Cognitive behavioral therapy (CBT) is a form of psychological treatment that has been demonstrated to be effective for a range of problems including depression, anxiety disorders, alcohol and drug use problems, marital problems, eating disorders, and severe mental illness. Numerous research studies suggest that CBT leads to significant improvement in functioning and quality of life. In many studies, CBT has been demonstrated to be as effective as, or more effective than, other forms of psychological therapy or psychiatric medications.
It is important to emphasize that advances in CBT have been made on the basis of both research and clinical practice. Indeed, CBT is an approach for which there is ample scientific evidence that the methods that have been developed actually produce change. In this manner, CBT differs from many other forms of psychological treatment.
CBT is based on several core principles, including:
- Psychological problems are based, in part, on faulty or unhelpful ways of thinking.
- Psychological problems are based, in part, on learned patterns of unhelpful behavior.
- People suffering from psychological problems can learn better ways of coping with them, thereby relieving their symptoms and becoming more effective in their lives.
CBT treatment usually involves efforts to change thinking patterns. These strategies might include:
- Learning to recognize one’s distortions in thinking that are creating problems, and then to reevaluate them in light of reality.
- Gaining a better understanding of the behavior and motivation of others.
- Using problem-solving skills to cope with difficult situations.
- Learning to develop a greater sense of confidence in one’s own abilities.
CBT treatment also usually involves efforts to change behavioral patterns. These strategies might include:
- Facing one’s fears instead of avoiding them.
- Using role playing to prepare for potentially problematic interactions with others.
- Learning to calm one’s mind and relax one’s body.
Not all CBT will use all of these strategies. Rather, the psychologist and patient/client work together, in a collaborative fashion, to develop an understanding of the problem and to develop a treatment strategy.
CBT places an emphasis on helping individuals learn to be their own therapists. Through exercises in the session as well as “homework” exercises outside of sessions, patients/clients are helped to develop coping skills, whereby they can learn to change their own thinking, problematic emotions, and behavior.
CBT therapists emphasize what is going on in the person’s current life, rather than what has led up to their difficulties. A certain amount of information about one’s history is needed, but the focus is primarily on moving forward in time to develop more effective ways of coping with life.
Medically Reviewed by Smitha Bhandari, MD on August 25, 2022
What are the causes of mental illness? Although the exact cause of most mental illnesses is not known, it is becoming clear through research that many of these conditions are caused by a combination of biological, psychological, and environmental factors. Some mental illnesses have been linked to abnormal functioning of nerve cell circuits or pathways that connect particular brain regions. Nerve cells within these brain circuits communicate through chemicals called neurotransmitters. "Tweaking" these chemicals -- through medicines, psychotherapy or other medical procedures -- can help brain circuits run more efficiently. In addition, defects in or injury to certain areas of the brain have also been linked to some mental conditions. Other biological factors that may be involved in the development of mental illness include:
Psychological factors that may contribute to mental illness include: Certain stressors can trigger an illness in a person who is susceptible to mental illness. These stressors include:
We can all be "sad" or "blue" at times in our lives. We have all seen movies about the madman and his crime spree, with the underlying cause of mental illness. We sometimes even make jokes about people being crazy or nuts, even though we know that we shouldn't. We have all had some exposure to mental illness, but do we really understand it or know what it is? Many of our preconceptions are incorrect. A mental illness can be defined as a health condition that changes a person's thinking, feelings, or behavior (or all three) and that causes the person distress and difficulty in functioning. As with many diseases, mental illness is severe in some cases and mild in others. Individuals who have a mental illness don't necessarily look like they are sick, especially if their illness is mild. Other individuals may show more explicit symptoms such as confusion, agitation, or withdrawal. There are many different mental illnesses, including depression, schizophrenia, attention deficit hyperactivity disorder (ADHD), autism, and obsessive-compulsive disorder. Each illness alters a person's thoughts, feelings, and/or behaviors in distinct ways. In this module, we will at times discuss mental illness in general terms and at other times, discuss specific mental illnesses. Depression, schizophrenia, and ADHD will be presented in greater detail than other mental illnesses.
Not all brain diseases are categorized as mental illnesses. Disorders such as epilepsy, Parkinson's disease, and multiple sclerosis are brain disorders, but they are considered neurological diseases rather than mental illnesses. Interestingly, the lines between mental illnesses and these other brain or neurological disorders is blurring somewhat. As scientists continue to investigate the brains of people who have mental illnesses, they are learning that mental illness is associated with changes in the brain's structure, chemistry, and function and that mental illness does indeed have a biological basis. This ongoing research is, in some ways, causing scientists to minimize the distinctions between mental illnesses and these other brain disorders. In this curriculum supplement, we will restrict our discussion of mental illness to those illnesses that are traditionally classified as mental illnesses, as listed in the previous paragraph.
Many people feel that mental illness is rare, something that only happens to people with life situations very different from their own, and that it will never affect them. Studies of the epidemiology of mental illness indicate that this belief is far from accurate. In fact, the surgeon general reports that mental illnesses are so common that few U.S. families are untouched by them.44
Few U.S. families are untouched by mental illness.
Even if you or a family member has not experienced mental illness directly, it is very likely that you have known someone who has. Estimates are that at least one in four people is affected by mental illness either directly or indirectly. Consider the following statistics to get an idea of just how widespread the effects of mental illness are in society: 4, 25, 44
According to recent estimates, approximately 20 percent of Americans, or about one in five people over the age of 18, suffer from a diagnosable mental disorder in a given year.
Four of the 10 leading causes of disability—major depression, bipolar disorder, schizophrenia, and obsessive-compulsive disorder—are mental illnesses.
About 3 percent of the population have more than one mental illness at a time.
About 5 percent of adults are affected so seriously by mental illness that it interferes with their ability to function in society. These severe and persistent mental illnesses include schizophrenia, bipolar disorder, other severe forms of depression, panic disorder, and obsessive-compulsive disorder.
Approximately 20 percent of doctor's appointments are related to anxiety disorders such as panic attacks.
Eight million people have depression each year.
Two million Americans have schizophrenia disorders, and 300,000 new cases are diagnosed each year.
Mental illness is not uncommon among children and adolescents. Approximately 12 million children under the age of 18 have mental disorders.4 The National Mental Health Association33 has compiled some statistics about mental illness in children and adolescents:
Mental health problems affect one in every five young people at any given time.
An estimated two-thirds of all young people with mental health problems are not receiving the help they need.
Less than one-third of the children under age 18 who have a serious mental health problem receive any mental health services.
As many as 1 in every 33 children may be depressed. Depression in adolescents may be as high as 1 in 8.
Suicide is the third leading cause of death for 15- to 24-years-olds and the sixth leading cause of death for 5- to 15-year-olds.
Schizophrenia is rare in children under age 12, but it occurs in about 3 of every 1,000 adolescents.
Between 118,700 and 186,600 youths in the juvenile justice system have at least one mental illness.
Of the 100,000 teenagers in juvenile detention, an estimated 60 percent have behavioral, cognitive, or emotional problems.
Each mental illness has its own characteristic symptoms. (See Section 10 for information about some specific illnesses.) However, there are some general warning signs that might alert you that someone needs professional help.4 Some of these signs include
marked personality change,
inability to cope with problems and daily activities,
strange or grandiose ideas,
excessive anxieties,
prolonged depression and apathy,
marked changes in eating or sleeping patterns,
thinking or talking about suicide or harming oneself,
extreme mood swings—high or low,
abuse of alcohol or drugs, and
excessive anger, hostility, or violent behavior.
A person who shows any of these signs should seek help from a qualified health professional.
To be diagnosed with a mental illness, a person must be evaluated by a qualified professional who has expertise in mental health. Mental health professionals include psychiatrists, psychologists, psychiatric nurses, social workers, and mental health counselors. Family doctors, internists, and pediatricians are usually qualified to diagnose common mental disorders such as depression, anxiety disorders, and ADHD. In many cases, depending on the individual and his or her symptoms, a mental health professional who is not a psychiatrist will refer the patient to a psychiatrist. A psychiatrist is a medical doctor (M.D.) who has received additional training in the field of mental health and mental illnesses. Psychiatrists evaluate the person's mental condition in coordination with his or her physical condition and can prescribe medication. Only psychiatrists and other M.D.s can prescribe medications to treat mental illness.
