby to experience abnormal muscle movements (twitch-like symptoms) or withdrawal symptoms at birth. The antipsychotic medications to be aware of include: Abilify, Haldol, Risperdal, Seroquel, and Zyprexa.  After birth, most of the time, these symptoms will disappear within a few hours or days. Some babies, however, will have to remain in the hospital for follow-up monitoring and treatment.

As a general rule of thumb, doctors try to limit the amount of medication a developing baby is exposed to during pregnancy. Even though some medications have no known risks to the fetus, it doesn’t mean there aren’t unknown risks. By keeping dosages to a minimum and trying not to add on new drugs, the doctor hopes to limit these unknown risks.

See also "Bipolar Depression Symptoms in Women"

article references

Bipolar relationship tips may seem unnecessary to anyone who doesn't know what it's like to live with this condition. Every relationship has hurdles to overcome, and being with someone who has a mental illness is no different in that respect. However, bipolar disorder has its own unique set of challenges that can make romantic relationships more complicated. If you're struggling with relationship problems because of your bipolar diagnosis or you're not sure how to handle a relationship with someone who has bipolar, read on for bipolar relationship tips.  

Bipolar Relationship Tips: How to Handle a Relationship with Bipolar In the Mix

Are you looking for bipolar relationship tips to help you navigate life and love with a mental illness? Every relationship has its challenges, but bipolar disorder can bring its own set of issues to a romantic relationship. While many people with bipolar maintain healthy relationships, that doesn’t mean it’s always easy.

Here are five bipolar relationship tips to help you maintain happy and healthy relationships.

Bipolar Relationship Tip 1: Be honest

Find a partner you can be honest with about your condition. Trust is an integral part of any relationship, and being open about your mental health is a great way to clue your partner in on your symptoms, triggers and treatment. Your partner is likely to form a large part of your support network going forward, so it’s vital that you feel you can speak openly about your experience and ask for help when you need it.

Bipolar Relationship Tip 2: Tell your partner early-on

Although no rule says you have to disclose your mental illness to anyone unless you feel comfortable, if you're in a new relationship, it's best to tell your partner before you've made a long-term commitment to one another. Having a diagnosis of bipolar disorder shouldn't change how your partner feels about you, but it may be important to get it out in the open so that they have a chance to consider how it may affect the relationship.

This bipolar relationship tip is discretionary, as only you know when the time is right to tell your partner about your condition. However, there are benefits to opening up early on.

If your new partner is supportive, then you can build your relationship from a place of openness and trust, and they won’t be surprised when you experience a mood episode. If your new partner decides your illness is too much for them to handle, then the relationship was never going to work anyway, and you won’t have wasted your time on someone who’s not right for you.

Bipolar Relationship Tip 3: Avoid blaming the illness

It’s easy to blame your illness for everything that goes wrong in your relationship, but the reality is that people with bipolar disorder aren’t ill all the time. This is one bipolar relationship tip that’s worth paying attention to, as not everyone realizes they’re doing it.

There will inevitably be times when your bipolar symptoms cause problems in your relationship. If you experience mania, for instance, you may have trouble maintaining a conversation, or you might engage in impulsive behaviors, such as heavy drinking or overspending. However, you'll also have to deal with other sources of conflict, and it won't always be the fault of your illness.

Bipolar Relationship Tip 4: Identify and avoid your triggers

If you can identify triggers for bipolar episodes, you may be able to lessen the frequency and severity of manic or depressive episodes and reduce their impact on your life and relationship.

Common mood triggers for bipolar include:

• Changes in sleep habits, particularly lack of sleep
• Sensory overload, such as loud noises, bright lights and crowds of people
• Stress from work, financial trouble or relationship conflict
• Excitement about an important day or event, such as a wedding or party
• Changes to everyday routine
• Quitting or changing your medication
• Drugs and alcohol
• Switching time zones when traveling or on vacation
• Changes in weather

Not all of these triggers will be avoidable all of the time, so it’s important to develop coping skills to help you deal with them. Ongoing treatment, such as therapy and/or mood stabilizer medication, can also lessen the effect of episodes when bipolar is triggered.

Bipolar Relationship Tip 5: Keep communicating

Unsurprisingly, communication is a vital part of making a bipolar relationship work, whether it’s you or your partner who has the illness. This is especially important when your symptoms are severe, or when episodes make you behave in troubling ways, such as drinking too much, overspending or skipping your medication. Although your partner may be concerned or upset to hear what you're feeling and how you're behaving, it's best to be honest. Not only does this keep the line of communication open and lead to greater intimacy, but it also holds you accountable for your actions during an episode.

These bipolar relationship tips are helpful whether you're in the early stages of a relationship or you've been with your partner for years. If bipolar disorder is causing severe problems in your home or romantic life, however, you should consider seeking additional help from your doctor and think about seeing a couples' counselor.

article references

A controversial new study links teen sexual intercourse with depression and suicide attempts. The findings are particularly true for young girls, says the Heritage Foundation, a conservative think tank that sponsored the research. About 25% of sexually active girls say they are depressed all, most, or a lot of the time; 8% of girls who are not sexually active feel the same.

