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Bipolar disorder

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  • Acquired immunodeficiency syndrome (AIDS), antidepressants, antipsychotics, anxiety, attention deficit hyperactivity disorder (ADHD), benzodiazepines, brain, congestive heart failure (CHF), cyclothymic disorder, dementia, depression, dialysis dementia, dopamine, electroconvulsive therapy (ECT), extrapyramidal, hallucinations, hypomania, Huntington's Disease, inhibition, Kleine-Levin syndrome, Klinefelter's syndrome, major depression, manic-depressive illness, multiple sclerosis (MS), neoplasm, neurotransmitter, norepinephrine, paresis, Parkinson's Disease, pellagra, Pick's disease, postpartum mania, psychotherapy, schizophrenia, seasonal affective disorder (SAD), serotonin, suicidal, temporal lobe epilepsy, thyroid, Tourette syndrome, Tourette's disorder, viral encephalitis, Wilson's disease.

Background
  • Bipolar disorder, also known as manic-depressive illness, is a psychiatric disease characterized by periods of abnormally elevated moods, often followed by episodes of depression.
  • Different from the normal highs and lows that everyone experiences, the symptoms of bipolar disorder are severe and extreme. They can result in damaged relationships, poor job or school performance, and even suicide. An individual with bipolar disorder has episodes of mania characterized by an abnormally elevated mood, sleeplessness, racing thoughts, and pressured speech. Individuals with bipolar disorder can go from feeling very sad, despairing, helpless, worthless, and hopeless (depression) to feeling as if they are on top of the world, hyperactive, creative, and grandiose (mania).
  • In severe cases, thoughts become increasingly chaotic, and may become delusional. Without treatment, the disorder often has disastrous consequences. During manic episodes, peoples' actions may cause them to lose jobs, destroy relationships, go into debt, and even put themselves into dangerous situations. Hospitalization is sometimes required to prevent such consequences or suicide.
  • The National Institute of Mental Health (NIMH) estimates that about 5.7 million American adults or about 2.6% of the population age 18 and older in any given year have bipolar disorder. There is no cure for bipolar illness, but symptoms can be managed. Bipolar disorder typically develops in late adolescence or early adulthood. However, some people have their first symptoms during childhood, and some develop them late in life. It is often not recognized as an illness, and people may suffer for years before it is properly diagnosed and treated.
  • The episodes of mood swings tend to become closer together with age. Extreme mania can lead to aggressive behavior and homicidal acts.
  • According to the American Psychiatric Association, bipolar disorder includes four types of mood episodes including depression, mania, hypomania, and mixed mood.
  • Medications and psychotherapy help to stabilize moods and alleviate symptoms.
  • A number of persons with bipolar disorder may turn to drugs and alcohol to "self-treat" their emotional disorder, resulting in substance dependence.

Signs and symptoms
  • Bipolar disorder is characterized by an alternating pattern of emotional highs (mania) and lows (depression). The intensity of the associated signs and symptoms varies. Bipolar disorder can range from a mild condition to a severe condition, and there may be periods of normal behavior. Many patients may need therapy and hospitalization.
  • Manic phase: Signs and symptoms in the manic phase may include increased energy level, feelings of euphoria, extreme optimism and inflated self-esteem, rapid speech, racing thoughts, agitation and increased physical activity, poor judgment, risky or unusual activities to the extreme, even if it is likely that bad things will happen, difficulty sleeping or less sleep needed, tendency to be easily distracted, inability to concentrate, and aggressive behavior.
  • Depressive phase: Neurochemical imbalances during depression cause a wide range of symptoms, including persistent feelings of sadness, anxiety, guilt or hopelessness, loss of interest in things the person previously enjoyed including sex, disturbances in sleep, an increased need for sleep, changes in weight or appetite, fatigue, problems concentrating or making decisions, irritability, chronic pain without a known cause, and recurring thoughts of suicide or death.
  • A depressive episode is diagnosed if five or more of these symptoms last for most of the day, nearly every day, for a period of two weeks or longer.
  • Hypomania: A mild to moderate level of mania is called hypomania. Hypomania may feel good to the person who experiences it and may even be associated with good functioning and enhanced productivity. Thus, even when family and friends learn to recognize the mood swings as possible bipolar disorder, the person may deny that anything is wrong. Without proper treatment, however, hypomania may become severe mania in some people or can switch into depression.
  • Psychosis: Often severe episodes of mania or depression include symptoms of psychosis, or psychotic symptoms. Common psychotic symptoms are hallucinations (hearing, seeing, or otherwise sensing the presence of things not actually there) and delusions (false, strongly held beliefs not influenced by logical reasoning or explained by a person's usual cultural concepts). Psychotic symptoms in bipolar disorder tend to reflect the extreme mood state at the time.
  • The various mood states in bipolar disorder are thought of as a spectrum or continuous range. At one end is severe depression, then moving into moderate depression and then mild low mood, which many people call "the blues" when it is short-lived. Then there is normal or balanced mood, then hypomania (mild to moderate mania), and finally severe mania.
  • Mixedbipolar state: Some patients experience symptoms of mania and depression together that alternate back and forth (called a mixed bipolar state). Symptoms of a mixed state often include agitation, trouble sleeping, significant change in appetite, psychosis, and suicidal thoughts. A person may have a very sad, hopeless mood and at the same time feel extremely energized.
  • Bipolar disorder may appear on the surface as other unrelated mental problems. For instance, alcohol or drug abuse, poor school or work performance, or stressed and strained interpersonal relationships may actually be caused by bipolar disorder.