Unlike some disease diagnoses, doctors can't do a blood test or culture some microorganisms to determine whether a person has a mental illness. Maybe scientists will develop discrete physiological tests for mental illnesses in the future; until then, however, mental health professionals will have to diagnose mental illnesses based on the symptoms that a person has. Basing a diagnosis on symptoms and not on a quantitative medical test, such as a blood chemistry test, a throat swab, X-rays, or urinalysis, is not unusual. Physicians diagnose many diseases, including migraines, Alzheimer's disease, and Parkinson's disease based on their symptoms alone. For other diseases, such as asthma or mononucleosis, doctors rely on analyzing symptoms to get a good idea of what the problem is and then use a physiological test to provide additional information or to confirm their diagnosis.
When a mental health professional works with a person who might have a mental illness, he or she will, along with the individual, determine what symptoms the individual has, how long the symptoms have persisted, and how his or her life is being affected. Mental health professionals often gather information through an interview during which they ask the patient about his or her symptoms, the length of time that the symptoms have occurred, and the severity of the symptoms. In many cases, the professional will also get information about the patient from family members to obtain a more comprehensive picture. A physician likely will conduct a physical exam and consult the patient's history to rule out other health problems.
Mental health professionals evaluate symptoms to make a diagnosis of mental illness. They rely on the criteria specified in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; currently, the fourth edition), published by the American Psychiatric Association, to diagnose a specific mental illness.5 For each mental illness, the DSM-IV gives a general description of the disorder and a list of typical symptoms. Mental health professionals refer to the DSM-IV to confirm that the symptoms a patient exhibits match those of a specific mental illness. Although the DSM-IV provides valuable information that helps mental health professionals diagnose mental illness, these professionals realize that it is important to observe patients over a period of time to understand the individual's mental illness and its effects on his or her life. We present the DSM-IV criteria for the specific diseases discussed in this module in Section 10, Information about Specific Mental Illnesses.
Mental health professionals evaluate symptoms to make a diagnosis of mental illness.
The term mental illness clearly indicates that there is a problem with the mind. But is it just the mind in an abstract sense, or is there a physical basis to mental illness? As scientists continue to investigate mental illnesses and their causes, they learn more and more about how the biological processes that make the brain work are changed when a person has a mental illness.
Before thinking about the problems that occur in the brain when someone has a mental illness, it is helpful to think about how the brain functions normally. The brain is an incredibly complex organ. It makes up only 2 percent of our body weight, but it consumes 20 percent of the oxygen we breathe and 20 percent of the energy we take in. It controls virtually everything we as humans experience, including movement, sensing our environment, regulating our involuntary body processes such as breathing, and controlling our emotions. Hundreds of thousands of chemical reactions occur every second in the brain; those reactions underlie the thoughts, actions, and behaviors with which we respond to environmental stimuli. In short, the brain dictates the internal processes and behaviors that allow us to survive.
How does the brain take in all this information, process it, and cause a response? The basic functional unit of the brain is the neuron. A neuron is a specialized cell that can produce different actions because of its precise connections with other neurons, sensory receptors, and muscle cells. A typical neuron has four structurally and functionally defined regions: the cell body, dendrites, axons, and the axon terminals.
The cell body is the metabolic center of the neuron. The nucleus is located in the cell body and most of the cell's protein synthesis occurs here.
A neuron usually has multiple fibers called dendrites that extend from the cell body. These processes usually branch out somewhat like tree branches and serve as the main apparatus for receiving input from other nerve cells.
The cell body also gives rise to the axon. The axon is usually much longer than the dendrites; in some cases, an axon can be up to 1 meter long. The axon is the part of the neuron that is specialized to carry messages away from the cell body and to relay messages to other cells. Some large axons are surrounded by a fatty insulating material called myelin, which enables the electrical signals to travel down the axon at higher speeds.
Near its end, the axon divides into many fine branches that have specialized swellings called axon terminals or presynaptic terminals. The axon terminals end near the dendrites of another neuron. The dendrites of one neuron receive the message sent from the axon terminals of another neuron.
The site where an axon terminal ends near a receiving dendrite is called the synapse. The cell that sends out information is called the presynaptic neuron, and the cell that receives the information is called the postsynaptic neuron. It is important to note that the synapse is not a physical connection between the two neurons; there is no cytoplasmic connection between the two neurons. The intercellular space between the presynaptic and postsynaptic neurons is called the synaptic space or synaptic cleft. An average neuron forms approximately 1,000 synapses with other neurons. It has been estimated that there are more synapses in the human brain than there are stars in our galaxy. Furthermore, synaptic connections are not static. Neurons form new synapses or strengthen synaptic connections in response to life experiences. This dynamic change in neuronal connections is the basis of learning.
Neurons communicate using both electrical signals and chemical messages. Information in the form of an electrical impulse is carried away from the neuron's cell body along the axon of the presynaptic neuron toward the axon terminals. When the electrical signal reaches the presynaptic axon terminal, it cannot cross the synaptic space, or synaptic cleft. Instead, the electrical signal triggers chemical changes that can cross the synapse to affect the postsynaptic cell. When the electrical impulse reaches the presynaptic axon terminal, membranous sacs called vesicles move toward the membrane of the axon terminal. When the vesicles reach the membrane, they fuse with the membrane and release their contents into the synaptic space. The molecules contained in the vesicles are chemical compounds called neurotransmitters. Each vesicle contains many molecules of a neurotransmitter. The released neurotransmitter molecules drift across the synaptic cleft and then bind to special proteins, called receptors, on the postsynaptic neuron. A neurotransmitter molecule will bind only to a specific kind of receptor.
The binding of neurotransmitters to their receptors causes that neuron to generate an electrical impulse. The electrical impulse then moves away from the dendrite ending toward the cell body. After the neurotransmitter stimulates an electrical impulse in the postsynaptic neuron, it releases from the receptor back into the synaptic space. Specific proteins called transporters or reuptake pumps carry the neurotransmitter back into the presynaptic neuron. When the neurotransmitter molecules are back in the presynaptic axon terminal, they can be repackaged into vesicles for release the next time an electrical impulse reaches the axon terminal. Enzymes present in the synaptic space degrade neurotransmitter molecules that are not taken back up into the presynaptic neuron.
The nervous system uses a variety of neurotransmitter molecules, but each neuron specializes in the synthesis and secretion of a single type of neurotransmitter. Some of the predominant neurotransmitters in the brain include glutamate, GABA, serotonin, dopamine, and norepinephrine. Each of these neurotransmitters has a specific distribution and function in the brain; the specifics of each are beyond the scope of this module, but a few of the names will arise in reference to particular mental illnesses.
Mental health professionals base their diagnosis and treatment of mental illness on the symptoms that a person exhibits. The goal for these professionals in treating a patient is to relieve the symptoms that are interfering with the person's life so that the person can function well. Research scientists, on the other hand, have a different goal. They want to learn about the chemical or structural changes that occur in the brain when someone has a mental illness. If scientists can determine what happens in the brain, they can use that knowledge to develop better treatments or find a cure.
The techniques that scientists use to investigate the brain depend on the questions they are asking. For some questions, scientists use molecular or biochemical methods to investigate specific genes or proteins in the neurons. For other questions, scientists want to visualize changes in the brain so that they can learn more about how the activity or structure of the brain changes. Historically, scientists could examine brains only after death, but new imaging procedures enable scientists to study the brain in living animals, including humans. It is important to realize that these brain imaging techniques are not used for diagnosing mental illness. Mental illnesses are diagnosed by the set of symptoms that an individual exhibits. The imaging techniques described in the following paragraphs would not enable the mental health professional to diagnose or treat the patient more effectively. Some of the techniques are also invasive and expose patients to small amounts of radiation. Research studies using these tests are generally not conducted with children or adolescents.
One extensively used technique to study brain activity and how mental illness changes the brain is positron emission tomography (PET). PET measures the spatial distribution and movement of a radioactive chemical injected into the tissues of living subjects. Because the patient is awake, the technique can be used to investigate the relationship between behavioral and physiological effects and changes in brain activity. PET scans can detect very small (nanomolar) concentrations of tracer molecules and achieve spatial resolution of about 4 millimeters. In addition, computers can reconstruct images obtained from a PET scan in two or three dimensions.