The study comes in the midst of a flurry of new reports on the sexual activity of teenagers. Such research is fodder for the growing debate on sex education in schools. The Bush administration backs abstinence programs.

The Heritage study taps the government-funded National Longitudinal Survey of Adolescent Health. The Heritage researchers selected federal data on 2,800 students ages 14-17. The youngsters rated their own "general state of continuing unhappiness" and were not diagnosed as clinically depressed.

The Heritage researchers do not find a causal link between "unhappy kids" and sexual activity, says Robert Rector, a senior researcher with Heritage. "This is really impossible to prove." But he says that study findings send a clear message about unhappy teens that differs from one portrayed in the popular culture, that "all forms of non-marital sexual activity are wonderful and glorious, particularly the younger (teen) the better," he says.

The Heritage study finds:

- About 14% of girls who have had intercourse have attempted suicide; 5% of sexually inactive girls have.

- About 6% of sexually active boys have tried suicide; less than 1% of sexually inactive boys have.

Tamara Kreinin of the Sexuality Information and Education Council of the United States (SIECUS) says "we need to take depression among the young very seriously." But it is a "disservice" to blame sexual activity and ignore "divorce, domestic violence, sexual abuse, substance abuse, lack of parental and community support and questions about sexual orientation," she says. SIECUS supports school programs with information on birth control and abstinence.

Research has examined the impact of individual quality of life issues on sexual function, but little research has looked at the way different quality of life measures interact with respect to sexual function complaints.

Our study sought to look at the interplay of issues such as depression, general stress, sexual distress, and relationship health with each other and with sexual function in the context of women experiencing sexual function complaints.

Sexual function and depression

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 anti-depressants make 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 anti-depressants and those who are not.

Sexual function and marriage

Again, some studies say there is no connection between sexual function and the state of the marriage; others say they are inextricably intertwined. Researchers Sager (1976) and Hayden (1999) found marital discord and sexual dysfunction to be so connected that it was impossible to analyze them separately.

Couples seeking therapy were different as well. Those in general couple's therapy were more antagonistic and less affectionate than those who sought therapy specifically for their sexual problems (Frank et al., 1977). Couple's therapy is a form of talk therapy, with the goal of resolving conflict in a relationship. Sex therapy is also talk therapy but is directed at solving sexual difficulties or sometimes a very specific sexual problem such as lack of libido, lack of arousal or early ejaculation. Rust (1988) found that the relationship between marital discord and sexual function was much closer in men with impotence or erectile dysfunction than in women with orgasmic disorder or vaginismus.

Sexual function and stress

There are relatively few studies that show the impact of stress on a woman's sexual function although the complicated relationship between sexual function and stress has been seen in mice. Dominant mice that were placed under stress showed impaired sexual function (D'Amato, 2001) yet, male mice that were stressed showed enhanced sexual performance at puberty (Alameida et al., 2000). However, it seems likely that stress must impact negatively on the female sexual experience. In a recent survey of 1000 adults, stress was ranked as the number one detractor from sexual enjoyment (26%) above other potential detractors such as children, work and boredom.

There may be a connection between stress, testosterone levels and female sexual function. This connection is becoming increasingly clear.

We studied 31 women who had a variety of overlapping sexual function complaints including hypoactive sexual desire disorder, problems with orgasm, arousal and lubrication issues, low sexual satisfaction and pain. They each completed five questionnaires regarding overall sexual function, sexual distress, perceived general stress, relationship health, and depression. A high score indicated positive functioning, for example, a 6 on the arousal scale would indicate that arousal was not a problem and a 6 on the pain scale would indicate no pain at all associated with sex. Generally, the lower the score, the higher the incidence of a sexual function problem. Overall, scores were low for all measures and on overall function. This particular group of women seemed to have a high incidence of orgasmic dysfunction.

Our evaluation of the surveys found that while this group experienced high sexual distress, they had low general stress, moderately healthy marital relationships and low levels of depression. So we see a difference between sexual distress and other quality of life measures.

Depression was associated with all the measures of sexual function, sexual distress, general stress and relationship health. In addition, sexual distress not only increased with depression, but also with problems in sexual function. Those who experienced good relationship health had fewer sexual function problems, but those who had negative relationship had greater depression and general stress.

General stress did not correlate with any of the Female Sexual Function Index sub-scores. This may be further evidence that women may experience general stress differently than sexual stress. Orgasm also proved to be an interesting case, correlating only with depression. As well, it was the only category unaffected the state of the relationship -evidence that it may be a somewhat unique aspect of female sexual function. Women did not appear to be experiencing as much distress over orgasm complaints, suggesting that perhaps this aspect of the sexual experience is seen as less central than others.