  • Bipolar disorder in children and adolescents can be difficult to distinguish from other problems that may occur in these age groups. For example, while irritability and aggressiveness may indicate bipolar disorder, they can also be symptoms of attention deficit hyperactivity disorder (ADHD), conduct disorder, oppositional defiant disorder, or other types of mental disorders more common among adults such as major depression or schizophrenia. Drug abuse also may lead to such symptoms.
  • Suicidal thoughts: Suicidal thoughts may accompany bipolar disorder, normally in the depressive phase. Anyone who has suicidal feelings, talks about suicide, or attempts suicide should be taken seriously and should receive immediate help from a mental health specialist.

Diagnosis
  • No specific tests are available to definitively diagnose bipolar disorder. The diagnosis is made on the basis of all the signs and symptoms.
  • Bipolar disorder is diagnosed on the basis of symptoms that occur during a manic episode, a history of previous episodes, and family history. A diagnosis may be made solely by the presence of a manic episode - depression need not have occurred, or a patient with depression may be misdiagnosed for just having depression. In addition to the mood abnormality, other symptoms must also be present before a diagnosis can be made, including inflated self-esteem, decreased need for sleep, rapid speech, racing thoughts, loss of attention span, increase or decrease in activities (whether social or work-related) and increase in activities that may lead to problems (for example, buying sprees or sexual indiscretions).
  • A clinician will need to rule out the possibility that the patient's symptoms are a result of an underlying medical or drug-related condition. An initial episode that occurs after the age of 40 is particularly suggestive of mania secondary to another cause.
  • A drug screen should be part of the workup, as amphetamines or cocaine can precipitate manic symptoms. Prescription drugs may also cause manic symptoms, so they must be ruled out.
  • If an individual experiences at least four symptoms of mania and depression for a period of at least two weeks, that person may have bipolar disorder or another form of mood disorder.
  • Tests may be ordered to rule out other causes, such as blood or urine tests to determine the balance of salts and sugar in the blood, hormone function, blood cell counts, and drug and alcohol levels. Computerized tomography (CT) scan, positron emission tomography (PET), or magnetic resonance imagining (MRI) of the head may be ordered to check for blood clots, bleeding, or tumors. An electroencephalogram (EEG) to test brain waves for abnormalities, may be ordered if the person is thought to have a seizure disorder. A spinal tap (lumbar puncture) may be ordered to get a sample of spinal fluid to determine if a brain infection, such as meningitis or encephalitis (both forms of brain inflammation), exists. These test may not only rule out other conditions that may be present (such as brain tumor or other disease), they may also determine if imbalances in neurochemistry are present.
  • Treatment is based on the results of these tests. If test results are all normal, the diagnosis is most likely a psychiatric disorder, such as bipolar disorder.
  • Diagnosis also involves ruling out other mental health conditions that may produce symptoms similar to bipolar disorder. These may include other mood disorders, such as schizophrenia, attention-deficit/hyperactivity disorder, and borderline personality disorder.
  • After determining if the individual has a bipolar illness, then the type of bipolar disorder will be determined based on criteria from the Diagnostic and Statistical Manual of Mental Disorders-IV-TR (DSM-IV-TR). The categories are Bipolar I, Bipolar II, Cyclothymia, and Bipolar Disorder NOS (Not Otherwise Specified).
  • Bipolar I Disorder: Bipolar I disorder involves one or more manic or mixed episodes, and often one or more major depressive episodes. A depressive episode may last for several weeks or months. Between episodes of bipolar I disorder, there may be periods of normal functioning. Symptoms may also be related to seasonal changes.
  • Bipolar II Disorder: Bipolar II disorder involves one or more major depressive episodes along with at least one hypomanic episode. Hypomanic episodes have symptoms similar to manic episodes but are less severe. There may be periods of normal functioning between episodes of bipolar II disorder. Symptoms may also be related to seasonal changes. Seasonal affective disorder (or SAD) is a common cause of depression, particularly during the winter season. Bipolar disorder may also respond to these seasonal changes, with symptoms of depression being more prominent during the winter months.
  • Cyclothymic Disorder: Cyclothymic disorder is a long-term fluctuating mood disturbance with periods of hypomania and periods of depression. It is a milder form of bipolar disorder. That's because the periods of both depression and hypomania are shorter, less severe, and do not occur with regularity.
  • Bipolar Disorder Not Otherwise Specified: This type of bipolar disorder is when the individual does not fit into other categories of bipolar disorders.
  • Types of episodes: According to the American Psychiatric Association, bipolar disorder includes four types of mood episodes or disturbances, including depression, mania, hypomania, and a mixture of them.
  • Depression: People with bipolar disorder can feel depressed, sometimes for long periods of time. Some may not even want to get out of bed or eat. They isolate from friends and family and most don't enjoy doing things they used to enjoy.
  • Mania: Mania is the extreme opposite of depression. Mania may start with a good feeling, almost like a "high." Or it may make a person feel very irritable and angry. People with mania may do very risky things due to a loss of inhibition.
  • Hypomania: Hypomania is a milder, less dramatic form of mania. A person may feel good and may think that he or she is getting more things done. However, the good feeling can change into full-blown mania or depression at any time.
  • Mixed mood: Feelings of mania and depression can also alternate in the same day, meaning someone may feel manic upon rising and depressed by the evening. This is called a mixed episode.
  • Other: Children with bipolar disorder do not often meet the strict DSM-IV definition. In pediatric cases, the cycling can occur very quickly. Rapid cycling occurs when the cycles between depression and mania occur quickly, sometimes within the same day or the same hour. When the symptoms of both mania and depression occur simultaneously, mixed cycling occurs.