PET requires the use of compounds that are labeled with positron-emitting isotopes. A positron has the same mass and spin as an electron but the opposite charge; an electron has a negative charge and a positron has a positive charge. A cyclotron accelerates protons into the nucleus of nitrogen, carbon, oxygen, or fluorine to generate these isotopes. The additional proton makes the isotope unstable. To become stable again, the proton must break down into a neutron and a positron. The unstable positron travels away from the site of generation and dissipates energy along the way. Eventually, the positron collides with an electron, leading to the emission of two gamma rays at 180 degrees from one another. The gamma rays reach a pair of detectors that record the event. Because the detectors respond only to simultaneous emissions, scientists can precisely map the location where the gamma rays were generated. The radioactive chemicals used for PET are very short lived. The half-life (the time for half of the radioactive label to disintegrate) of the commonly used radioisotopes ranges from approximately two minutes to less than two hours, depending on the specific compound. Because a PET scan requires only small amounts (a few micrograms) of short-lived radioisotopes, this technique can be used safely in humans.
PET scans can answer a variety of questions about brain function, including where the neurons are most active. Scientists use different radiolabeled compounds to investigate different biological questions. For example, radiolabeled glucose can identify parts of the brain that become more active in response to a specific stimulus. Active neurons metabolize more glucose than inactive neurons. Active neurons emit more positrons, and this shows as red or yellow on PET scans compared with blue or purple in areas where the neurons are not highly active. (Different computer enhancement techniques may use a different color scheme, but the use of a spectrum with red indicating high activity and blue indicating low activity is common.) Scientists can use PET to measure changes in the activity of specific brain areas in a person who has a mental illness. Scientists can also investigate how the mentally ill brain changes after a person receives treatment.
PET imaging is not the only technique that researchers use to investigate how mental illness changes the brain. Different techniques provide different information to scientists. Another important technique is magnetic resonance imaging (MRI). Unlike PET, which reveals changes in activity level, MRI is used to look at structural changes in the brain. For example, MRI studies reveal that the ventricles, or spaces within the brain, are larger in individuals who have schizophrenia compared with those of healthy individuals. Other techniques that scientists use to investigate function in the living brain include single photon emission computed tomography (SPECT), functional magnetic resonance imaging (fMRI), and electroencephalography (EEG). Each technique has its own advantages, and each provides different information about brain structure and function. Scientists often use more than one technique when conducting their research.
Scientists believe that mental illnesses result from problems with the communication system in the brain.
At this time, scientists do not have a complete understanding of what causes mental illnesses. If you think about the structural and organizational complexity of the brain together with the complexity of effects that mental illnesses have on thoughts, feelings, and behaviors, it is hardly surprising that figuring out the causes of mental illnesses is a daunting task. The fields of neuroscience, psychiatry, and psychology address different aspects of the relationship between the biology of the brain and individuals' behaviors, thoughts, and feelings, and how their actions sometimes get out of control. Through this multidisciplinary research, scientists are trying to find the causes of mental illnesses. Once scientists can determine the causes of a mental illness, they can use that knowledge to develop new treatments or to find a cure.
Most scientists believe that mental illnesses result from problems with the communication between neurons in the brain (neurotransmission). For example, the level of the neurotransmitter serotonin is lower in individuals who have depression. This finding led to the development of certain medications for the illness. Selective serotonin reuptake inhibitors (SSRIs) work by reducing the amount of serotonin that is taken back into the presynaptic neuron. This leads to an increase in the amount of serotonin available in the synaptic space for binding to the receptor on the postsynaptic neuron. Changes in other neurotransmitters (in addition to serotonin) may occur in depression, thus adding to the complexity of the cause underlying the disease.
Scientists believe that there may be disruptions in the neurotransmitters dopamine, glutamate, and norepinephrine in individuals who have schizophrenia. One indication that dopamine might be an important neurotransmitter in schizophrenia comes from the observation that cocaine addicts sometimes show symptoms similar to schizophrenia. Cocaine acts on dopamine-containing neurons in the brain to increase the amount of dopamine in the synapse.
Although scientists at this time do not know the causes of mental illnesses, they have identified factors that put individuals at risk. Some of these factors are environmental, some are genetic, and some are social. In fact, all these factors most likely combine to influence whether someone becomes mentally ill.
Genetic, environmental, and social factors interact to influence whether someone becomes mentally ill.
Environmental factors such as head injury, poor nutrition, and exposure to toxins (including lead and tobacco smoke) can increase the likelihood of developing a mental illness.
Genes also play a role in determining whether someone develops a mental illness. The illnesses that are most likely to have a genetic component include autism, bipolar disorder, schizophrenia, and ADHD. For example, the observation that children with ADHD are much more likely to have a sibling or parent with ADHD supports a role for genetics in determining whether someone is at risk for ADHD. In studies of twins, ADHD is significantly more likely to be present in an identical twin than a fraternal twin. The same can be said for schizophrenia and depression. Mental illnesses are not triggered by a change in a single gene; scientists believe that the interaction of several genes may trigger mental illness. Furthermore, the combination of genetic, environmental, and social factors might determine whether a case of mental illness is mild or severe.
Social factors also present risks and can harm an individual's, especially a child's, mental health. Social factors include
severe parental discord,
death of a family member or close friend,
parent's mental illness,
parent's criminality,
overcrowding,
economic hardship,
abuse,
neglect, and
exposure to violence.
At this time, most mental illnesses cannot be cured, but they can usually be treated effectively to minimize the symptoms and allow the individual to function in work, school, or social environments. To begin treatment, an individual needs to see a qualified mental health professional. The first thing that the doctor or other mental health professional will do is speak with the individual to find out more about his or her symptoms, how long the symptoms have lasted, and how the person's life is being affected. The physician will also do a physical examination to determine whether there are other health problems. For example, some symptoms (such as emotional swings) can be caused by neurological or hormonal problems associated with chronic illnesses such as heart disease, or they can be a side effect of certain medications. After the individual's overall health is evaluated and the condition diagnosed, the doctor will develop a treatment plan. Treatment can involve both medications and psychotherapy, depending on the disease and its severity.
At this time, most mental illnesses cannot be cured, but they can usually be treated effectively to minimize the symptoms and allow the individual to function in work, school, or social environments.
Medications are often used to treat mental illnesses. Through television commercials and magazine advertisements, we are becoming more aware of those medications. To become fully effective, medications for treating mental illness must be taken for a few days or a few weeks. When a patient begins taking medication, it is important for a doctor to monitor the patient's health. If the medication causes undesirable side effects, the doctor may change the dose or switch to a different medication that produces fewer side effects. If the medication does not relieve the symptoms, the doctor may prescribe a different medication.2
Sometimes, individuals who have a mental illness do not want to take their medications because of the side effects. It is important to remember that all medications have both positive and negative effects. For example, antibiotics have revolutionized treatment for some bacterial diseases. However, antibiotics often affect beneficial bacteria in the human body, leading to side effects such as nausea and diarrhea. Psychiatric drugs, like other medications, can alleviate symptoms of mental illness but can also produce unwanted side effects. People who take a medication to treat an illness, whether it is a mental illness or another disease, should work with their doctors to understand what medication they are taking, why they are taking it, how to take it, and what side effects to watch for.
Occasionally, the media reports stories in which the side effects of a psychiatric medication are tied to a potentially serious consequence, such as suicide. In these cases, it is usually very difficult to determine how much suicidal behavior was due to the mental disorder and what the role of the medication might have been. Medications for treating mental illness can, like other medications, have side effects. The psychiatrist or physician can usually adjust the dose or change the medication to alleviate side effects.
Psychotherapy is a treatment method in which a mental health professional (psychiatrist, psychologist, or other mental health professional) and the patient discuss problems and feelings. This discussion helps patients understand the basis of their problems and find solutions. Psychotherapy may take different forms. The therapy can help patients
change thought or behavior patterns,
understand how past experiences influence current behaviors,
solve other problems in specific ways, or
learn illness self-management skills.
Psychotherapy may occur between a therapist and an individual; a therapist and an individual and his or her family members; or a therapist and a group. Often, treatment for mental illness is most successful when psychotherapy is used in combination with medications. For severe mental illnesses, medication relieves the symptoms and psychotherapy helps individuals cope with their illness.3
Just as there are no medications that can instantly cure mental illnesses, psychotherapy is not a one-time event. The amount of time a person spends in psychotherapy can range from a few visits to a few years, depending on the nature of the illness or problem. In general, the more severe the problem, the more lengthy the psychotherapy should be.3
"The last great stigma of the twentieth century is the stigma of mental illness."