Women who reported low levels of desire did not seem to be distressed by this - it is the classic picture of the patient whose low libido is not a problem for her, but is a problem for her partner. Arousal, an aspect of sexual function that incorporates both physical and emotional factors, correlated with all quality of life measures except for general stress.

Conclusion

The small number of patients in this study certainly had an impact. There may have been other correlations that we simply couldn't detect. Our sample represented women seeking treatment for sexual function complaints and therefore, cannot necessarily be generalized to women as a whole. The variables we addressed are all quite related and difficult to consider in isolation.

In future research, it will be beneficial to study the causal relationships among the variables using control groups or controlled interventions. Using a larger population of women in order to separate out those who are taking antidepressants will give us different results. We could also subdivide women into groups based on primary sexual complaint (e.g. hypoactive sexual desire disorder vs. pain) and see if quality of life measures differ among the groups. (November 2001)

(with Marie Miles, BA and Patty Niezen, RNP)

One of the most popular antidepressants, best known by the brand name Prozac (Fluoxetine), can affect the development of babies when pregnant women take the drug, according to a government report released on Tuesday.

Normal doses can cause babies to be born lighter and sleepier than normal, or make them jittery or cause respiratory problems, the panel appointed by the National Toxicology Program said.

"These effects appear to result more readily from in utero exposure late in gestation," the report, issued for public comment, reads.

The report is a summary from a working group of experts who studied dozens of medical studies using the drug, known generically as fluoxetine.

"The observed toxicity may be reversible, although long-term follow-up studies have not been conducted to look for residual effects," it adds.

"The evidence suggests that developmental toxicity can also occur in the form of shortened gestational duration and reduced birth weight at term."

The experts also noted several reports that found fluoxetine could affect a patient's ability to achieve sexual climax -- both male and female.

It can get into breast milk and is found in the blood of newborns of mothers taking the drug.

The report, available on the Internet here (pdf), says fluoxetine is widely used and can now be found in the environment.

"Fluoxetine has been reported in U.S. surface waters, presumably derived from urine and feces of people on therapy," the report reads. One researcher found fluoxetine in bluegill fish.

"The presence of fluoxetine ... in wastewater/groundwater/sediment should be investigated," the report recommends.

But the report noted it could be more dangerous for an expectant or new mother to be seriously depressed.

"Mood disorders are common in women of child-bearing years and it has been estimated that 15.6 percent of women meet criteria for major depression during the third trimester of pregnancy," the report reads.

The panel also said more study was needed to find out how and why antidepressants such as fluoxetine can stimulate production of new brain cells. That could also affect a fetus or newborn baby in unexpected ways, they said.

Prozac is made by Eli Lilly and Co. (LLY) and is also available in generic form. REUTERS

Learn about the benefits of marriage and family therapy and where to find a qualified, licensed marriage and family therapist.

What is Marriage and Family Therapy?

A family's patterns of behavior influences the individual and therefore may need to be a part of the treatment plan. In marriage and family therapy, the unit of treatment isn't just the person - even if only a single person is interviewed - it is the set of relationships in which the person is embedded.

Marriage and family therapy is:

• brief
• solution-focused
• specific, with attainable therapeutic goals
• designed with the "end in mind."

Marriage and family therapists treat a wide range of serious clinical problems including: depression, marital problems, anxiety, individual psychological problems, and child-parent problems.

Research indicates that marriage and family therapy is as effective, and in some cases more effective than standard and/or individual treatments for many mental health problems such as: adult schizophrenia, affective (mood) disorders, adult alcoholism and drug abuse, children's conduct disorders, adolescent drug abuse, anorexia in young adult women, childhood autism, chronic physical illness in adults and children, and marital distress and conflict.

Marriage and family therapists regularly practice short-term therapy; 12 sessions on average. Nearly 65.6% of the cases are completed within 20 sessions, 87.9% within 50 sessions. Marital/couples therapy (11.5 sessions) and family therapy (9 sessions) both require less time than the average individuated treatment (13 sessions). About half of the treatment provided by marriage and family therapists is one-on-one with the other half divided between marital/couple and family therapy, or a combination of treatments.

Who are Marriage and Family Therapists?

Marriage and Family Therapists (MFTs) are mental health professionals trained in psychotherapy and family systems and licensed to diagnose and treat mental and emotional disorders within the context of marriage, couples and family systems.

Marriage and family therapists are a highly experienced group of practitioners, with an average of 13 years of clinical practice in the field of marriage and family therapy. They evaluate and treat mental and emotional disorders, other health and behavioral problems, and address a wide array of relationship issues within the context of the family system.

Marriage and Family Therapists broaden the traditional emphasis on the individual to attend to the nature and role of individuals in primary relationship networks such as marriage and the family. MFTs take a holistic perspective to health care; they are concerned with the overall, long-term well-being of individuals and their families.

MFTs have graduate training (a Master's or Doctoral degree) in marriage and family therapy and at least two years of clinical experience. Marriage and family therapists are recognized as a "core" mental health profession, along with psychiatry, psychology, social work and psychiatric nursing.

