The cardinal feature of major depression is a period of at least 1 month of sad, blue, depressed mood which is pervasive, occurring most of the day, every day, and/or loss of interest or pleasure in all or almost all activities.
At least three or four of the following associated features should also be present for a diagnosis of major depression:
Insomnia or increased sleep
Loss of appetite, weight loss, or increased appetite and weight gain
Low energy, persistent fatigue
Low self-esteem, guilt, feelings of worthlessness
Agitation or a slowed-down demeanor, noticeable to people who know the patient well
When left untreated, major depression may eventually resolve spontaneously.
However, it is also associated with significant role impairment, such as inability to function at home or work, and also substantially increases the risk for suicide.
Antidepressant medications of the tricyclic type (e.g., desipramine, nortriptyline or imipramine) or the serotonin reuptake inhibitor type (fluoxetine [Prozac], sertraline[Zoloft]) are probably the treatments of choice.
They should be used by experienced clinicians and carefully monitored as there is an increased risk of adverse drug interactions in outpatients who are actively abusing stimulants.
Methadone impairs the metabolism of tricyclics and results in increased tricyclic blood levels which may be dangerous; blood level monitoring is recommended.
Fluoxetine, but not sertraline, impairs the metabolism of a variety of drugs metabolized by cytochrome P450, including some drugs of abuse.
Psychotherapy may also be helpful in the treatment of major depression.
Specifically, cognitive therapy (Beck 1979) and interpersonal therapy (Klerman et al. 1984) have been tested and found effective.
This is a type of depression that includes the same symptoms as major depression and is milder but chronic.
The typical patient is sad and depressed at least half the time for at least 2 years.
Sometimes patients will report this pattern for many years or for their entire lifetime.
Like major depression, dysthymia responds to psychotherapy or antidepressant medication.
Although the milder symptoms have historically caused many clinicians to avoid medication treatment, medication is effective and should be tried, especially if psychotherapy fails.
This is a relatively rare affective disorder in which patients experience both major depressive episodes and manic episodes.
Manic episodes are periods of days to weeks or longer of a markedly altered mood which may be euphoric or irritable, accompanied by characteristic symptoms including grandiose feelings of being endowed with special powers or talents, decreased need for sleep, enormous amounts of energy despite lack of sleep, talking constantly, and high physical activity.
In more severe episodes, judgment is impaired or patients may develop a paranoid psychosis that is similar to that of acute schizophrenia or severe stimulant abuse (see below).
The course is one of alternating episodes of depression and mania.
Patients may function well between episodes but the episodes themselves can be highly disruptive to social and occupational functioning.
The risk of suicide is increased.
Increased levels of drug use may occur during either depressive or manic phases.
Bipolar disorder acutely responds to neuroleptics and can be successfully managed chronically with lithium or, failing that, one of several other mood stabilizing drugs (carbamazepine [Tegretol], valproic acid).
A history of Conduct Disorder during childhood or adolescence is the first cardinal feature of this disorder.
This involves a persistent pattern, prior to age 15, of breaking the rules (e.g., truancy, lying, stealing, fighting), disregard for the rights of others, and/or outright cruelty to others (e.g., torturing animals, deliberately doing physical harm to another person, forced sex).
The second cardinal feature of this disorder is a continued pattern during adulthood of illegal activity, irresponsibility, unstable personal relationships, disregard for the rights of others, or cruelty to others during adulthood.
Care in making this diagnosis is needed since it can easily be confused with the illegal activity frequently engaged in by drug users to support their habits.
The latter group's illegal activity should decrease as treatment for drug abuse results in improvement.
Antisocial personality is associated with poor outcome in substance abuse treatment.
However, some recent research suggests that patients show improvement during treatment, yet outcomes still appear less successful because of their poorer baseline beginning (Woody et al. 1991; 1985).
Panic Disorder is characterized by the frequent occurrence (at least weekly for a month or more) of panic attacks.
These are episodes which occur suddenly, reaching a peak of intensity in just a few minutes, and which often seem to occur spontaneously without any frightening circumstance.
There is a feeling of fear, terror, or panic accompanied by a constellation of characteristic physical symptoms including shortness of breath, chest tightness or pain, heart pounding, upset stomach, an urge to flee, and a feeling that one is dying or becoming terribly ill.