  • Often other psychiatric disorders are diagnosed in bipolar children. Problems that may be misdiagnosed as bipolar disorder include depression, attention deficit hyperactivity disorder (ADHD), obsessive compulsive disorder (OCD), schizophrenia, and Tourette syndrome (a neurological disorder characterized by nervous "tick", both physical and verbal).
  • Misdiagnosis may lead to incorrect medications, which can trigger mania and/or suicidal ideation and attempts. The energy, impulse control difficulties, and lack of maturity in bipolar children can make suicide risk a serious concern, even with children younger than 8 years old.

Complications
  • Alcohol and drug abuse are very common among people with bipolar disorder. Research findings suggest that many factors may contribute to substance abuse problems and bipolar disorder, including self-medication of symptoms.
  • Anxiety disorders, such as post-traumatic stress disorder and obsessive-compulsive disorder, may also be common in people with bipolar disorder. Anxiety disorders can be diagnosed by a psychiatrist. Studies suggest up to 42% of individuals with bipolar disorder also suffer from anxiety.
  • Bipolar disorder can have devastating effects on relationships as well as finances stemming from spending sprees during a manic episode or nearly complete isolation and withdrawal during a depressive phase.
  • Suicide may be a complication of untreated, mistreated, or misdiagnosed bipolar disorder.

Treatment
  • Bipolar illness should be treated by a qualified health care provider such as a psychiatrist. Most people with bipolar disorder - even those with the most severe forms - can achieve substantial stabilization of their mood swings and related symptoms with proper treatment. Because bipolar disorder is a recurrent illness, long-term preventive treatment is strongly recommended and almost always indicated. A strategy that combines medication and psychosocial treatment is optimal for managing the disorder over time.
  • Psychotherapy: Psychotherapy is most often used simultaneously with medications. A therapist will help detect patterns leading up to episodes of bipolar disorder, trying to identify triggers for these episodes. Psychotherapy helps provide strategies for managing stress and coping with uncertainties.
  • Psychosocial interventions: Psychosocial interventions commonly used for bipolar disorder include cognitive behavioral therapy, psychoeducation, family therapy, and a newer technique, interpersonal and social rhythm therapy.
  • Cognitive behavioral therapy helps people with bipolar disorder learn to change inappropriate or negative thought patterns and behaviors associated with the illness. Cognitive behavioral therapy helps the individual understand more about their illness, deal with feelings of hopelessness and guilt, help resolve family conflicts that arise, gain better control over impulses and moods, and assist in decision-making. Although bipolar disorder is a difficult problem, there are useful treatments that can help the individual maintain a more normal life.
  • Psychoeducation involves teaching people with bipolar disorder about the illness and treatment, and how to recognize signs of relapse so that early interventions can be made before a full-blown bipolar episode occurs. Psychoeducation also may be helpful for family members.
  • Family therapy uses strategies to reduce the level of distress within the family that may either contribute to or result from the ill person's symptoms. Family and friends of an individual with bipolar disorder must be familiar with the signs and symptoms of the disease and when the disease is in a manic or depressive state.
  • Interpersonal and social rhythm therapy helps people with bipolar disorder both to improve relationships with others and to regularize their own daily routines. Regular daily routines and sleep schedules may help protect against manic episodes.
  • As with medication, it is important to follow the treatment plan for any psychosocial intervention to achieve the greatest benefit.
  • Medications: Most people with bipolar disorder take medication to regulate their moods. Lithium (Eskalith®, Lithobid®) has been widely used as a mood stabilizer and is generally the first line of treatment for manic episodes. Other drugs such as anti-seizure medications, antidepressants, antipsychotic drugs, and benzodiazepines may be used, either alone or in combination.
  • Anti-seizure medications: Anti-seizure medications, such as valproic acid (Depakene®) and divalproex (Depakote®) and carbamazepine (Tegretol®) are also commonly used as mood regulators. Topiramate (Topamax®) and gabapentin (Neurontin®) may also be used off label (not approved by the U.S. Food and Drug Association) to stabilize mood. Lamotrigine (Lamictal®) is an anticonvulsant agent that has shown efficacy in the prevention of mood episodes in adult patients with bipolar I disorder.
  • Antidepressants: Antidepressant medications are utilized to treat the depression associated with bipolar disorder. These may include the serotonin reuptake inhibiting drugs (SSRI) paroxetine (Paxil®), fluoxetine (Prozac®, Sarafem®), and sertraline (Zoloft®) or bupropion (Wellbutrin®). The use of antidepressants alone for depression associated with bipolar disorder may cause a manic episode to occur. For that reason, antidepressants are often combined with other medications, such as anti-seizure drugs.
  • Antipsychotics: In other circumstances, doctors may use antipsychotic medications such as clozapine (Clozaril®), risperidone (Risperdal®) or olanzapine (Zyprexa®) for acute mania. The antipsychotic medicine quetiapine (Seroquel®) has been approved by the U.S. Food and Drug Administration (FDA) to treat both the manic and depressive episodes of bipolar disorder. Evidence suggests that clozapine may be helpful as a mood stabilizer for people who do not respond to lithium or anticonvulsants. Most common side effects include drowsiness, impaired coordination, fatigue, confusion and disorientation, dizziness, decreased concentration, short-term memory problems, dry mouth, blurred vision, and irregular heartbeat.
  • Benzodiazepines: Benzodiazepines, such as clonazepam (Klonopin®) or lorazepam (Ativan®), may be used for insomnia, panic attacks, and stress. However, since these medications may be habit-forming if used for more than a few weeks, they are best prescribed on a short-term basis. Other types of sedative medications, such as zolpidem (Ambien®), are sometimes used instead, although the potential for abuse still occurs.