Since 1970 there has been a 50-fold increase in the number of marriage and family therapists. At any given time they are treating over 1.8 million people.

Why use a Marriage and Family Therapist?

Research studies repeatedly demonstrate the effectiveness of marriage and family therapy in treating the full range of mental and emotional disorders and health problems. Adolescent drug abuse, depression, alcoholism, obesity and dementia in the elderly -- as well as marital distress and conflict -- are just some of the conditions Marriage and Family Therapists effectively treat.

Studies also show that clients are highly satisfied with the services of Marriage and Family Therapists. Clients report marked improvement in work productivity, co-worker relationships, family relationships, partner relationships, emotional health, overall health, social life, and community involvement

In a recent study, consumers report that marriage and family therapists are the mental health professionals they would most likely recommend to friends. Over 98 percent of clients of marriage and family therapists report therapy services as good or excellent.

After receiving treatment, almost 90% of clients report an improvement in their emotional health, and nearly two-thirds report an improvement in their overall physical health. A majority of clients report an improvement in their functioning at work, and over three-fourths of those receiving marital/couples or family therapy report an improvement in the couple relationship. When a child is the identified patient, parents report that their child's behavior improved in 73.7% of the cases, their ability to get along with other children significantly improved and there was improved performance in school.
Marriage and family therapy's prominence in the mental health field has increased due to its brief, solution-focused treatment, its family-centered approach, and its demonstrated effectiveness. Marriage and family therapists are licensed or certified in 48 states and are recognized by the federal government as members of a distinct mental health discipline.

Today more than 50,000 marriage and family therapists treat individuals, couples, and families nationwide. Membership in the American Association for Marriage and Family Therapy (AAMFT) has grown from 237 members in 1960 to more than 23,000 in 1996. This growth is a result, in part, of renewed public awareness of the value of family life and concern about the increased stresses on families in a rapidly changing world.

What are the qualifications for a Marriage and Family Therapist?

Marriage and family therapy is a distinct professional discipline with graduate and postgraduate programs. Three options are available for those interested in becoming a marriage and family therapist: master's degree (2-3 years), doctoral program (3-5 years), or post-graduate clinical training programs (3-4 years). Historically, marriage and family therapists have come from a wide variety of educational backgrounds including psychology, psychiatry, social work, nursing, pastoral counseling, and education.

The Federal government has designated marriage and family therapy as a core mental health profession along with psychiatry, psychology, social work, and psychiatric nursing. Currently, 48 states also support and regulate the profession by licensing or certifying marriage and family therapists with many other states considering licensing bills.

The regulatory requirements in most states are substantially equivalent to the American Association of Marriage and Family Therapists Clinical Membership standards. After graduation from an accredited program, a period - usually two years - of post-degree supervised clinical experience is necessary before licensure or certification. When the supervision period is completed, the therapist can take a state licensing exam, or the national examination for marriage and family therapists conducted by the AAMFT Regulatory Boards. This exam is used as a licensure requirement in most states.

How can I find a Marriage and Family Therapist?

AAMFT Clinical Members meet stringent training and education requirements that qualify them for the independent practice of marriage and family therapy.

AAMFT requires Clinical Members to abide by the AAMFT Code of Ethics, the most stringent ethical code in the marriage and family therapy profession. This code delineates specific ethical behavior and guidelines for members to follow to ensure the ethical treatment of clients.

Clinical Membership in the AAMFT signifies an MFT's dedication to his or her ongoing professional development. Each month, AAMFT Clinical Members receive important updates on current clinical and research developments in the field, as well as numerous opportunities throughout the year to attend professional development conferences.

Source: American Association of Marriage and Family Therapy

“Do I have bipolar?” If you’re asking yourself that question, maybe you’ve noticed that your moods, your ups and downs, are more extreme than most other people’s. It could also be that these key symptoms of bipolar disorder are affecting your life, your job, your relationships. If so, then it’s time to get some straight answers to the question, “Do I have bipolar?”

(Get the free bipolar disorder ebook, “Guide to Bipolar Disorder.”)

Do I Have Bipolar Symptoms?

Someone might say to you, “You’re so bipolar!” and chances are that is not the case. Most likely, that person is noticing some moodiness or indecisiveness that everyone feels at times.

On the other hand, if a loved one notices you struggling or you feel yourself struggling with extreme ups and downs that cause you to act and feel unlike yourself, check out this list of bipolar symptoms to see if you recognize any of them in yourself.

You can also take our online bipolar test, which acts as a symptom checker. When done, print out the results and share them with your doctor.

(Discover how bipolar disorder symptoms affect women uniquely.)

I Think I Do Have Bipolar Disorder: What Now?

If you see the symptoms of bipolar disorder in yourself and begin thinking you do have bipolar disorder, then the next step is to see your doctor or mental health professional. Only a doctor can diagnose bipolar disorder, and without the diagnosis, you can’t begin treatment. Go here to learn more about how bipolar disorder is diagnosed.

