Depression and Anxiety White Paper

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Depression and Anxiety White Paper

 Karen L. Swartz, M.D., received her B.A. from Princeton University and her M.D. from the Johns Hopkins University School of Medicine. She completed her psychiatry residency at  Johns Hopkins Hospital, where she served as chief resident. She is the Director of Clinical and Educational Programs at the Johns Hopkins Mood Disorders Center. Dr. Swartz is  also the Associate Director for Residency Education and an Assistant Professor in the Department of Psychiatry and Behavioral Sciences at the Johns Hopkins School of  Medicine. She is also Codirector of the Women’s Mood Disorders Center and is a recognized expert on the subject of premenstrual dysphoric disorder (PMDD), mood disorders during pregnancy, postpartum depression and psychosis, and menopause-related depression.

Dr. Swartz is founder and director of the Adolescent Depression Awareness Program (ADAP), a school-based program designed to educate high school students, faculty, and parents about adolescent depression. Now in its 12th year, the ADAP curriculum has been taught to over 17,000 high school students. Dr. Swartz and the ADAP team have also developed a comprehensive training program that prepares high school counselors and teachers as ADAP instructors to facilitate dissemination of the program. In addition to the Baltimore-Washington area, the program has been taught in Oklahoma, Delaware, Texas, Ohio, and Minnesota. Dr. Swartz is now working with colleagues within the National Network of Depression Centers on further national expansion of this innovative program.

Dr. Swartz has received the Welcome Back Award in recognition of her leadership in destigmatizing depression through community education. She has also been honored with  the National Alliance for the Mentally Ill’s Heroes in the Fight Award for her efforts to destigmatize mental illness and for clinical excellence. She was recently inducted as a  Distinguished Fellow of the American Psychiatric Association.

Her research has focused on psychiatric disorders in women and in the general population, including the study of whether affective disorders predict migraine headaches, the  incidence of social phobias in the Baltimore area, and the heterogeneity and course of affective disorders. Dr. Swartz has also written articles for such journals as Archives of  General Psychiatry, Current Opinion in Psychiatry, the International Review of Psychiatry, and the Journal of the American Academy of Child and Adolescent Psychiatry.


Dear Reader:

Welcome to the 2011 Depression and Anxiety White Paper—your personal guide to understanding the causes, symptoms, and management of mood disorders, including depression and bipolar disorder, as well as numerous anxiety disorders, ranging from panic and generalized anxiety to obsessions and compulsions, post-traumatic stress, and phobias.

This year’s highlights include:

  • Bipolar disorder demystified: Types and treatments explained.
  • Why depression increases your risk of dementia.
  • Mild depression: To medicate or not.
  • Do certain antidepressants increase suicide risk more than others?
  • Why your antidepressant could be raising your blood pressure.
  • The power of positive psychology.
  • A promising new brain stimulation technique for depression.
  • How to exercise your way to a better mood.
  • The difference between generalized anxiety disorder and panic disorder.
  • 5 key steps to prevent caregiver burnout and depression.

If you have any depression- or anxiety-related queries you would like answered in the White Papers or comments about the White Papers in general, please e-mail the editors

Wishing you the best of health in 2011,

Karen L. Swartz, M.D.


Mood Disorders

Causes of Mood Disorders
Symptoms and Diagnosis of Mood Disorders

Major Depression
Atypical Depression
Seasonal Affective Disorder
Grief Versus Depression
Depression in Older Adults
Effects of Depression on Physical Health
Bipolar Disorder

Natural History and Prognosis of Mood Disorders

Bipolar Disorder

Treatment of Mood Disorders

Treatment of Depression with Medications
Treatment of Bipolar Disorder with Medications
Electroconvulsive Therapy
Light Therapy
Supplemental Treatments
Future Treatments

Anxiety Disorders

Symptoms of Anxiety

Effects of Anxiety on Physical Health
Panic Disorder
Generalized Anxiety Disorder
Obsessive-Compulsive Disorder
Post-Traumatic Stress Disorder
Phobic Disorders

Treatment of Anxiety

General Medication Treatment
Treatment of Specific Anxiety Disorders

Chart: Antidepressant Drugs 2010
Chart: Drugs for the Treatment of Bipolar Disorder 2011
Chart:Commonly Used Antianxiety Drugs 2011

Abbreviations and Acronyms
Health Information Organizations and Support Groups
Leading Hospitals for Psychiatry
Excerpt from page 10-11

Bipolar Disorder Demystified

Essential Information about types and treatments

One of the more enigmatic mental illnesses, bipolar disorder (or manic depressive illness) causes shifts in mood, energy, and activity levels that are often severe enough to affect one’s day-today functioning. Characterized by unpredictable highs and lows and self-destructive behavior, the illness affects approximately 5.7 million adults in the United States.

While bipolar disorder usually strikes initially in adolescence or early adulthood, experts estimate that about 10% of people with the condition have their first episode after age 50. Some of these people remain undiagnosed, as their symptoms are mistaken for such disorders as cognitive impairment, delirium, or substance abuse.

As with any chronic illness, managing bipolar disorder requires lifelong attention. Without treatment, episodes become more frequent and severe. When successfully controlled, however, people with bipolar disorder can lead full and productive lives.

Beyond Typical Mood Swings

Bipolar disorder involves mood swings that are more exaggerated than typical fluctuations. The “up” periods are known as manic episodes, mania, or hypomania (a less severe form of mania); the “down” periods are called depressive episodes, or depression.

Manic episodes are characterized by aggression, agitation, or irritation; a decreased need for sleep; euphoria; high distractibility; an increased sex drive; inflated self-esteem; racing thoughts; rapid speech; spending sprees; and delusions, hallucinations, or psychosis.