—Tipper Gore, wife of the former U.S. Vice President37
"Mentally ill people are nuts, crazy, wacko." "Mentally ill people are morally bad." "Mentally ill people are dangerous and should be locked in an asylum forever." "Mentally ill people need somebody to take care of them." How often have we heard comments like these or seen these types of portrayals in movies, television shows, or books? We may even be guilty of making comments like them ourselves. Is there any truth behind these portrayals, or is that negative view based on our ignorance and fear?
Stigmas are negative stereotypes about groups of people. Common stigmas about people who are mentally ill are
Individuals who have a mental illness are dangerous.
Individuals who have a mental illness are irresponsible and can't make life decisions for themselves.
People who have a mental illness are childlike and must be taken care of by parents or guardians.
People who have a mental illness should just get over it.11
Each of those preconceptions about people who have a mental illness is based on false information. Very few people who have a mental illness are dangerous to society. Most can hold jobs, attend school, and live independently. A person who has a mental illness cannot simply decide to get over it any more than someone who has a different chronic disease such as diabetes, asthma, or heart disease can. A mental illness, like those other diseases, is caused by a physical problem in the body.
Stigmas against individuals who have a mental illness lead to injustices, including discriminatory decisions regarding housing, employment, and education. Overcoming the stigmas commonly associated with mental illness is yet one more challenge that people who have a mental illness must face. Indeed, many people who successfully manage their mental illness report that the stigma they face is in many ways more disabling than the illness itself. The stigmatizing attitudes toward mental illness held by both the public and those who have a mental illness lead to feelings of shame and guilt, loss of self-esteem, social dependence, and a sense of isolation and hopelessness.11, 44 One of the worst consequences of stigma is that people who are struggling with a mental illness may be reluctant to seek treatment that, in most cases, would significantly relieve their symptoms.
Providing accurate information is one way to reduce stigmas about mental illness. Advocacy groups protest stereotypes imposed upon those who are mentally ill. They demand that the media stop presenting inaccurate views of mental illness and that the public stops believing these negative views. A powerful way of countering stereotypes about mental illness occurs when members of the public meet people who are effectively managing a serious mental illness: holding jobs, providing for themselves, and living as good neighbors in a community. Interaction with people who have mental illnesses challenges a person's assumptions and changes a person's attitudes about mental illness.
Providing accurate information is one way to reduce stigmas about mental illness.
Attitudes about mental illness are changing, although there is a long way to go before people accept that mental illness is a disease with a biological basis. A survey by the National Mental Health Association found that 55 percent of people who have never been diagnosed with depression recognize that depression is a disease and not something people should "snap out of."34 This is a substantial increase over the 38 percent of survey respondents in 1991 who recognized depression as a disease.
Most people don't think twice before going to a doctor if they have an illness such as bronchitis, asthma, diabetes, or heart disease. However, many people who have a mental illness don't get the treatment that would alleviate their suffering. Studies estimate that two-thirds of all young people with mental health problems are not receiving the help they need and that less than one-third of the children under age 18 who have a serious mental health problem receive any mental health services. Mental illness in adults often goes untreated, too. What are the consequences of letting mental illness go untreated?
In September 2000, the U.S. surgeon general held a conference on children's mental health. The former surgeon general, Dr. David Satcher, emphasized the importance of mental health in children by stating, "Children and families are suffering because of missed opportunities for prevention and early identification, fragmented services, and low priorities for resources. Overriding all of this is the issue of stigma, which continues to surround mental illness."45
The consequences of mental illness in children and adolescents can be substantial. Many mental health professionals speak of accrued deficits that occur when mental illness in children is not treated. To begin with, mental illness can impair a student's ability to learn. Adolescents whose mental illness is not treated rapidly and aggressively tend to fall further and further behind in school. They are more likely to drop out of school and are less likely to be fully functional members of society when they reach adulthood.45 We also now know that depressive disorders in young people confer a higher risk for illness and interpersonal and psychosocial difficulties that persist after the depressive episode is over. Furthermore, many adults who suffer from mental disorders have problems that originated in childhood.44 Depression in youth may predict more severe illness in adult life.27 Attention deficit hyperactivity disorder, once thought to affect children and adolescents only, may persist into adulthood and may be associated with social, legal, and occupational problems.14
Mental illness impairs a student's ability to learn. Adolescents whose mental illness is not treated rapidly and aggressively tend to fall further and further behind in school.
The high incidence of mental illness has a great impact on society. Depression alone causes employers to lose over $23 billion each year due to decreased productivity and absenteeism of employees.46 The Global Burden of Disease Study, conducted by the World Health Organization, assessed the burden of all diseases in units that measure lost years of healthy life due to premature death or disability (disability-adjusted life years, or DALYs). Over 15 percent of the total DALYs were due to mental illness.26 In 1996, the United States spent more than $69 billion for the direct treatment of mental illnesses. Indirect costs of mental illness due to lost productivity in the workplace, schools, or homes represented a $79 billion loss for the U.S. economy in 1990.44
Treatment, including psychotherapy and medication management, is cost-effective for patients, their families, and society. The benefits include fewer visits to other doctors' offices, diagnostic laboratories, and hospitals for physical ailments that are based in psychological distress; reduced need for psychiatric hospitalization; fewer sick days and disability claims; and increased job stability. Conversely, the costs of not treating mental disorders can be seen in ruined relationships, job loss or poor job performance, personal anguish, substance abuse, unnecessary medical procedures, psychiatric hospitalization, and suicide.3
A diagnosis of mental illness is rarely simple and straightforward. There are no infallible physiological tests that determine whether a person has a mental illness. Diagnosis requires that qualified healthcare professionals identify several specific symptoms that the person exhibits. Each mental illness has characteristic signs and symptoms that are related to the underlying biological dysfunction. The following sections describe the symptoms and outcomes of three mental illnesses that are highlighted in this curriculum supplement: depression, attention deficit hyperactivity disorder, and schizophrenia.
Depression, or depressive disorders, is a leading cause of disability in the United States as well as worldwide. It affects an estimated 9.5 percent of American adults in a given year.28 Nearly twice as many women as men have depression.25 Epidemiological studies have reported that up to 2.5 percent of children and 8.3 percent of adolescents in the United States suffer from depression.22
Depression is more than just being in a bad mood or feeling sad. Everyone experiences these feelings on occasion, but that does not constitute depression. Depression is actually not a single disease; there are three main types of depressive disorders.23, 27 They are
major depressive disorder,10
dysthymia, and
bipolar disorder (manic-depression).
While some of the symptoms of depression are common during a passing "blue mood," major depressive disorder is diagnosed when a person has five or more of the symptoms nearly every day during a two-week period.27 Symptoms of depression include
a sad mood,
a loss of interest in activities that one used to enjoy,
a change in appetite or weight,
oversleeping or difficulty sleeping,
physical slowing or agitation,
energy loss,
feelings of worthlessness or inappropriate guilt,
difficulty concentrating, and
recurrent thoughts of death or suicide.
When people have depression, their lives are affected severely: they have trouble performing at work or school, and they aren't interested in normal family and social activities. In adults, an untreated major depressive episode lasts an average of nine months. At least half of the people who experience an episode of major depression will have another episode of depression at some point.44
In children, depression lasts an average of seven to nine months with symptoms similar to those in adults.44 Symptoms in children may include
sadness,
loss of interest in activities they used to enjoy,
self-criticism,
feelings that they are unloved,
hopelessness about the future,
thoughts of suicide,
irritability,
indecisiveness,
trouble concentrating, and
lack of energy.
Children and adolescents with depression are more likely than adults to have anxiety symptoms and general aches and pains, stomachaches, and headaches. The majority of children and adolescents who have a major depressive disorder also have another mental illness such as an anxiety disorder, disruptive or antisocial behavior, or a substance-abuse disorder. Children and adolescents who suffer from depression are more likely to commit suicide than are other youths. As in adults, episodes of depression are likely to recur.44
Dysthymia is less severe than major depressive disorder, but it is more chronic. In dysthymia, a depressed mood along with at least two other symptoms of depression persist for at least two years in adults, or one year in children or adolescents.22 These symptoms may not be as disabling, but they do keep affected people from functioning well or feeling good. Dysthymia often begins in childhood, adolescence, or early adulthood.25 On average, untreated dysthymia lasts four years in children and adolescents.44
A third type of depressive disorder is bipolar disorder, also called manic-depression. A person who has bipolar disorder alternates between episodes of major depression and mania (periods of abnormally and persistently elevated mood or irritability). During manic periods, the person will also have three or more of the following symptoms:
overly inflated self-esteem,
decreased need for sleep,
increased talkativeness,
racing thoughts,
distractibility,
increased goal-directed activity or physical agitation, and
excessive involvement in pleasurable activities that have a high potential for painful consequences.27
While in a manic phase, adolescents may engage in risky or reckless behaviors such as fast driving and unsafe sex.