There are specific diagnostic criteria your symptoms must meet before you can be diagnosed with bipolar, so getting to your doctor as soon as possible is important.

Get more information about diagnosing bipolar disorder.

Learn where to get mental health help.

What Treatments Are There for Bipolar Disorder?

Although bipolar disorder is a serious mental illness with severe ramifications, there are effective treatments for bipolar disorder. These treatments will assist in helping manage your symptoms so that you can lead a full and stable life. Trust your doctors to help you find the right treatment plan for you—you’ll be happy that you did.

Learn the importance of getting treatment for bipolar disorder.

So back to your question: “Do I have bipolar disorder?” Without seeing a qualified doctor, you won’t know for sure. That’s your first step to find out.

More Information About Bipolar Disorder

• What Is Bipolar Disorder? Definition, Symptoms and Treatment
• Causes of Bipolar Disorder
• 5 Best Bipolar Disorder Self Help Books (and why they are helpful)

Depression and its effect on our relationships

Most people who are depressed lose interest in sex. Try to remember that it is unlikely that your partner's depression has anything to do with you.

Depression adversely affects every aspect of our lives - including our relationships. Indeed, when one partner is depressed, the relationship may suffer so badly that it doesn't survive. But, in fact, a good relationship is very therapeutic for a depressed person, because when we're really low we need love, support and closeness more than ever - even if we can't show it ourselves.

Depressed people usually feel withdrawn. They don't feel they can raise the necessary energy to pursue their normal routine or to do things with the family, or even to notice when their partner is being attentive. And that partner can quickly feel that he or she is in the way, or unwanted, or unloved. Sometimes a partner will misinterpret the other person's 'low' moods and become convinced that the depressed partner feels hostile towards them, or wants to end the relationship. Occasionally, things will seem so bad at home that a spouse will fear that the depressed person is having an affair. Partners can also feel that somehow they may even have caused the depressive illness.

This is all skewed thinking, but it's difficult to stay calm and confident when the person you thought you knew is acting strangely and appears to be so unhappy. However, any partner of a depressed patient should realize that it's normal to be upset by this situation. So even if you're at your wits' end because your loved one has lost the ability to concentrate on what you're saying, or to raise a smile, or to appreciate any of the good moments in life, try to accept that all these things are simply part of this awful illness. Try to remember too that it's unlikely your partner's depression has anything at all to do with you.

Sex and Performance

Unfortunately, we don't know nearly enough about the chemical changes that occur in the brain during depression. And practically no worthwhile research has been done on how these changes affect sex. However, from the clinical point of view, what is clear is that a depressive illness tends to affect ALL the bodily systems, dislocating them and often slowing them down. This effect is most marked with regard to SLEEP (which is almost invariably disrupted) and on any activity that requires verve, spontaneity and good coordination. That includes sex! So most people who are depressed tend to lose interest in sex. Admittedly, this isn't always the case, and some depressed people manage to maintain normal sex lives - sometimes even finding that sex is the only thing that gives them comfort and reassurance.

In men, the general damping down of brain activity causes feelings of tiredness and hopelessness, which may be associated with loss of libido and erection problems. And in women, this diminished brain activity tends to be associated with lack of interest in sex, and very often with difficulty in reaching orgasm. All these problems tend to diminish as the depressive illness gets better. Indeed, renewed interest in sex may be the first sign of recovery.

Sex and antidepressants

One vital point to bear in mind is that antidepressant medicines such as Prozac (which are now prescribed on a massive scale) can themselves often interfere with sexual function. One of the commonest side effects is interference with the process of orgasm, so that it is delayed, or doesn't occur at all. If this happens to you, ask your doctor for a change in medication.

How depressed people can help themselves and their relationship

Some days will seem better than others. On your better days, try to make an effort to show love and appreciation to your partner.

• Choose a code-word - the title of a favorite film, for example - and use it with your partner to indicate that you'd love a cuddle, but you don't feel like sex.

• Try to go for a walk every day - preferably with your partner. Walking not only gets you out in the fresh air, which will give you a bit of a lift, but also - like other forms of exercise - releases endorphins in the brain. These are 'happy' chemicals that rapidly elevate your mood.

• Even on your worst days, try to spot happy moments - a bird singing, a new flower blooming in your garden or a child's smile. Try to train yourself to notice three of these heart-warming moments per day.

• You may have an odd relationship with food while you're depressed - you could have little appetite, or find yourself constantly comfort eating - but try to eat five pieces of fruit per day. This is a caring thing to do for yourself and is good for your physical and mental health.

• You may feel you can't concentrate, but try to watch a TV comedy with your partner for just half an hour every day. Anything that will pierce your gloom and help to elevate your mood will give you some respite from your depression.

• Listen to music that matters to you.

• Have faith that the depression will pass, and that you will enjoy your life again.