Depressive episodes are marked by difficulty concentrating, remembering, or making decisions; eating disturbances; loss of appetite and weight loss, or overeating and weight gain; fatigue or listlessness; feelings of worthlessness, hopelessness, and/or guilt; loss of self-esteem; persistent sadness; sleep disturbances; suicidal thoughts; or withdrawal from people and activities that were once enjoyed.

Mood swings vary in length and frequency. Some people suffer mostly with major depression, with only the occasional manic episode; others experience “rapid cycling,” with at least four episodes of depression, mania, or hypomania occurring within one year.

Sometimes, people with bipolar disorder have “mixed” states, during which mania and depression occur simultaneously or in rapid sequence. A person in a mixed state might have tremendous energy but also feel extremely sad or hopeless. In between mood swings, many people have periods of stable mood.

Types of Bipolar Disorder

According to the Diagnostic and Statistical Manual of Mental Dis-orders IV (DSM-IV), there are four types of bipolar disorder, differing primarily in symptom severity and the length of time between manic and depressive episodes.

Bipolar type I is the most severe and potentially dangerous form of the illness, capable of causing great difficulty in daily activities and relationships. It is characterized by manic or mixed episodes that last at least seven days or by manic symptoms that are so severe that the person needs emergency hospital care. Manic or mixed episodes are followed by episodes of major depression that last weeks or even years. Fortunately, many people with bipolar I disorder experience long symptom-free periods.

Bipolar type II involves alternating hypomanic (lasting at least four days) and depressive episodes but no full-blown manic  or mixed episodes. While “up” periods are marked by milder symptoms, depressive episodes may be severe and debilitating. Generally, people with bipolar type II can function in their normal daily routine while hypomanic and might simply seem to be extremely cheerful, sociable, or “the life of the party.” During the depressive phase, the level of functioning varies significantly among individuals. Typically, an episode of significant depression follows soon after hypomania. Rapid cycling of moods is more likely to occur with bipolar II than with bipolar I.

Cyclothymia is an even more mild form of mood cycling with highs and lows that continue for at least two years but never reach the severity of major depression or mania. This can make it hard to distinguish from normal variations in mood and personality. In most people, the pattern is irregular and unpredictable, and hypomania or depression can last for days or weeks. In between up and down moods, a person might have normal moods for more than a month.

Bipolar disorder not otherwise specified (BP-NOS) is diagnosed when symptoms don’t meet the criteria for bipolar I or II or cyclothymia. Symptoms may not last long enough, or the person may have too few of them. But the symptoms are clearly out of the person’s normal range of behavior.

Getting a Diagnosis

One of the biggest challenges for people with mood swings is an accurate diagnosis. Doctors must rule out any medical conditions and medications that could explain the symptoms.

A head injury, stroke, delirium, thyroid disorders, lupus, substance abuse, and HIV infection can cause symptoms that mimic bipolar disorder. In addition, commonly used medications like corticosteroids (for example, prednisone), used to treat inflammatory diseases such as rheumatoid arthritis and psoriasis, as well as thyroid medication for hypothyroidism can cause mood swings.

Another barrier to an accurate diagnosis is that most people visit their doctor for depressive rather than manic symptoms and are subsequently diagnosed with major depression. In addition, people with bipolar disorder often have a co-occurring anxiety condition (like obsessive-compulsive disorder) that can complicate the diagnosis.

Treating Bipolar Disorder

Once an accurate diagnosis is made, determining the appropriate treatment is the next challenge. Given the variations in how the disease manifests itself, not all treatments will have the same results for everyone.

Still, the goals remain the same regardless of the type of bipolar disorder diagnosed: to control a manic or depressive episode in progress, to prevent further episodes, to increase the time between episodes, and to decrease the severity of episodes when they occur. The latter is called maintenance therapy.

The mood-stabilizing drug lithium (Lithobid) is the mainstay for treating a manic episode. Many other types of medications are used as well. For example, mood stabilizers like valproic acid (Depakene, Stavzor) and divalproex (Depakote) are increasingly used as an alternative to lithium when side effects are a problem. Other options include antipsychotics (neuroleptics) like aripiprazole (Abilify) and olanzapine (Zyprexa), anticonvulsants like carbamazepine (Equetro), and benzodiazepines like lorazepam (Ativan). Most of these drugs are effective for mixed episodes as well.

For depressive episodes, lithium and antipsychotics such as quetiapine (Seroquel) are typically used. When they do not offer relief, doctors often turn to the anticonvulsant lamotrigine (Lamictal). Antidepressants are an option but must be used with extreme care because they can trigger manic episodes. Electroconvulsive therapy (ECT) is also a choice but only for severe depressive episodes that do not respond to medication. ECT is also sometimes used for difficult-to-treat mania.

After a depressive, manic, or mixed episode is brought under control, people with bipolar disorder must continue to take medication to prevent further episodes. The most commonly prescribed maintenance therapy is lithium alone or in combination with valproic acid, Depakote, Equetro, or Lamictal. Antipsychotics like Abilify and Zyprexa also help prevent relapses, especially when used in combination with lithium.

Psychotherapy is another important component of treatment, helping a person manage stress, stay on medications, solve problems, and prevent relapse.

Treating Older Adults

Few studies have examined bipolar treatments for older adults, but experts expect them to work just as well as they do in younger patients. Still, it’s important for older people to take the following precautions to ensure the best outcome with bipolar drugs.

First, your doctor should start you at a low dosage, and any dose increases should be done gradually, in part because your body metabolizes medication more slowly with age.

Second, make sure your doctor knows all of your medications and health conditions. Some can interact with your bipolar drugs, making them less effective or more likely to cause side effects.

Third, contact your doctor if you experience dizziness on standing, mental impairment, or movement problems. These common side effects of certain bipolar medications can increase your risk of falls and fractures.

3rd April, 2014

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