  • Electroconvulsive therapy:Electroconvulsive therapy (ECT) involves the use of electrical current to stimulate various parts of the brain, and is used mainly in people who have episodes of major depression associated with suicidal tendencies, or in people whose medication has proved to be ineffective. ECT profoundly affects brain metabolism and blood flow to various areas of the brain. How that correlates to easing depression remains unknown, but this therapy is often highly effective. Safety of ECT is controversial, and adverse effects such as confusion, memory loss, headache, hypotension (low blood pressure), and tachycardia (increased heart rate) may occur.
  • Hospitalization: Bipolar disorder is a serious medical illness. Urgent care and hospitalization may be necessary when someone seems to be a danger to themselves or others, or if they are psychotic. A person experiencing a particularly severe episode of manic-depressive illness should be brought to the hospital immediately to prevent suicide or possible violence to another person. An acute episode is treated with medications and a low-stimulation environment. Depending on the individual's symptoms and history, longer-term hospitalization may be required.

Integrative therapies
  • Note: Most alternative therapies for bipolar disorder have focused on the prevention and treatment of depression and not manic episodes.
  • Strong scientific evidence:
  • Music therapy: Music has been referred to as an ancient tool of healing. Many different forms of music intervention have been used to reduce depression and anxiety in a variety of medical conditions and medical procedures. There is evidence that music therapy may increase responsiveness to antidepressant medication. In elderly adults with depression, a home-based program of music therapy may have long-lasting effects for mood enhancement. In depressed adult women, music therapy may lead to reductions in heart rate, respiratory rate, blood pressure, and depressed mood. Music therapy is generally known to be safe.
  • Sage: Sage has long been suggested as a possible therapy for mood enhancement. Several trials provide evidence for this use of sage, even in stressful situations. Additional study is needed to confirm these findings and determine the best dose.
  • Avoid if allergic or hypersensitive to sage species, their constituents, or to members of the Lamiaceae family. Use cautiously with hypertension (high blood pressure). Use sage essential oil or tincture cautiously in patients with epilepsy. Avoid with previous anaphylactic reactions to sage species, their constituents, or to members of the Lamiaceae family. Avoid if pregnant or breastfeeding.
  • St. John's wort: Extracts of St. John's wort (Hypericum perforatum) have been recommended traditionally for a wide range of medical conditions, with the most common modern-day use being the treatment of depression. St. John's wort has been extensively studied in Europe over the last two decades, with more recent research in the United States. Short-term studies (one to three months) suggest that St. John's wort is more effective than placebo (sugar pill), and equally effective as tricyclic antidepressants (TCAs) in the treatment of mild-to-moderate depressive disorder. Comparisons to the more commonly prescribed selective serotonin reuptake inhibitor (SSRI) antidepressants, such as fluoxetine (Prozac®) or sertraline (Zoloft®), are more limited. However, other data suggest that St. John's wort may be just as effective as SSRIs with fewer side effects. Safety concerns exist as with most conventional and complementary therapies. Studies of St. John's wort for severe depression have not provided clear evidence of effectiveness.
  • In published studies, St. John's wort has generally been well tolerated at recommended doses for up to one to three months. The most common adverse effects include gastrointestinal upset, skin reactions, fatigue/sedation, restlessness or anxiety, sexual dysfunction (including impotence), dizziness, headache, and dry mouth. Caution is advised when taking St. John's wort, as numerous adverse effects including many drug interactions are possible. Drug interactions with St. John's wort can have severe consequences. One small study reported elevated thyroid stimulating hormone (TSH) levels to be associated with taking St. John's wort. St. John's wort should not be used if pregnant or breastfeeding, unless otherwise directed by a doctor.
  • Good scientific evidence:
  • 5-hydroxytryptophan (5-HTP): Supplement use of 5-HTP may help balance serotonin in the body. Serotonin is the brain chemical associated with sleep, mood, movement, eating and nervousness. While cells outside the brain, such as platelets in the blood and some cells in the intestine, produce and utilize serotonin, all serotonin used by brain cells must be made within the neurons themselves. When serotonin is not properly constructed within the brain, the result can be irritability, aggression, impatience, anxiety and depression. The results of numerous studies in humans suggest that 5-HTP may aid in the treatment of depression. However, it is not known whether 5-HTP is as effective as commonly prescribed antidepressant drugs.
  • Caution is advised when taking 5-HTP supplements, as numerous adverse effects including drug interactions are possible. 5-HTP is not recommended during pregnancy or breastfeeding, unless otherwise advised by a doctor.
  • Art therapy: Art therapy enables the expression of inner thoughts or feelings when verbalization is difficult or not possible. It involves the application of a variety of art modalities including drawing, painting, clay and sculpture. Art therapy may be an effective intervention for hospitalized, suicidal adolescents. There is evidence that it can be used to aid in developing a sense of identity and optimism about the future. It may also aid in relaxation and willingness to communicate, and may result in shorter hospitalization.
  • Art therapy may evoke distressing thoughts or feelings. Use under the guidance of a qualified art therapist or other mental health professional. Some forms of art therapy use potentially harmful materials. Only materials known to be safe should be used. Related clean-up materials (like turpentine or mineral spirits) that release potentially toxic fumes should only be used with good ventilation.
  • Dehydroepiandoseterone (DHEA): DHEA is a hormone made in the human body that serves as precursor to male and female sex hormones (androgens and estrogens). The majority of clinical trials investigating the effect of DHEA on depression support its use for this purpose under the guidance of a healthcare provider. Further research is needed to confirm these results.