How the partners of depressed people can help themselves and their relationship

Don't keep saying that you understand what your partner is going through - you don't. Instead say: 'I can't know exactly how you're feeling, but I am trying very hard to understand and to help.'

Don't despair. Some days you'll feel that your love for your partner doesn't seem to make any difference at all to them. But hang on in there. Your love and constant support does make a big difference and can help persuade your partner of their value.

Do encourage your partner to get all the professional help available. Depression is not something to be stoically endured alone.

Remember: it's exactly as if your partner was recovering from a serious physical illness or from surgery. Give plenty of tender loving care and encourage them to rest and recuperate. And don't expect improvement to be rapid.

Do spend time every day doing nice things for yourself. Being around a depressed person is very draining, so it's important that you look after yourself. Have some time alone, or get out to a film or the hairdresser or see friends. Depressed people often want to stay home and do nothing, but if you do this too, you'll get terribly fed up.

Remember that this period in your life will pass - and that your partner is the same person underneath the depression as he or she was before.

"I choose my behavior; the world chooses my consequences" is a phrase that any recovering sex addict would do well to hold in vivid consciousness. When the awareness of a pattern of sexual addiction starts to become clear, a trail of consequences is likely to follow close behind. Rather than attempt to manage or minimize the consequences, the sex addict is advised to curtail sexual acting out and embrace a quality recovery program taught and modeled by other recovering addicts.

Despite the conviction to move toward the rigorous honesty of recovery, the addict is likely to experience the cold sweat of repercussions of previous behavior. The secret life is unveiled revealing affairs, exhibitionism, voyeurism, or other behaviors comprising a particular sex addict's modus operandi of acting out. Like the trapeze artist in the circus, the addict encounters the moment between letting go of one trapeze and catching the other. Such a crisis will make one exquisitely aware of hopelessness and depression. Hopefully, it will also dawn on the addict that he/she is powerless and that a Higher Power alone can and will be there in that moment.

Six classes of depressive types expressed in sex addicts

The mental health practitioner who treats sex addiction is called upon to diagnose and treat the depression that is likely to be present before, during, and after the between-trapeze experience. This depression may present in several different forms, which can be summarized in the following classes:

1. Most commonly, a chronic, low grade depression or dysthymia in a shame-based person who has low self esteem and relatively undeveloped social skills. This dysthymic disorder may be punctuated with major depression especially likely at the time of significant relationship losses or at the time of exposure of the pattern of sex addiction. Shame, loneliness, and awareness of lost time spent in active addiction may haunt the addict. When shame rolls in, depression follows the flood. This type tends to have a strong superego and be at risk for self-punitive suicidal thoughts and behavior.

2. A seeming lack of depression in a perfectionistic, shameless-acting high achiever. Despite not having a history of previous clinical depression, this person may experience an overwhelming major depression as perfectionism and narcissism no longer stem the tide of mounting negative consequences of sexual behavior. Since this person may have a lofty professional and occupational position, the sexual acting out may involve level III abuse of a power position with employees, clients, or patients. If professional consequences (e.g. loss of license, termination of employment) lead to a further and more devastating breakdown in personal relationships (e.g. divorce, marital separation), the person's shame can be catastrophic and overwhelming, making suicide a real and pressing danger. This person may even need to be hospitalized against his or her will until adequate defenses can be reestablished and a recovery process begun.

3. The depleted workaholic whose life is without joy, and who has no balance in social or recreational spheres. This sex addict is likely to find someone or a series of subjects at work to groom as he/she presents as a martyr-like victim slaving to support a family yet deserving of a sexual release. When depression finally breaks through clinically, after the pattern of sexual behavior is exposed, it is likely to be massive because this addict has little to fall back on when the merry-go-round of work stops. The workaholic pattern becomes a central treatment issue with both sex addiction and depression seen as outgrowths of the long term lack of self-care. If a workaholic pattern recurs after treatment, relapse into sex addiction is almost certain, whether it be in the behavior or thoughts of the addict. Therefore, a goal in treatment and after for this person is to halt the pattern of self-abandonment expressed previously through workaholism, sex addiction, and martyrdom.

4. Psychotic depression in a person who may be older (45-60 or above) and who has a pre-morbid obsessive-compulsive style and a suspicious temperament. This person may have practiced a type of sex addiction that included perpetrating children or teenagers but kept it concealed for years. When the addiction progresses and the behavior is discovered, the public outcry and shame may be processed by the addict via psychotic defenses of massive denial and projection. The addict may sink into a stuporous depression with psychotic features including frank paranoid thoughts of feeling acted upon by outside forces and profound social withdrawal. The reality of the perpetrating behavior is alien to the denying lifestyle the person has practiced for years. The recovery from psychosis is gradual and in-depth work on recovery from the addictive sexual cycle must be put off until aggressive pharmacological treatment takes effect.