Bipolar disorder frequently begins during adolescence or young adulthood. Adults with bipolar disorder often have clearly defined episodes of mania and depression, with periods of mania every two to four years. Children and adolescents with bipolar disorder, however, may cycle rapidly between depression and mania many times within a day.29 Bipolar disorder in youths may be difficult to distinguish from other mental illnesses because the symptoms often overlap with those of other mental illnesses such as ADHD, conduct disorder, or oppositional defiant disorder.
Depression, like other mental illnesses, is probably caused by a combination of biological, environmental, and social factors, but the exact causes are not yet known. For years, scientists thought that low levels of certain neurotransmitters (such as serotonin, dopamine, or norepinephrine) in the brain caused depression. However, scientists now believe that the interplay of factors leading to depression is much more complex. Genetic causes have been suggested from family studies that have shown that between 20 and 50 percent of children and adolescents with depression have a family history of depression and that children of depressed parents are more than three times as likely as children with nondepressed parents to experience a depressive disorder.44 Abnormal endocrine function, specifically of the hypothalamus or pituitary, may play a role in causing depression. Other risk factors for depressive disorders in youths include
stress,
cigarette smoking,
loss of a parent,
the breakup of a romantic relationship,
attention disorders,
learning disorders,
abuse,
neglect, and
other trauma including experiencing a natural disaster.22
Depression, like other mental illnesses, is probably caused by a combination of biological, environmental, and social factors, but the exact causes are not yet known.
Scientists have studied changes in the brain associated with depressive disorders. Imaging studies using PET have shown that brain activity in certain areas is substantially decreased in a depressed individual whereas activity in other brain regions is increased compared with the same individual after successful treatment.13 PET imaging has also shown that depressed patients have lower neurotransmitter receptor binding potential in some areas of the brain.48 Scientists looking at changes in the brains of bipolar patients found decreases in the size of the cerebellum (the part of the brain that regulates balance and controlled movements), changes in the metabolism of some chemical compounds, and a decrease in the activity of specific brain regions (prefrontal cortex) during the depression phase.42
A variety of antidepressant medications and psychotherapies are used to treat depression. The most effective treatment for most people is a combination of medication and psychotherapy.23
Many of us are aware that medications are available to treat depressive disorders—we see the ads on television and in magazines. Up to 70 percent of people with depression can be treated effectively with medication.44 Medications used to treat depressive disorders usually act on the neurotransmission pathway. For example, some medications affect the activity of certain neurotransmitters, such as serotonin or norepinephrine. Different depressive disorders require different medication therapies. For example, individuals who have bipolar disorder are often treated with a mood-stabilizing drug, such as lithium, during their manic phase and a combination of mood-stabilizer and antidepressant medications during their depressive phase.
Medications usually lead to relief from the symptoms of depression within six to eight weeks. If one drug doesn't relieve symptoms, doctors can prescribe a different antidepressant drug. As with drugs to treat other mental illnesses, patients are monitored closely by their doctor for symptoms of depression and for side effects. Patients who continue to take their medication for at least six months after recovery from major depression are 70 percent less likely to experience a relapse.1
Psychotherapy helps patients learn more effective ways to deal with the problems in their lives. These therapies usually involve 6 to 20 weekly meetings. These treatment plans should be revised if there is no improvement of symptoms within three or four months.44
The combination of medications and psychotherapy is effective in the majority of cases and represents the standard care; however, doctors can employ other methods. One therapy that is highly effective when antidepressants and psychotherapy are not effective is electroconvulsive therapy (ECT), or electroshock therapy.23 ECT is not commonly used in children and adolescents. When ECT is performed, the individual is anesthetized and receives an electrical shock in specific parts of the brain. The patient does not consciously experience the shock. ECT can provide dramatic and rapid relief, but the effects usually last a fairly short time. After ECT, individuals usually take antidepressant medications.
The combination of medications and psychotherapy is effective in the majority of cases.
A few years ago, the herbal supplement St. John's wort received great attention in the media as an over-the-counter treatment for mild to moderate depression. However, many of the claims did not have good scientific evidence to back them up. The effectiveness and safety of St. John's wort remain uncertain, and its use is generally not recommended.31
People who have depression (or another depressive disorder) feel exhausted, worthless, helpless, and hopeless. These negative thoughts and feelings that are part of depression make some people feel like giving up. As treatment takes effect, these thoughts begin to go away. Some strategies that can help a person waiting for treatment to take effect include
setting realistic goals in light of the depression and assuming a reasonable amount of responsibility;
breaking large tasks into small ones, setting some priorities, and doing what one can as one can;
trying to be with other people and to confide in someone—it is usually better than being alone and secretive;
participating in activities that may make one feel better;
getting some mild exercise, going to a movie or a ball game, or participating in religious, social, or other activities;
expecting one's mood to improve gradually, not immediately (feeling better takes time);
postponing important decisions until the depression has lifted and discussing big decisions with family or friends who have a more objective view of the situation;
remembering that positive thinking will replace the negative thinking that is part of the depression as one's depression responds to treatment; and
letting one's family and friends help.23
A potential, tragic consequence of untreated depression is suicide. In 1997, over 30,000 people in the United States died from suicide, and suicide was the third leading cause of death among 10- to 24-year-olds.22, 25 Over 90 percent of these people had a mental illness, typically either a depressive disorder or a substance-abuse disorder.25 Research from the National Institute of Mental Health estimates that as many as seven percent of adolescents who develop a major depressive disorder become victims of suicide.22
Danger signs that a teen may be considering suicide include
undergoing dramatic personality change;
giving away prized possessions;
writing notes or poems about death;
talking about suicide, even jokingly;
making comments such as, "I can't take it anymore" or "I won't be a problem for you much longer";
previously attempting suicide;
running away from home; and
having other symptoms or risk factors for depression, such as difficulty getting along with parents and friends, difficulty in school, or acting bored or withdrawn.
Children and adolescents who are suicidal report feelings of depression, anger, anxiety, hopelessness, and worthlessness. They feel helpless to change frustrating circumstances or to find a solution for their problems. In addition to depression, family conflicts and suicidal death of a relative, friend, or acquaintance are risk factors for suicide among children and adolescents.44 In the case of another person's suicide, children or teens may need intervention to prevent feelings of guilt, trauma, or social isolation. Programs offered by school professionals that address these concerns can be extremely helpful for identifying grieving youths who may need help.
Public health approaches to preventing suicide include establishing telephone crisis hot lines, restricting access to suicide methods (for example, firearms), counseling media to reduce "copycat" suicides, screening teens for risk factors of suicide, and training professionals to improve recognition and treatment of mood disorders. Research about the effectiveness of these methods indicates that the screening and training strategies are more helpful for preventing suicides among young people than the other methods are.44
Attention deficit hyperactivity disorder (ADHD) is the most commonly diagnosed behavioral disorder of childhood. In any six-month period, ADHD affects an estimated 4.1 percent of youths ages 9 to 17. Boys are two to three times more likely than girls to develop ADHD.25 Although ADHD is usually associated with children, the disorder can persist into adulthood.19 One researcher6 estimated that as many as two-thirds of the children he evaluated with ADHD continued to have the disorder in their twenties, and that many of those who no longer fit the clinical description of ADHD nonetheless had significant problems at work or in other social settings.
The three predominant symptoms of ADHD are impaired ability to regulate activity level (hyperactivity), to attend to tasks (inattention), and to inhibit behavior (impulsivity).19 Individuals who have ADHD may display predominantly hyperactive/ impulsive behavior, predominately inattentive behavior, or a combination of both. Children and adolescents with ADHD
are often unpopular among their peers,
have trouble in school,
have higher injury rates than their peers,
have difficulty paying attention to details,
are easily distracted,
find it difficult and unpleasant to finish their schoolwork,
put off things that require continued mental effort,
make careless mistakes,
are disorganized,
appear not to listen when spoken to, and
fail to follow through on tasks.18, 30, 44
The DSM-IV5 specifies several conditions in addition to the symptoms listed above before making a diagnosis of ADHD. For a diagnosis of ADHD, the behaviors must
appear before age seven,
continue for at least six months,
be more frequent or severe than in other children of the same age, and
cause dysfunction in at least two areas of life, such as school, home, work, or social settings.19
The diagnosis of ADHD can be made reliably using well-tested diagnostic interview methods. However, as of yet, there is no independent valid test for ADHD.