  • Few side effects are reported when DHEA supplements are taken by mouth in recommended doses. Avoid if allergic to DHEA. Side effects may include fatigue, nasal congestion, headache, acne, or rapid/irregular heartbeats. In women, the most common side effects are abnormal menses, emotional changes, headache, and insomnia. Individuals with a history of abnormal heart rhythms, blood clots or hypercoagulability, and those with a history of liver disease, should avoid DHEA supplements. Patients who are taking antidepressants should avoid DHEA. Avoid with a history of seizures. Use cautiously with adrenal or thyroid disorders or anticoagulants (blood thinners), or drugs, herbs, or supplements for diabetes, heart disease, seizure, or stroke. Stop use two weeks before surgery/dental/diagnostic procedures with bleeding risk, and do not use immediately after these procedures. Avoid if pregnant or breastfeeding.
  • Hypnotherapy, hypnosis: Hypnosis appears effective in the treatment of psychosomatic disorders. Additional research is needed to support this finding.
  • Use cautiously with mental illnesses like psychosis/schizophrenia, manic depression, multiple personality disorder or dissociative disorders. Use cautiously with seizure disorders.
  • Music therapy: There is evidence that music therapy may increase responsiveness to antidepressant medication. In elderly adults with depression, a home-based program of music therapy may have long-lasting effects. In depressed adult women, music therapy may lead to reductions in heart rate, respiratory rate, blood pressure, and depressed mood. Music therapy is generally known to be safe.
  • Phenylalanine: In early human study, L-phenylalanine, DL-phenylalanine, and D-phenylalanine were shown to reduce symptoms associated with depression. However, high quality clinical trials are needed for better assessment of the antidepressant effectiveness of various forms of phenylalanine dietary supplements.
  • Use cautiously in patients taking monoamine oxidase inhibitors (MAOIs), or in patients with hypertension, anxiety disorders, psychiatric disorders, or sleep disorders. Avoid in patients with Parkinson's disease or tardive dyskinesia. Avoid in patients with hypersensitivity to phenylalanine or with phenylketonuria (PKU).
  • Psychotherapy: Psychotherapy is an interactive process between a person and a qualified mental health professional (psychiatrist, psychologist, clinical social worker, licensed counselor, or other trained practitioner). A broad range of psychotherapies have been shown to be effective for the treatment of mild to moderate depression, ante- and postpartum depression, and depression in children. Although prescription medication is the most effective treatment for bipolar disorder, psychotherapy may help patients take their medication, prevent relapses, and reduce suicidal behavior.
  • Psychotherapy cannot always resolve mental or emotional conditions. Psychiatric drugs are sometimes needed. In some cases, symptoms may get worse if the proper medication is not taken. Not all therapists are qualified to work with all problems. Use cautiously with serious mental illness or some medical conditions because some forms of psychotherapy may stir up strong emotional feelings and expression. Psychotherapy may help with post-partum depression, but is not a substitute for medication that may be needed in severe cases.
  • St. John's wort: Well-designed studies have investigated the effect of St. John's wort on symptoms associated with somatoform disorders. The results suggest St. John's wort may be effective in this population. Further well-designed clinical trials would add to this information and allow recommendations to be made.
  • In published studies, St. John's wort has generally been well tolerated at recommended doses for up to one to three months. The most common adverse effects include gastrointestinal upset, skin reactions, fatigue/sedation, restlessness or anxiety, sexual dysfunction (including impotence), dizziness, headache, and dry mouth. Caution is advised when taking St. John's wort, as numerous adverse effects including many drug interactions are possible. Drug interactions with St. John's wort can have severe consequences. One small study reported elevated thyroid stimulating hormone (TSH) levels to be associated with taking St. John's wort. St. John's wort should not be used if pregnant or breastfeeding, unless otherwise directed by a doctor.
  • Yoga: Yoga is an ancient system of relaxation, exercise, and healing with origins in Indian philosophy. Several human studies support the use of yoga for depression in both children and adults. Although this preliminary research is promising, better studies are needed.
  • Yoga is generally considered to be safe in healthy individuals when practiced appropriately. Avoid some inverted poses with disc disease of the spine, fragile or atherosclerotic neck arteries, risk for blood clots, extremely high or low blood pressure, glaucoma, detachment of the retina, ear problems, severe osteoporosis, or cervical spondylitis. Certain yoga breathing techniques should be avoided in people with heart or lung disease. Yoga techniques are believed to be safe during pregnancy and breastfeeding when practiced under the guidance of expert instruction (the popular Lamaze techniques are based on yogic breathing). However, poses that put pressure on the uterus, such as abdominal twists, should be avoided in pregnancy.
  • Unclear or conflicting scientific evidence:
  • Acupressure, shiatsu: Acupressure, or shiatsu, has been used in China for thousands of years for health and healing. Several studies suggest that acupressure therapy may be effective for depression. Further research is needed.
  • With proper training, acupressure appears to be safe if self-administered or administered by an experienced therapist. No serious long-term complications have been reported, according to scientific data. Hand nerve injury and herpes zoster ("shingles") cases have been reported after shiatsu massage. Forceful acupressure may cause bruising.
  • Acupuncture: Acupuncture, or the use of needles to manipulate the "chi" or body energy, originated in China over 5,000 years ago. A small number of studies have sought to compare acupuncture with medications used in depression. More studies are needed on this use.
  • Needles must be sterile in order to avoid disease transmission. Avoid with valvular heart disease, infections, bleeding disorders, or with drugs that increase the risk of bleeding (anticoagulants), medical conditions of unknown origin, or neurological disorders. Avoid on areas that have received radiation therapy and during pregnancy. Use cautiously with pulmonary disease (such as asthma or emphysema). Use cautiously in elderly or medically compromised patients, diabetics, or with history of seizures. Avoid electroacupuncture with arrhythmia (irregular heartbeat) or in patients with pacemakers.