5. Bipolar depression in a person who may or may not be a true sex addict. Since the manic phase and mixed manic/depressive phases of bipolar disorder are often accompanied by hyper-sexuality with heightened sex drive and increased sexual behaviors of boundary-less type, the clinician, in attempting to make an accurate diagnosis, should be mindful to search for a true pattern of sex addiction behavior which transcends the mood swings of bipolar disorder. A bipolar patient may also be a sex addict, but a significant subset of bipolars show hyper-sexuality during mania that is not part of a pattern of sex addiction. The bipolar group as a whole is at significant risk for suicide (the lifetime suicide rate for untreated bipolars is 15%) and risk can do nothing but rise for the portion who are both bipolar and sex addicts. The dual bipolar/sex addict patient may actually complain of two types of depression; one that is without a particular stimulus (the bipolar depression that comes on suddenly like a black cloud overhead), and another depression which mounts slowly and is accompanied by shame and the emptiness of active addiction much like the dysthymia of Class #1.

6. A sociopath who may feel pain from consequences of addiction or perpetration, but lacks true remorse and may feign a victim stance for secondary gain from significant others and legal authorities. The dramatic victim behavior may mimic depression, but usually lacks the classic vegetative signs (sleep, appetite, energy, and interest disorders) of true major depression. If a person with antisocial personality disorder threatens suicide or acts on suicidal thoughts, it is usually in retaliation toward authority figures, related to substance abuse, or associated with additional accompanying character pathology (e.g. borderline personality).The sociopathic pattern should eventually be evident by the triad of lack of remorse for perpetrator behavior, failure to learn from past mistakes, and projection onto others of blame (lack of accountability). Such a person may have been through multiple previous treatments accompanied by a professed wish to work a strong recovery program yet, in reality, followed by failure to "walk the talk."

The six classes of depressive types show that the entire array of depressive disorders is expressed in sex addicts. As a practical help to the mental health therapist, it might be useful to codify some of the clinical tools to employ in assessing and treating the depressed, suicidal sex addict. First, the practitioner will want to be able to distinguish the type, depth, and severity of the depression. Second, the therapist should as accurately as possible know what to consider in terms of risk of suicide.

Steps for Determining Severity of Depression

Determining the severity of depression combines a play-it-by-the-book (DSM IV) approach to asking about each possible depressive symptom with an intuitive awareness of what could happen (call it clinical "thinking dirty") as the sex addict in treatment relates to mounting consequences. These steps are suggested:

1. Take no shortcuts in the intake process. Get a broad anthropological/cultural view of the person while conducting a careful search for symptoms and signs of depression and/or suicidal ideation and plans. The cultural context and support system have a telling influence on suicidal potential.

2. Withhold too early conclusions about character pathology. "Hip-shooting" labeling (e.g. borderline, narcissistic, antisocial) only closes off possibilities in the clinician's mind and prevents the therapist from seeing the patient in all his/her potential for resilient recovery or calamities such as suicide.

3. Request psychological testing to back up interview data and clinical observations. Something may surface that was not considered earlier (e.g. schizotypal thinking or a low-grade thought disorder.

4. Search out nooks and crannies in relation to suicidaland homicidal thoughts. For example, if a person denies active suicidal thoughts, he/she may still wish that a semi-truck would meet them head on. Likewise, even though a patient is a mother of children and says she would never kill herself because her children need her, has she recently bought life insurance or given away belongings?

5. Review any past history of suicidal ideation or attempts. What are the similarities and differences (e.g. strength or lack of strength of support network) to the present situation? Has the person ever faced anything as humiliating as the exposure of sex addict behavior?

6. Consider, "How deep is this person's shame?" Will the person consider suicide to be the only "viable" way out of a lifelong shame-existence bind?

7. Inquire about how the person has taken out anger in the past. Toward self? Toward others? He/she is likely to follow the same pattern again.

8. Determine the dynamic significance of the type of sexual acting out practiced by the patient (e.g. the exhibitionist who could never get his mother's attention). Has that meaning been processed with the patient and the power taken out of the pattern, or does shame still envelop the patient and fuel suicidal/homicidal thoughts?

9. Measure whether the patient's medication for severe depression is at a therapeutic level. Smoldering along with depression that is only partially treated can heighten the patient's hopelessness and could lead to suicide (e.g. Is this as good as it gets?).

10. Assess medication compliance. What has been the response of the depression to medication? Does the patient understand the importance of taking medication as prescribed, and for as long as prescribed? Are any side effects intolerable to the patient (e.g. decreased sex drive, anorgasmia, or impotence)?

11. Examine any progress made in treatment in processing anger, shame, and other overwhelming emotions. Have the circumstances of the person's life changed for the better? For the worse? Remember, if nothing changes, nothing changes.

12. Gauge employment and economic prospects. Has sex-addict behavior led to consequences at work? Will there be further repercussions and consequences?