Among children, ADHD frequently occurs along with other learning, behavior, or mood problems such as learning disabilities, oppositional defiant disorder, anxiety disorders, and depression.
The exact causes of ADHD are unknown; however, research has demonstrated that factors that many people associate with the development of ADHD do not cause the disorder. For example, ADHD is not caused by minor head injuries, damage to the brain from complications during birth, food allergies, excess sugar intake, too much television, poor schools, or poor parenting.7, 19 No single cause of ADHD has been discovered. Rather, a number of significant risk factors affecting neurodevelopment and behavior expression have been implicated. Events such as maternal alcohol and tobacco use that affect the development of the fetal brain can increase the risk for ADHD. Injuries to the brain from environmental toxins such as lack of iron have also been implicated.
Scientists have investigated the role of the neurotransmitter dopamine in the development of ADHD because this neurotransmitter plays a key role in regulating movement, increasing motivation and alertness, and inducing insomnia. The observation that ADHD tends to run in families strongly suggests that the disease has a genetic component. Children who have ADHD usually have at least one close relative who also has the disorder.24 One group of researchers found that a child whose identical twin has ADHD is 11 to 18 times more likely to develop the disorder than a nontwin sibling.
Investigations of particular genes involved in ADHD have focused on a dopamine receptor gene (DRD) on chromosome 11 and the dopamine transporter gene (DAT1) on chromosome 5.44 Ongoing studies continue to examine these genes and others as factors in ADHD. Most likely, a combination of several genes and environmental factors determines whether a person has ADHD.
Imaging studies have shown differences in the brains of boys with ADHD compared with boys who do not have ADHD. Researchers found that certain parts of the brain are, on average, smaller in boys with ADHD.8 Other studies found that the total brain volume is smaller in girls who have ADHD than in control subjects; these results match similar findings about the brains of boys with ADHD.9 Scientists have speculated that the changes in the particular brain regions may be involved in the inability to inhibit thoughts, which is a symptom of ADHD.
A variety of medications and behavioral interventions are used to treat ADHD. The most widely used medications are methylphenidate (Ritalin), d-amphetamine, and other amphetamines. These drugs are stimulants that affect the level of the neurotransmitter dopamine at the synapse.40 Nine out of 10 children improve while taking one of these drugs.19
When used as prescribed by qualified physicians, these drugs are considered quite safe. Side effects associated with moderate doses are decreased appetite and insomnia. These side effects generally occur early in treatment and often decrease with time. Some studies have shown that the stimulants used to treat ADHD decrease growth rate, but ultimate height is not affected.
Interventions used to treat ADHD include several forms of psychotherapy, such as cognitive-behavioral therapy, social skills training, support groups, and parent and educator skills training. A combination of medication and psychotherapy is more effective than either treatment alone in improving social skills, parent-child relations, reading achievement, and aggressive symptoms.24
Treating ADHD with a combination of medication and psychotherapy is more effective than either treatment alone in improving social skills, parent-child relations, reading achievement, and aggressive symptoms.
In addition to the well-established treatments described above, some parents and therapists have tried a variety of nutritional interventions to treat ADHD. A few studies have found that some children benefit from such treatments. Nevertheless, no well-established nutritional interventions have consistently been shown to be effective for treating ADHD.24
As the symptoms indicate, ADHD interferes with a person's daily life. Treatment is available to help individuals and relieve the symptoms, but some simple strategies — including those listed below —can also help.
Asking the teacher or boss to repeat instructions (rather than guessing what they were).
Breaking large assignments or job tasks into small, simple tasks. Set a deadline for each task and give a reward as each one is completed.
Making a list of what needs to be done each day. Plan the best order for doing each task. Then make a schedule for doing them. Use a calendar or daily planner to keep on track.
Working in a quiet area. Do one thing at a time. Take short breaks.
Writing things that need to be remembered in a notebook with dividers. Carry the book at all times.
Posting notes as reminders of things to do.
Storing similar things together.
Creating a routine. Get ready for school or work at the same time, in the same way, every day.
Exercising, eating a balanced diet, and getting enough sleep.
Schizophrenia affects approximately 1 percent of the population, or 2.2 million U.S. adults. Men and women are equally affected.25, 32 The illness usually emerges in young people in their teens or twenties. Although children over the age of five can develop schizophrenia, it is rare before adolescence.21 In children, the disease usually develops gradually and is often preceded by developmental delays in motor or speech development. Childhood-onset schizophrenia tends to be harder to treat and has a less favorable prognosis than does the adult-onset form.
There are many myths and misconceptions about schizophrenia. Schizophrenia is not a multiple or split personality, nor are individuals who have this illness constantly incoherent or psychotic. Although the media often portray individuals with schizophrenia as violent, in reality, very few affected people are dangerous to others.32 In fact, individuals with schizophrenia are more likely to be victims of violence than violent themselves.
Schizophrenia has severe symptoms. A diagnosis of schizophrenia requires that at least two of the symptoms below be present during a significant portion of a one-month period:
delusions (false beliefs such as conspiracies, mind control, or persecution);
hallucinations (usually voices criticizing or commenting on the person's behavior);
disorganized speech (incomprehensible or difficult to understand);
grossly disorganized or catatonic behavior; and
negative symptoms such as flat emotions, lack of facial expressions, and inattention to basic self-care needs such as bathing and eating.5
However, the presence of either one of the first two symptoms is sufficient to diagnose schizophrenia if the delusions are especially bizarre or if the hallucinations consist of one or more voices that keep a running commentary on the person's behavior or thoughts.5
The DSM-IV specifies additional criteria for a diagnosis of schizophrenia:
social or occupational dysfunction,
persistence of the disturbance for at least six months,
exclusion of a mood disorder,
exclusion of a substance-abuse or medical condition that causes similar symptoms, and
consideration of a possible pervasive developmental disorder.44
The course of schizophrenia varies considerably from one individual to the next. Most people who have schizophrenia experience at least one, and usually more, relapses after their first psychotic episode.32 Relapses are periods of more intense symptoms of illness (hallucinations and delusions). During remissions, the negative symptoms related to emotion or personal care are usually still present. About 10 percent of patients remain severely ill for long periods of time and do not return to their previous state of mental functioning. Several long-term studies found that as many as one-third to one-half of people with schizophrenia improve significantly or even recover completely from their illness.44
Like the other mental illnesses discussed here, scientists are still working to determine what causes schizophrenia. Also like the other mental illnesses, genetic and environmental factors most likely interact to cause the disease. Several studies suggest that an imbalance of chemical neurotransmitter systems of the brain, including the dopamine, GABA, glutamate, and norepinephrine neurotransmitter systems, are involved in the development of schizophrenia.20, 36
Family, twin, and adoption studies support the idea that genetics plays an important role in the illness. For example, children of people with schizophrenia are 13 times more likely, and identical twins are 48 times more likely, to develop the illness than are people in the general population.44 Scientists continue to look at genes that may play a role in causing schizophrenia. One gene of interest to scientists who study schizophrenia codes for an enzyme that breaks down dopamine in the synapse.12 Investigations to confirm the role of this and other genes are ongoing.
Imaging studies have revealed differences in brain structure and function in individuals with schizophrenia compared with control individuals. Brain imaging studies show that young people who have schizophrenia have structural differences in their brains compared with individuals who do not have schizophrenia. These changes include a reduced total volume of the cerebrum (the upper portion of the brain, which is divided into halves), a reduced amount of gray matter (the tissue that makes up a majority of the brain and consists mainly of neuron cell bodies and dendrites), enlarged brain ventricles (the cavities, or spaces, in the brain that are filled with cerebrospinal fluid), and other abnormalities.38, 39, 41 PET scans of identical twins have revealed that the twin with schizophrenia has lower brain activity in the frontal lobes (the front section of the cerebral lobes) than does the twin who does not have schizophrenia.47 One group of researchers used MRI to periodically scan the brains of teens with childhood-onset schizophrenia and an age-matched control group over a five-year period. They found that teens with schizophrenia lose four times the amount of neurons in a specific region of the brain that teens in the control group lose.43
There is no cure for schizophrenia; however, effective treatments that make the illness manageable for most affected people are available. The optimal treatment includes antipsychotic medication combined with a variety of psychotherapeutic interventions.44
Since the 1950s, doctors have used antipsychotic drugs, such as chlorpromazine and haloperidol, to relieve the hallucinations and delusions typical of schizophrenia. Recently, newer (also called atypical) antipsychotic drugs such as risperidone and clozapine have proven to be more effective. Early and sustained treatment that includes antipsychotic medication is important for long-term improvement of the course of the disease. Patients who discontinue medication are likely to experience a relapse of their illness.32
People who manage schizophrenia best combine medication with psychosocial rehabilitation (life-skills training).17 Therapies that combine family and community support, education, and behavioral and cognitive skills to address specific challenges help schizophrenic patients improve their functioning and the quality of their lives.