  • Aromatherapy: Fragrant oils have been used for thousands of years. Aromatherapy is a technique in which essential oils from plants are used with the intention of preventing or treating illness, reducing stress, or enhancing well-being. Preliminary research suggests that lavender (Lavendula officinalis) aromatherapy may be helpful as an adjunct to prescription medications used for depression. Additional research is necessary before a conclusion can be made.
  • Essential oils should be administered in a carrier oil to avoid toxicity. Avoid with a history of allergic dermatitis. Use cautiously if driving/operating heavy machinery. Avoid consuming essential oils. Avoid direct contact of undiluted oils with mucous membranes. Use cautiously if pregnant.
  • Ayurveda: Ayurveda, which originated in ancient India over 5,000 years ago, is probably the world's oldest system of natural medicine. Early evidence suggests that a traditional Ayurvedic formula containing extracts of four Indian herbs, Ashvatha, Kapikachu, Dhanvayasa, and Bhuriphali, may have benefits similar to conventional anti-depressant medication. Further studies are needed to confirm the effects of this ayurvedic preparation for mild to moderate depression.
  • Ayurvedic herbs should be used cautiously because they are potent and some constituents can be potentially toxic if taken in large amounts or for a long time. Some herbs imported from India have been reported to contain high levels of toxic metals. Ayurvedic herbs can interact with other herbs, foods and drugs. A qualified healthcare professional should be consulted before taking.
  • Bach flower remedies: Depression is one of the major uses of Bach flower remedies. Currently, there is a lack of high-quality clinical trials that have investigated the use of Bach flower remedies for major depressive disorder. Higher quality research is needed in this area. Back flower remedies should not be used in lieu of more proven therapies.
  • Chasteberry: There is limited evidence suggesting possible benefits of chasteberry in the alleviation of symptoms of pre-menstrual dysphoric disorder (PMDD). Further evidence is necessary before a conclusion can be drawn.
  • Avoid if allergic or hypersensitive to members of the Vitex (Verbenaceae) family or any chasteberry components. When taken in recommended doses, chasteberry appears to be well tolerated with few side effects. Use cautiously in patients taking oral contraceptives or hormone replacement therapy. Use cautiously with dopamine agonists or antagonists. Avoid with hormone sensitive cancers or conditions (like ovarian cancer or breast cancer). Avoid if pregnant, breastfeeding or if undergoing in vitro fertilization.
  • Chromium: Early studies show that chromium picolinate may improve symptoms of depression in people with atypical depression. There is currently a lack of sufficient available evidence to recommend chromium for bipolar disorder. Further research is needed before a recommendation can be made.
  • Trivalent chromium appears to be safe because side effects are rare or uncommon. However, hexavalent chromium may be poisonous (toxic). Avoid if allergic to chromium, chromate, or leather. Use cautiously with diabetes, liver problems, a weakened immune system (such as HIV/AIDS patients or organ transplant recipients), depression, Parkinson's disease, heart disease, or stroke or in patients who are taking medications for these conditions. Use cautiously if driving or operating machinery. Use cautiously if pregnant or breastfeeding.
  • Coleus: Limited studies have assessed the efficacy of coleus in the treatment of depression. High quality clinical trials are warranted.
  • Avoid if allergic or hypersensitive to coleus. Use cautiously with antidepressants, blood pressure drugs, blood-thinners, pain relievers, anticoagulants, blood sugar drugs, bronchodilators, heart drugs (like anti-arrhythmics), drugs dependent on stomach pH (like ketoconazole), thyroid drugs, bladderwrack, garlic, ginkgo, St. John's wort, and other herbs or supplements with similar effects.
  • Creatine: Early research suggests a potential beneficial of creatine supplements in depression. Large, well-designed studies are needed.
  • Avoid if allergic to creatine or with diuretics (like hydrochlorothiazide, furosemide (Lasix®)). Use caution in asthma, diabetes, gout, kidney, liver or muscle problems, stroke or a history of these conditions. Avoid dehydration. Avoid if pregnant or breastfeeding.
  • Feldenkrais method®: Early research revealed improved mood among participants who enrolled in a one-year program that included the Feldenkrais Method®. There is currently a lack of available scientific studies or reports of safety of the Feldenkrais Method®.
  • Folate: Folic acid or folate deficiency has been found among many individuals suffering from depression and has been linked to poor response to antidepressant therapies. Folate supplements have been used for enhancing treatment response to antidepressants. Limited clinical research suggests that folic acid is not effective as a replacement for conventional antidepressant therapy. Blood tests can determine if an individual is low in vitamins such as folic acid.
  • Folate appears to be well tolerated in recommended doses. Avoid if allergic or hypersensitive to folate or any of the product ingredients. It is recommended that pregnant women consume 400 micrograms of folate daily in order to reduce the risk of fetal defects. Folate is likely safe if breastfeeding.
  • Ginkgo: Preliminary study suggests that ginkgo (Ginkgo biloba) may not be effective for depression and seasonal affective disorder (SAD). Other research in elderly patients with depression shows possible minor benefits. Ginkgo may help in decreasing sexual side effects such as loss of libido in individuals taking antidepressants. Overall, there is not enough evidence to form a clear conclusion. It remains unclear if ginkgo is effective for improving mood in post-menopausal women. Further well-designed research is needed as existing study reports conflicting evidence.