13. Ask the patient what he or she sees for the future. Hope or hopelessness?

14. Practice appropriate boundary setting with the patient as he/she relates to co-workers and people outside the circle of recovering sex addicts. To whom will the person claim sex addiction, and with whom will anonymity and strict boundaries be maintained? Role play some of these scenarios. Would the person rather die than face so-and-so?

15. Concretize aftercare plans. Who will see the patient for outpatient treatment? Is that therapist knowledgeable about sex addiction treatment and recovery? Will the therapist refer the patient if suicidality becomes prominent again? Is extended care needed? How many and what type of Twelve Step meetings will the person attend? Will the person get a sponsor and work Steps, or will he/she remain a "movie critic" at meetings as in the past? Will the person "put your whole self in" to recovery, like the song says?

16. Bring to light the person's growth or lack thereof of a concept of a Higher Power. Does the person think his/her preciousness is a reality? Would a Higher Power really care? Is there still a false Higher Power operating (e.g. money, power, self, another addiction, or a partner)?

In summary . . .

The sex addict is really hurting. It is the clinician's task to assess where the pain could lead while providing a safe, healing, holding environment.

Depression present at the start of treatment often deepens as shame crashes down upon the addict whose acting out pattern is revealed. Suicidal ideation at the "between trapeze" moment is a likely probability. The educated clinician's index of suspicion will help to anticipate the presence and depth of the depression, and the existence of self-destructive thoughts or plans. Caring and professional assessment and treatment will allow the sex addict to survive the shock of discovery and move toward the daily rewards of a healthy and spiritual recovery.

One of the most common side effects of a number of antidepressant medications is loss of sex drive. I could forgive our friends at fine companies such as Eli Lilly, Bristol Meyers Squibb, and Pfizer if dry mouth, irritability, disrupted sleep patterns, loss of appetite, sloth, and social phobia were the sole issues related to the medications I take on a daily basis. However, it is the sex thing I find most challenging.

I am a normal (ha!) 52-year-old father of four, in that sex is on my mind approximately 85% of the day and night, as opposed to 98% when I graduated from college just 30 years ago. I believe a 13% decline in libido is pretty good for a major depressive over a three-decade stretch of time. There are good reasons other than poor mental health for this dip in desire. Let's face it: I don't look the same as I did then. Those were the days of tanned olive skin, a full head of sun-streaked, neck-length hair, and a devil may care attitude. Though I weigh about the same as I did back then, I look about 150 years older. There are wrinkles everywhere on my face, about 1/3 the amount of hair, a hell of a lot of it gray, and eyelids that droop to my knees. So much for the advantages of aging.

Make no mistake, my wife is super hot. She is just a few years younger than me and looks at least 10 years younger than that. She has a pin-up body, very curvy, and gorgeous hair and eyes. My favorite hidden desires are watching her get prepped and dressed for work in the morning and following her around on those rare shopping sprees when she is on a mission to update her wardrobe. She favors clingy fabrics that generate a flamboyant look. She likes sexy shoes and when we go out she puts on a lot of make-up, which I love. She is a major babe.

Back in the pre-Prozac days, it was normal for me to become aroused just looking at her getting dressed. But now things are different. The "equipment" is on the fritz. Because of the drugs orgasms can take up to a week to achieve. My wife expects slightly better performance. I am left to sigh, look down and ask, "what is wrong with you?" The "equipment" gives no answer.

Like many women, my wife makes no effort to hide the fact she likes men. In times prior to my initial use of medication to treat depression, this was no bother at all. It was a good sign. I knew that when I came into the line of focus I would benefit from being an object of her attention. It happened all the time.

Not much anymore, though. The reality of her attitude toward men stands in stark contrast to my lack of "the urge." This hit home prior to a recent surgical procedure. A few minutes before she was taken into the operating room, her surgeon came by to see how she was feeling and to answer any questions either of us had. As he walked away after the brief conversation, she uttered the line that has become a trademark, "I could go for him." I understood. He was young, tall and slender, soft-spoken, smart as hell, and gave her all the time she needed.

I knew that in a few minutes she would be under sedation, on a bed in a quiet room, vulnerable. I imagined a scenario: the Doc asking his anesthesiologist, the nurse, and another attendant to leave the room. "Please leave us alone for a few minutes," he says quietly. "I am overcome by desire. Her beauty consumes me."

The operation then resumes and when it concludes she is brought to recovery holding hands with Doc and there is a smile on her face that I have never been seen before. They kiss deeply and he disappears behind a curtain. She sees me and says, "oh, it's you."

Being formerly secure in my masculinity, I have never had these kinds of thoughts before. But rather than beat myself up about it I have decided to pray that, as my sex drive reappears, I will have another chance with her. I know this. Well, maybe not so much know as hope like hell. In the face of doubt, I also take solace in science. Based on a weighted average using data I have accumulated over the past 9-12 months, I am confident we will have sex again sometime in midsummer, 2004.

In the meantime, I am thinking of applying to medical school.

Skip Corsini is a writer and consultant living in the San Francisco Bay Area.