By Godswill Boni, PharmD
Mental illness includes a wide range of thinking, emotion, and/or behavior disorders. There are many types of mental illness, and their duration can be short- or long-term. Sometimes it can be difficult to distinguish between a genuine mental illness or life’s worry or sadness. However, in general, the symptoms of mental illness can be more severe, lasts longer, and significantly affects a person’s ability to cope with life.
Mental disorders remain among the top ten leading causes of health burden worldwide, and their prevalence has increased over the past three decades. Mental illness comes in many forms, including anxiety, depression, and personality disorders. Many prominent people, including former U.S. presidents and celebrities, have lived with mental health disorders. In this blog, we will look at three common mental disorders — depression, schizophrenia, and bipolar — their causes, symptoms, diagnosis, and treatment.
DEPRESSION
Depressive disorders, also known as Major Depressive Disorder, are among the most common health conditions globally. People with depression suffer from persistent feelings of hopelessness, dejection, constant worry, poor concentration, a lack of energy, inability to sleep, and, sometimes, suicidal tendencies.
The statistics show that more women than men are affected by depression. The World Health Organization estimated that 5% of adults worldwide suffer from depression. About half of those with a first episode of depression recover and experience no further episodes. The remainder will experience persistent or recurrent depression; the risk of recurrence increases with each episode.
What causes depression?
The causes of depression are poorly understood but are thought to be complex, involving a combination of genetic, biological, and environmental factors, including stress. Certain drugs can also cause or worsen depression. These include beta-blockers, corticosteroids and benzodiazepine hypnotics. Neurotransmitters believed to be involved in depression include serotonin, dopamine, and norepinephrine.
How is depression diagnosed?
The diagnosis of depression can be difficult because it is not possible to measure brain chemical imbalances, and there are no specific tests. Diagnosis relies on symptom assessment. The Hamilton Depression Rating Scale (HDRS), also known as the Ham-D, is the most widely used depression assessment scale. Patients rate their symptoms on a numerical scale, and diagnosis is based on the total score. The Cleveland Clinic provides a guide to diagnosing Persistent depressive disorder and Clinical depression (major depressive disorder). According to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria, the diagnosis requires at least five of the following symptoms (even if they are in response to a significant loss like bereavement or financial ruin) during the same two-week period. These include:
- Mood- depressed
- Sleep – Increased/decreased
- Interest/pleasure – diminished
- Guilt or feelings of worthlessness
- Energy-decreased
- Concentration- decreased
- Appetite- Increased/decreased
- Psychomotor agitation or retardation
- Suicidal ideation
Various resources are available from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR)
How is depression treated?
Treatment of depression depends on its severity. For mild depression, psychotherapy or medications can be effective. Individuals with moderate to severe depression generally require medications and psychotherapy. The initial choice of drugs should be based on the side effect profile, safety concerns, and patient-specific symptoms.
For most patients, the treatment of clinical depression starts with selective serotonin reuptake inhibitors (SSRI) or serotonin noradrenaline reuptake inhibitors. When depression occurs concurrently with another psychological condition, such as bipolar disorder, the drug considerations include mirtazapine or bupropion. Patient history is critical when selecting treatment for mental illnesses; what did or did not work in the past should help guide therapy.
Non-pharmacological treatment options that have been shown to reduce depressive symptoms include; St John’s wort, SAMe (S-adenosyl-L-methionine), and valerian.
Depression in pregnancy and postpartum
Depression in pregnant women often goes unrecognized and untreated. However, untreated maternal depression during pregnancy, especially in the late second or early third trimesters, is associated with increased rates of adverse outcomes (e.g., premature birth, low birth weight, fetal growth restriction, and post-natal complications).
The American College of Obstetricians and Gynecologists (ACOG) guidelines for mild depression in pregnancy recommend psychotherapy first, followed by drug treatment if needed. Breastfeeding is beneficial for most women for physical and emotional symptoms and is also beneficial for the baby. Drug safety in breastfeeding is essential. SSRIs or tricyclics are generally preferred (except for doxepin, per the ACOG recommendations). Brexanolone (Zulresso) is the first drug FDA-approved for postpartum depression. The drug is given as a continuous IV infusion over 60 hours (two and a half days) and can cause excessive sedation.
SCHIZOPHRENIA
Schizophrenia is a disorder that affects a person’s behaviour, including how they think, feel and act. The World Health Organization estimates that about 24 million people, or 1 in 300 people (0.32%) worldwide, are affected with schizophrenia, and specifically among adults, the rate is 0.45%.
What causes schizophrenia?
The exact cause of schizophrenia isn’t known, but a combination of factors is thought to play a role, including genetics, environment, altered brain chemistry, neurotransmitters, and structure. Urban living, poverty, childhood trauma, neglect, and prenatal infections are all risk factors for schizophrenia. Patients with schizophrenia have increased dopamine levels and may also have changes in glutamate levels. Dopamine and glutamate modulate each other, but the role of glutamate in schizophrenia is not well understood. Genetics, environment, stressors, and some drugs can also be contributing factors.
How is schizophrenia diagnosed?
When diagnosing schizophrenia, clinicians consider a combination of factors, including family history and positive and negative symptoms. The Cleveland Clinic provides a guide to schizophrenia diagnosis. According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), a schizophrenia diagnosis requires
- At least two of the five main symptoms (hallucinations, disorganized/incoherent speaking, disorganized/unusual movements, delusions, and negative symptoms)
- Symptoms must last for at least one month and be sufficient to disrupt social interactions or occupation.
How is schizophrenia treated?