Panic attacks often prompt emergency room visits.
Care is required in making the diagnosis since heavy stimulant abuse can mimic panic attacks.
Panic Disorder often co-occurs with depressive disorders and may increase the risk of suicide.
Alcohol and benzodiazepines may temporarily relieve panic, and consequent abuse of these substances may be observed.
Panic disorder often leads to agoraphobia (see below).
Panic Disorder may be treated with cognitive/behavioral techniques including deep muscle relaxation, breathing exercises, and self-talk in which the patient is trained to reassure himself or herself that the attack is not serious and will pass.
Panic Disorder also responds to the same antidepressant medications as major depression.
Benzodiazepines may also be effective in treating the symptoms but are to be avoided or used with extreme caution because of their addictive potential in this population.
Agoraphobia is a persistent fear of one or several characteristic situations, including leaving the house, closed-in spaces (such as stores, theatres, or elevators), heights, bridges, tunnels, buses, or subways.
Usually associated with panic attacks, it can lead to substantial functional impairment since patients go out of their way to avoid the feared situations and may be unable to shop, commute to work, or even stay at the workplace.
As with panic disorder, alcohol and sedatives provide relief and their abuse may be observed.
Social phobia is a strong fear of doing things in front of other people or groups, particularly speaking, but sometimes also writing or eating.
The feared situation, such as speaking in a group, consistently triggers an intense physical fear reaction including sweating, heart pounding, or stomach upset.
This phobia is often lifelong and its onset in childhood or adolescence can be elicited.
For example, a patient may report having been fearful to raise his or her hand or be called on in school.
This phobia is often chronic.
Social life and work may be impaired.
For example, a patient may avoid promotions at work for fear of needing to participate in group activities.
A major treatment implication of social phobia is that self-help groups and other group- oriented treatments may be frightening and untenable.
Less is known about treatment of social phobia.
Cognitive behavioral treatments such as relaxation and progressive desensitization should be tried.
Pharmacotherapies that may be helpful include propranolol (Inderal) and other "beta-blockers," which are commonly used to treat hypertension and seem to block the physical aspects of the fear reaction, and antidepressants.
As with other anxiety disorders, benzodiazepines will relieve the symptoms but should be avoided under most circumstances due to the abuse potential.
The cardinal features of PTSD are a history of severe traumatic events (such as combat or being beaten or raped), followed by recurrent nightmares and vivid daytime flashbacks with an experience of reliving the trauma.
The cardinal feature of ADHD is an early childhood (elementary school) history of difficulty with attention and concentration.
This is often reflected as trouble at school, either for not paying attention or for being restless and disruptive in class.
The adult syndrome involves continued restlessness and difficulty concentrating which may impair work and relationships.
Some children outgrow this disorder, but a third to a half will continue to display symptoms into adulthood.
Stimulants such as methylphenidate (Ritalin) are the treatment of choice in childhood, and self-medication with amphetamines or cocaine during adulthood may occur.
Stimulant treatment in adulthood is potentially effective but carries the obvious risk of worsened abuse in a narcotic/stimulant abusing population.
Tricyclic antidepressants such as desipramine or nortriptyline are also effective and do not carry the risk of addiction.
Occupational therapy or vocational training to help patients cope with their attention deficits may also be helpful.
The cardinal features of schizophrenia are persistent paranoid or bizarre delusions, auditory hallucinations (hearing voices), or other perceptual symptoms such as a feeling of receiving messages from appliances.
Severe stimulant abuse will cause a paranoid psychosis that is indistinguishable from schizophrenia, except that it should resolve within days to weeks of cessation of stimulants.
There is almost always substantial impairment of social and work functioning.
The course is often one of inexorable deterioration unless treated.
Patients often develop so-called "negative symptoms" which resemble depression and include loss of interest or pleasure and blunted affect.
Schizophrenics may be drawn to stimulant abuse because it temporarily ameliorates this negative state.
Neuroleptics ("major tranquilizers") such as haloperidol (Haldol) and chlorpromazine (Thorazine) are the mainstay of treatment together with a supportive psychosocial intervention.
These patients often come across as odd and isolated and are not likely to fit in well in standard drug abuse programs.
Programs specially tailored for the drug-abusing schizophrenic are more appropriate but may be rare in many locales.
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