  • Caution is advised when taking ginkgo supplements as numerous adverse effects and drug interactions are possible. Avoid if allergic or hypersensitive to members of the Ginkgoaceaefamily. If allergic to mango rind, sumac, poison ivy or oak, or cashews, then allergy to ginkgo is possible. Avoid with blood-thinners (such as aspirin or warfarin) due to an increased risk of bleeding. Ginkgo should be stopped two weeks before surgical procedures. Ginkgo seeds are dangerous and should be avoided. Skin irritation and itching may also occur due to ginkgo allergies. Ginkgo is not recommended during pregnancy or breastfeeding, unless otherwise advised by a doctor.
  • Ginseng: A review of several studies suggested that ginseng may improve mood in post-menopausal women. Additional studies are needed before a conclusion can be made.
  • Avoid ginseng with a known allergy to plants in the Araliaceae family. There has been a report of a serious life-threatening skin reaction, possibly caused by contaminants in ginseng formulations.
  • Guarana: Caffeine, the active ingredient in guarana, may have positive effects on mood enhancement. Caffeine may increase alertness and feelings of well-being and improve performance on sustained attention tasks and simulated driving performance. Slow release caffeine consumption has been correlated with a decrease in calmness and an increase in sleep onset latency.
  • Avoid if allergic/hypersensitivite to guarana (Paullinia cupana), caffeine, tannins or species of the Sapindaceae family. Avoid with hypertension, psychological or psychiatric disorders, liver impairment, and arrhythmias. Avoid with other stimulatory agents, especially ephedra. Use cautiously with breast disease, impaired kidney function, diabetes, pre-existing mitral valve prolapse, iron deficiency, gastric or duodenal ulcers, bleeding disorders, glaucoma, or if at risk for osteoporosis. Use cautiously if undergoing electroconvulsive therapy (ECT). Avoid if pregnant or breastfeeding.
  • Healing touch (HT): Preliminary data suggests that a series of healing touch (HT) sessions over time may reduce depression. However, data are insufficient to form definitive conclusions, and studies of better design are needed. HT should not be regarded as a substitute for established medical treatments. Use cautiously if pregnant or breastfeeding.
  • Kundalini yoga: Kundalini yoga is one of many traditions of yoga that share common roots in ancient Indian philosophy. It is comprehensive in that it combines physical poses with breath control exercises, chanting (mantras), meditations, prayer, visualizations, and guided relaxation. It is an elaborate system focused on healing and "purifying" the mind, body, and emotions. There is preliminary evidence that Kundlini yoga practice may be of benefit in depression. More trials are needed to establish whether this is a viable therapy for depression before a recommendation can be made.
  • Avoid exercises that involve stoppage of breath with heart or lung problems, insomnia, or with poor memory or concentration. Avoid certain inverted poses with disc disease of the spine, fragile or atherosclerotic neck arteries, risk for blood clots, extremely high or low blood pressure, glaucoma, detachment of the retina, ear problems, severe osteoporosis or cervical spondylitis. Use cautiously with mental disorders as some techniques may cause an altered state of consciousness. Kundalini yoga is considered safe and beneficial for use during pregnancy and lactation when practiced under the guidance of expert instruction. Teachers of yoga are generally not medically qualified and should not be regarded as sources of medical advice for management of clinical conditions.
  • Lavender: Preliminary research suggests that lavender may be helpful as an adjunct to prescription medications for mild-to-moderate depression. Additional research is necessary before a conclusion can be made.
  • Avoid if allergic or hypersensitive to lavender. Avoid with history of seizures, bleeding disorders, eating disorders (anorexia, bulimia), or anemia (low levels of iron). Avoid if pregnant or breastfeeding.
  • L-carnitine: L-carnitine (also known as acetyl-L-carnitine) is an antioxidant and may help blood flow as well as neurological function. Although the results are promising there is currently insufficient evidence to support the use of acetyl-L-carnitine in the treatment of depression. Well-designed clinical trials with adequate subject number are required.
  • Caution is advised when taking acetyl-L-carnitine supplements as numerous adverse effects including drug interactions are possible. Avoid with known allergy or hypersensitivity to carnitine. Use cautiously with peripheral vascular disease, hypertension (high blood pressure), alcohol-induced liver cirrhosis, and diabetes. Use cautiously in low birth weight infants and individuals on hemodialysis. Use cautiously if taking anticoagulants (blood thinners), beta-blockers, or calcium channel blockers. Avoid if pregnant or breastfeeding.
  • Massage: Various forms of therapeutic superficial tissue manipulation have been practiced for thousands of years across cultures. Massage is relaxing and may decrease stress. There is currently insufficient evidence to determine if massage is beneficial in patients with depression. Additional research is necessary in order to form a scientifically based recommendation.
  • Avoid with bleeding disorders, low platelet counts, or if on blood-thinning medications (such as heparin or warfarin). Areas should not be massaged where there are fractures, weakened bones from osteoporosis or cancer, open/healing skin wounds, skin infections, recent surgery or blood clots. Use cautiously if history of physical abuse or if pregnant or breastfeeding. Massage should not be used as a substitute for more proven therapies for medical conditions. Massage should not cause pain to the client.
  • Meditation: There is currently not enough scientific evidence to suggest the effectiveness of meditation for mood enhancement. Some forms of meditation may prevent relapse in patients who have had bouts of major depression. More studies are needed.
  • Use cautiously with underlying mental illnesses. People with psychiatric disorders should consult with their primary mental healthcare professional(s) before starting a program of meditation, and should explore how meditation may or may not fit in with their current treatment plan. Avoid with risk of seizures. The practice of meditation should not delay the time to diagnosis or treatment with more proven techniques or therapies, and should not be used as the sole approach to illnesses.
  • Melatonin: Melatonin has been suggested for the improvement of sleep disturbances in depression and bipolar disorder although research is limited in this area. There are several small, brief studies of melatonin in patients with seasonal affective disorder (SAD). This research is not well designed or reported, and further study is necessary before a clear conclusion can be reached.