Antipsychotics are drugs that are mainly used which primarily block dopamine receptors. Newer antipsychotic agents also block serotonin, and other receptors thought to be involved in schizophrenia. The drug side effects have an important role in selecting the initial treatment. First-generation antipsychotics (including chlorpromazine, fluphenazine, haloperidol, and perphenazine) tend to have neurologic side effects. Second-generation antipsychotics have a lower risk of extrapyramidal side effects. Second-generation antipsychotics include; aripiprazole, risperidone, clozapine, olanzapine, and lurasidone. Some patients, however, do very well on first-generation antipsychotics, and for such patients, there is no need to switch them to second-generation antipsychotics.
BIPOLAR DISORDER
Bipolar disorder manifests as fluctuation in mood, from an extremely sad or hopeless state of depression to an abnormally elevated, overexcited, or irritable mood called mania or hypomania.
A mood episode with symptoms of mania and depression is called a mixed state. Bipolar disorder is classified as bipolar I or bipolar II, which differ primarily by the severity of the mania the patient experience. Another milder form is called “cyclothymic disorder,” where the criteria for depression or mania are not fully met.
Available data suggest that the lifetime worldwide prevalence of bipolar disorder is around 1%, and the rate is higher for bipolar I than for bipolar II disorders. Bipolar disorder can lead to problems with relationships and employment and disrupt lives. In addition, it can lead to anxiety disorders, drug abuse, and suicide.
What causes bipolar disorder?
The exact cause of the bipolar disorder is unknown, and a combination of factors is involved. Heredity is thought to play a significant role. There is also evidence of dysregulation of the neurotransmitters serotonin, norepinephrine, and dopamine. Stressful life events are often associated with the initial development of symptoms and later exacerbations, although cause and effect have not been established. Some drugs can trigger exacerbations in some patients with bipolar disorder; these include:
- Sympathomimetics (e.g., cocaine, amphetamines)
- Alcohol
- Certain antidepressants
How is bipolar disorder diagnosed?
A combination of tests is used to diagnose bipolar disorder, including a physical exam and medical history, mental health evaluation, blood or urine tests to exclude causal drugs, and tests to exclude hyperthyroidism.
According to Dr. Joel Agorinya, a psychiatrist at the Accra Psychiatry hospital, “in the latest guidelines (the 11th revision of the International Classification of Diseases (ICD‐11) and the DSM-5), a single manic episode is sufficient to make a diagnosis of bipolar disorder. Thus, mania without a history of depression equals bipolar disorder.” Dr. Agorinya clarified, “in the past, it was either mania with depression or two or more episodes of mania before a diagnosis of bipolar disorder can be made, but this has changed.” A comparison of the ICD-11 and DSM-5 is available here and here.
The Cleveland Clinic provides a guide to diagnosing bipolar disorder. The DSM-5 diagnostic criteria for bipolar disorder states that the presence of three or more of the following symptoms are required for diagnosis.
- Inflated self-esteem
- Sleeping less
- Talkative
- Jumping from one topic to the next
- Easily distracted
- Increase in goal-directed activity
- Involved with high-risk, pleasurable activities (e.g., Buying sprees, sexual promiscuity, gambling)
How is bipolar disorder treated?
Drugs include mood stabilizers such as lithium, valproate, lamotrigine, and carbamazepine. Specific antidepressants (e.g., selective serotonin reuptake inhibitors) are sometimes added for severe depression. Ketamine infusion has also been effective in treating severe bipolar depression.
“In Ghana, the mood stabilizers available for managing the manic phase of patients with bipolar disorder include carbamazepine, valproate, and lamotrigine. They are used either alone or with antipsychotics such as risperidone, olanzapine, haloperidol, and chlorpromazine,” said Dr. Agorinya.
“Additionally, for bipolar patients in the depressive phase, we manage them with lamotrigine, oral. One might give benzodiazepines in the depressive stage if there is insomnia. Still, we don’t use benzodiazepines in the depressive stage because these people are usually of low energy and very calm. Benzodiazepines (lorazepam and diazepam) are withdrawn as soon as the patient is calm, but this should be done by slowly tapering the dose.”
Dr. Agorinya explained that according to the standard treatment guidelines used in Ghana, oral lithium is given at the appropriate dose to adults and children as maintenance management of both the acute manic phase and the acute depressive phase. Lithium levels should be monitored 12 hours after the dose, then twice weekly until the condition stabilizes, then once every month.
Other treatments for bipolar disorder include:
- Electroconvulsive therapy (ECT) is sometimes used for depression refractory to treatment and is also effective for mania.
- Phototherapy can be useful in treating depressive symptoms of seasonal or non-seasonal bipolar I or bipolar II disorder.
- Transcranial magnetic stimulation sometimes used to treat severe, resistant depression, has also proven effective in bipolar depression.
- Cognitive behavioral therapy
- Education and psychotherapy.
Bottom line
Mental illness, including depression schizophrenia and bipolar disorder, is a serious chronic disorder, and is among the top ten leading causes of health burden worldwide. Mental illness can be diagnosed and effectively treated. There is a need for education of the public on mental health and mental illness by health professionals. Knowledge of mental health and its appropriate treatment improves the quality of life. It also removes the stigma attached to mental health.
For more about mental disorders published by the World Health Organization, click here; for the World Mental Health report, click here; and for different types of mental health treatment, including questions to ask a doctor, click here.
Where available, it is advised to follow the Ministry of Health guidelines in your local setting.
Godswill Boni, PharmD, is a multi-talented pharmacist who loves health blogging and medical writing. You can reach him here.
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