The optimal treatment for schizophrenia includes antipsychotic medication and psychotherapy.
As a teacher, you may occasionally have students who show symptoms of or who have significant risk factors for a mental illness. A first step for helping these students is to contact the school nurse or guidance counselor. These individuals should know the appropriate next steps to take, including directing the student's parents or guardians to contact their physician or their city or county mental health services.
If you think a friend or colleague might have a mental illness, encourage him or her to see a physician. Physicians can make referrals to mental health specialists in the community. In addition, your state or county health departments may offer services for people struggling with a mental illness. The National Mental Health Association has an affiliate network throughout the country. The programs offered by the NMHA affiliates include support groups, public education and advocacy campaigns, rehabilitation, and housing services. You can access the NMHA's affiliate network through its Web site: //www.nmha.org/nav/section/affiliate.cfm.
The Additional Resources for Teachers section describes other online resources about mental illnesses (page 53).
1.
Agency for Health Care Policy and Research. Treatment of depression—newer pharmacotherapies. Summary, Evidence Report/Technology Assessment, Number 7. 1999. Retrieved June 27, 2001, from //www.ahcpr.gov/clinic/deprsumm.htm.
2.3.4.5.American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Press; 2000.
6.7.8.Castellanos FX, Giedd JN, Marsh WL, Hamburger SD, Vaituzis AC, Dickstein DP, Sarfatti SE, Vauss YC, Snell JW, Lange N, Kaysen D, Krain AL, Ritchie GF, Rajapakse JC, Rapoport JL. Quantitative brain magnetic resonance imaging in attention-deficit hyperactivity disorder. Archives of General Psychiatry. 1996;53:607–616. [PubMed: 8660127]
9.Castellanos FX, Giedd JN, Berquin PC, Walter JM, Sharp W, Tran T, Vaituzis AC, Blumenthal JD, Nelson J, Bastain TM, Zijdenbos A, Evans AC, Rapoport JL. Quantitative brain magnetic resonance imaging in girls with attention-deficit/hyperactivity disorder. Archives of General Psychiatry. 2001;58:289–295. [PubMed: 11231836]
10.Commission on Behavioral and Social Sciences Education, National Research Council. How People Learn: Brain, Mind, Experience, and School. Washington, DC: National Academies Press; 2000.
11.Corrigan P, Lundin R. Don’t Call Me Nuts. Tinley Park, IL: Recovery Press; 2001.
Egan MF, Goldberg TE, Koachana BS, Callicott JH, Mazzanti CM, Straub RE, Goldman D, Weinberger DR. Effect of COMT Val 108/158 Met genotype on frontal lobe function and risk for schizophrenia. Proceedings of the National Academy of Sciences USA. 2001;98:6917–6922. [PMC free article: PMC34453] [PubMed: 11381111]
13.14.15.Joint Committee on National Health Education Standards. National Health Education Standards: Achieving Health Literacy. Atlanta, GA: American Cancer Society; 1995.
16.Loucks-Horsley S, Love N, Hewson PW, Stiles KE. Designing Professional Development for Teachers of Science and Mathematics. Thousand Oaks, CA: Corwin Press; 1998.
17.18.19.20.21.22.23.24.National Institute of Mental Health. NIMH research on treatment for attention deficit hyperactivity disorder (ADHD): The multimodal treatment study—questions and answers. 2000c. Retrieved June 27, 2001, from //www.nimh.nih.gov/events/mtaqa.cfm.
25.26.27.28.29.30.31.32.33.34.35.National Research Council. National Science Education Standards. Washington, DC: National Academies Press; 1996.
36.Pearlson GD. Neurobiology of schizophrenia. Annals of Neurology. 2000;48:556–566. [PubMed: 11026439]
37.38.Rapoport JL, Castellanos FX, Gogate N, Janson K, Kohler S, Nelson P. Imaging normal and abnormal brain development: New perspectives for child psychiatry. Australian and New Zealand Journal of Psychiatry. 2001;35:272–281. [PubMed: 11437799]
39.Rapoport JL, Giedd J, Kumra S, Jacobsen L, Smith A, Lee P, Nelson J, Hamburger S. Childhood-onset schizophrenia. Progressive ventricular change during adolescence. Archives of General Psychiatry. 1997;54:897–903. [PubMed: 9337768]
40.Ratey J. An update on medications used in the treatment of attention deficit disorder. FOCUS Archives, National Attention Deficit Disorder Association. 1998. Retrieved July 8, 2001, from //www.add.org/images2/medupdate.htm.
41.Sowell ER, Toga AW, Asarnow R. Brain abnormalities observed in childhood-onset schizophrenia: A review of the structural magnetic resonance imaging literature. Mental Retardation and Developmental Disabilities Research Review. 2000;6:180–185. [PubMed: 10982495]
42.Stoll AL, Renshaw PF, Yurgelun-Todd DA, Cohen BM. Neuroimaging in bipolar disorder: What have we learned? Biological Psychiatry. 2000;15:505–517. [PubMed: 11018223]
43.Thompson PM, Vidal C, Giedd JN, Gochman P, Blumenthal J, Nicolson R, Toga AW, Rapoport JL. Mapping adolescent brain change reveals dynamic wave of accelerated gray matter loss in very early-onset schizophrenia. Proceedings of the National Academy of Sciences USA. 2001;98:11650–11655. [PMC free article: PMC58784] [PubMed: 11573002]
44.45.46.47.48.Yatham LN, Liddle PF, Shiah IS, Scarrow G, Lam RW, Adam MJ, Zis AP, Ruth TJ. Brain serotonin2 receptors in major depression: A positron emission tomography study. Archives of General Psychiatry. 2000;57:850–858. [PubMed: 10986548]
accrued deficits
The delays or lack of development in emotional, social, academic, or behavioral skills that a child or adolescent experiences because of untreated mental illness. The mental illness keeps the individual from developing these life skills at the usual stage of life. An individual may never fully make up for these deficiencies.
acuteRefers to a disease or condition that has a rapid onset, marked intensity, and short duration.
antidepressantA medication used to treat depression.
anxietyAn abnormal sense of fear, nervousness, and apprehension about something that might happen in the future.
anxiety disorderAny of a group of illnesses that fill people's lives with overwhelming anxieties and fears that are chronic and unremitting. Anxiety disorders include panic disorder, obsessive-compulsive disorder, post-traumatic stress disorder, phobias, and generalized anxiety disorder.
attention deficit disorder (ADD)See attention deficit hyperactivity disorder.
attention deficit hyperactivity disorder (ADHD)A mental illness characterized by an impaired ability to regulate activity level (hyperactivity), attend to tasks (inattention), and inhibit behavior (impulsivity). For a diagnosis of ADHD, the behaviors must appear before an individual reaches age seven, continue for at least six months, be more frequent than in other children of the same age, and cause impairment in at least two areas of life (school, home, work, or social function).
autismA mental illness that typically affects a person's ability to communicate, form relationships with others, and respond appropriately to the environment. Some people with autism have few problems with speech and intelligence and are able to function relatively well in society. Others are mentally retarded or mute or have serious language delays. Autism makes some people seem closed off and shut down; others seem locked into repetitive behaviors and rigid patterns of thinking.
axonThe long, fiberlike part of a neuron by which the cell carries information to target cells.
bipolar disorderA depressive disorder in which a person alternates between episodes of major depression and mania (periods of abnormally and persistently elevated mood). Also referred to as manic-depression.
cerebrumThe upper part of the brain that consists of the left and right hemispheres.
chronicRefers to a disease or condition that persists over a long period of time.
cognitionConscious mental activity that informs a person about his or her environment. Cognitive actions include perceiving, thinking, reasoning, judging, problem solving, and remembering.
conduct disorderA personality disorder of children and adolescents involving persistent antisocial behavior. Individuals with conduct disorder frequently participate in activities such as stealing, lying, truancy, vandalism, and substance abuse.
delusionA false belief that persists even when a person has evidence that the belief is not true.
dendriteThe specialized fibers that extend from a neuron's cell body and receive messages from other neurons.
depression (depressive disorders)A group of diseases including major depressive disorder (commonly referred to as depression), dysthymia, and bipolar disorder (manic-depression). See bipolar disorder, dysthymia, and major depressive disorder.
Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV)A book published by the American Psychiatric Association that gives general descriptions and characteristic symptoms of different mental illnesses. Physicians and other mental health professionals use the DSM-IV to confirm diagnoses for mental illnesses.
diseaseA synonym for illness. See illness.
disorderAn abnormality in mental or physical health. In this module, disorder is used as a synonym for illness.
dysthymiaA depressive disorder that is less severe than major depressive disorder but is more persistent. In children and adolescents, dysthymia lasts for an average of four years.
electroconvulsive therapy (ECT)A treatment for severe depression that is usually used only when people do not respond to medications and psychotherapy. ECT involves passing a low-voltage electric current through the brain. The person is under anesthesia at the time of treatment. ECT is not commonly used in children and adolescents.
electroencephalography (EEG)A method of recording the electrical activity in the brain through electrodes attached to the scalp.
electroshock therapySee electroconvulsive therapy.
frontal lobeOne of the four divisions of each cerebral hemisphere. The frontal lobe is important for controlling movement and associating the functions of other cortical areas.
gray matterThe portion of brain tissue that is dark in color. The gray matter consists primarily of nerve cell bodies, dendrites, and axon endings.
hallucinationThe perception of something, such as a sound or visual image, that is not actually present other than in the mind.
hypothalamusThe part of the brain that controls several body functions, including feeding, breathing, drinking, temperature, and the release of many hormones.
illnessA problem in which some part or parts of the body do not function normally, in a way that interferes with a person's life. For the purpose of this module, other terms considered to be synonyms for illness include disease, disorder, condition, and syndrome.
magnetic resonance imaging (MRI)An imaging technique that uses magnetic fields to take pictures of the structure of the brain.
major depressive disorderA depressive disorder commonly referred to as depression. Depression is more than simply being sad; to be diagnosed with depression, a person must have five or more characteristic symptoms nearly every day for a two-week period.
maniaFeelings of intense mental and physical hyperactivity, elevated mood, and agitation.
manic-depressionSee bipolar disorder.
mental illnessA health condition that changes a person's thinking, feelings, or behavior (or all three) and that causes the person distress and difficulty in functioning.
mental retardationA condition in which a person has an IQ that is below average and that affects an individual's learning, behavior, and development. This condition is present from birth.
myelinA fatty material that surrounds and insulates the axons of some neurons.
neuron (nerve cell)A unique type of cell found in the brain and body that processes and transmits information.
neurosisA term no longer used medically as a diagnosis for a relatively mild mental or emotional disorder that may involve anxiety or phobias but does not involve losing touch with reality.
neurotransmissionThe process that occurs when a neuron releases neurotransmitters that relay a signal to another neuron across the synapse.
neurotransmitterA chemical produced by neurons that carries messages to other neurons.
obsessive-compulsive disorder (OCD)An anxiety disorder in which a person experiences recurrent unwanted thoughts or rituals that the individual cannot control. A person who has OCD may be plagued by persistent, unwelcome thoughts or images or by the urgent need to engage in certain rituals, such as hand washing or checking.
oppositional defiant disorderA disruptive pattern of behavior of children and adolescents that is characterized by defiant, disobedient, and hostile behaviors directed toward adults in positions of authority. The behavior pattern must persist for at least six months.
panic disorderAn anxiety disorder in which people have feelings of terror, rapid heart beat, and rapid breathing that strike suddenly and repeatedly with no warning. A person who has panic disorder cannot predict when an attack will occur and may develop intense anxiety between episodes, worrying when and where the next one will strike.
phobiaAn intense fear of something that poses little or no actual danger. Examples of phobias include fear of closed-in places, heights, escalators, tunnels, highway driving, water, flying, dogs, and injuries involving blood.
pituitary glandAn endocrine organ closely linked with the hypothalamus. The pituitary secretes a number of hormones that regulate the activity of other endocrine organs in the human body.
positronA positively charged particle that has the same mass and spin as—but the opposite charge of—an electron.
positron emission tomography (PET)An imaging technique for measuring brain function in living subjects by detecting the location and concentration of small amounts of radioactive chemicals.
postsynaptic neuronThe neuron that receives messages from other neurons.
presynaptic neuronThe neuron that sends messages to other neurons by releasing neurotransmitters into the synapse.
psychiatristA medical doctor (M.D.) who specializes in treating mental diseases. A psychiatrist evaluates a person's mental health along with his or her physical health and can prescribe medications.
psychiatryThe branch of medicine that deals with identifying, studying, and treating mental, emotional, and behavioral disorders.
psychologistA mental health professional who has received specialized training in the study of the mind and emotions. A psychologist usually has an advanced degree such as a Ph.D.
psychosisA serious mental disorder in which a person loses contact with reality and experiences hallucinations or delusions.
psychotherapyA treatment method for mental illness in which a mental health professional (psychiatrist, psychologist, counselor) and a patient discuss problems and feelings to find solutions. Psychotherapy can help individuals change their thought or behavior patterns or understand how past experiences affect current behaviors.
receptorA molecule that recognizes specific chemicals, including neurotransmitters and hormones, and transmits the message into the cell on which the receptor resides.
relapseThe reoccurrence of symptoms of a disease.
reuptake pumpThe large molecule that carries neurotransmitter molecules back into the presynaptic neuron from which they were released. Also referred to as a transporter.
riskThe chance or possibility of experiencing harm or loss.
risk factorSomething that increases a person's risk or susceptibility to harm.
schizophreniaA chronic, severe, and disabling brain disease. People with schizophrenia often suffer terrifying symptoms such as hearing internal voices or believing that other people are reading their minds, controlling their thoughts, or plotting to harm them. These symptoms may leave them fearful and withdrawn. Their speech and behavior can be so disorganized that they may be incomprehensible or frightening to others.
selective serotonin reuptake inhibitors (SSRIs)A group of medications used to treat depression. These medications cause an increase in the amount of the neurotransmitter serotonin in the brain.
serotoninA neurotransmitter that regulates many functions, including mood, appetite, and sensory perception.
single photon emission computed tomography (SPECT)A brain imaging process that measures the emission of single photons of a given energy from radioactive tracers in the human body.
stigmaA negative stereotype about a group of people.
St. John's wortAn herb sometimes used to treat mild cases of depression. Although the popular media have reported successes using St. John's wort, it is not a recommended treatment. The scientific evidence for its effectiveness and safety is not conclusive.
symptomSomething that indicates the presence of a disease.
synapseThe site where presynaptic and postsynaptic neurons communicate with each other.
synaptic spaceThe intercellular space between a presynaptic and postsynaptic neuron. Also referred to as the synaptic cleft.
syndromeA group of symptoms or signs that are characteristic of a disease. In this module, the word syndrome is used as a synonym for illness.
transporterA large protein on the cell membrane of axon terminals. It removes neurotransmitter molecules from the synaptic space by carrying them back into the axon terminal that released them. Also referred to as the reuptake pump.
ventricleOne of the cavities or spaces in the brain that are filled with cerebrospinal fluid.
vesicleA membranous sac within an axon terminal that stores and releases neurotransmitters.
1
Relevant to Lessons 1, 2, and 5
23Relevant to Lessons 2, 3, 4, and 5.
4Relevant to Lessons 1, 2, and 4.
5Relevant to Lessons 2, and 3.
6Relevant to Lessons 4 and 5.
7Relevant to Lessons 1, 2, 3, 4, and 5.
8Relevant to Lessons 4 and 5.
9Relevant to Lessons 2, 3, 4, 5, and 6.
10In this module, the term depression refers to major depressive disorder. We will use the terms dysthymia and bipolar disorder specifically when we are referring to those types of depressive disorders.
11Relevant to Lessons 1, 2, 3, 4, 5, and 6.