  • Melatonin is not to be used for extended periods of time. Caution is advised when taking melatonin supplements as numerous adverse effects including drug interactions are possible. Melatonin is not recommended during pregnancy or breastfeeding, unless otherwise advised by a doctor. Use cautiously with drugs broken down by the liver, sedative drugs (Ambien®), barbiturates, narcotics, antidepressants, alcohol, drugs that increase the risk of bleeding such as warfarin (Coumadin®), non-steroidal anti-inflammatories (ibuprofen or naproxen), drugs that affect blood pressure (atenolol), drugs that lower levels of vitamin B6 in the body (such as birth control pills, hormone replacement therapy, or loop diuretics), diazepam, verapamil, temazepam, somatostatin, drugs that alter blood sugar levels (insulin), caffeine, succinylcholine, methamphetamine, isoniazid or herbs or supplements with similar effects (such as 5-HTP, Ginkgo biloba,garlic, saw palmetto, vitamin B12, chasteberry, arginine, DHEA, and Echinacea).
  • Omega-3 fatty acids, fish oil, alpha-linolenic acid: Essential fatty acids (including omega-3 fatty acids) have many roles in the body, including proper nerve and brain function. There have been several studies on the use of omega-3 fatty acids in depression and bipolar disorder; however, not enough reliable evidence is available to form a clear conclusion.
  • Omega-3 fatty acids found in fish oils are normally used. It is important to choose quality fish oil supplements, as heavy metals have been reported in some fish oil supplements. The label should say if the product has been tested for heavy metal contamination (such as lead and mercury). Avoid if allergic or hypersensitive to fish, omega-3 fatty acid products that come from fish, nuts, linolenic acid, or omega-3 fatty acid products that come from nuts. Avoid during active bleeding. Use cautiously with bleeding disorders, diabetes, low blood pressure or drugs, herbs or supplements that treat any such conditions. Use cautiously before surgery. The Environmental Protection Agency (EPA) recommends that intake be limited in pregnant/breastfeeding women to a single six-ounce meal per week, and in young children to less than two ounces per week. For farm-raised, imported, or marine fish, the U.S. Food and Drug Administration (FDA) recommends that pregnant/breastfeeding women and young children avoid eating types with higher levels of methylmercury and less than 12 ounces per week of other fish types. Women who might become pregnant are advised to eat seven ounces or less per week of fish with higher levels of methylmercury or up to 14 ounces per week of fish types with about 0.5 parts per million (such as marlin, orange roughy, red snapper, or fresh tuna).
  • Prayer, distant healing: Early study suggests that psychiatric inpatients may benefit from anonymous distant healing intention for depression. Additional research is needed.
  • Prayer is not recommended as the sole treatment approach for potentially serious medical conditions, and should not delay the time it takes to consult with a healthcare professional or receive established therapies. Sometimes religious beliefs come into conflict with standard medical approaches, and require an open dialog between patients and caregivers.
  • Psychotherapy: Telephone-administered cognitive-behavioral therapy may help treat depression for multiple sclerosis patients, although more study is needed in this area. Short-term psychotherapy for psychosomatic conditions may not be as effective as long-term psychotherapy. More research needs to be done to evaluate these approaches. Psychotherapy may also help seasonal affective disorder (SAD). For bipolar disorder, although prescription medication is the most effective treatment, psychotherapy may help patients take their medication, prevent relapses, and reduce suicidal behavior. Further study is needed to confirm these results.
  • Psychotherapy cannot always resolve mental or emotional conditions. Psychiatric drugs are sometimes needed. In some cases, symptoms may get worse if the proper medication is not taken. Not all therapists are qualified to work with all problems. Use cautiously with serious mental illness or some medical conditions because some forms of psychotherapy may stir up strong emotional feelings and expression. Psychotherapy may help with post-partum depression, but is not a substitute for medication that may be needed in severe cases.
  • Qi gong: Qi gong is a type of Traditional Chinese Medicine (TCM) that is thought to be at least 4,000 years old. Preliminary study shows that Qi gong may be beneficial for relieving stress. Available data remains inconclusive, yet thousands of years of effectiveness in China for stress and anxiety must be appreciated. Qi gong has been studied in elderly patients to assess if it helped with depression in those with chronic physical illnesses. Results were inconclusive, and further research is needed before a recommendation can be made. Qi gong may be used as an adjunct to more proven therapies.
  • Qi gong is generally considered to be safe in most people when learned from a qualified instructor. Use cautiously with psychiatric disorders. In cases of potentially serious conditions, Qi gong should not be used as the only treatment instead of more proven therapies, and should not delay the time it takes to see an appropriate healthcare provider.
  • Reflexology: Reflexology may provide some benefits to patients suffering from depression. However, results from numerous studies have been inconsistent. Further research is needed.
  • Avoid with recent or healing foot fractures, unhealed wounds, or active gout flares affecting the foot. Use cautiously and seek prior medical consultation with osteoarthritis affecting the foot or ankle, or severe vascular disease of the legs or feet. Use cautiously with diabetes, heart disease or the presence of a pacemaker, unstable blood pressure, cancer, active infections, past episodes of fainting (syncope), mental illness, gallstones, or kidney stones. Use cautiously if pregnant or breastfeeding. Reflexology should not delay diagnosis or treatment with more proven techniques or therapies.
  • Reiki: Reiki is a Buddhist practice that is approximately 2,500 years old. It is used for stress reduction and relaxation and is administered by "laying on hands" and moving around the "energy" of the body. There is evidence that Reiki may reduce symptoms of depression. Additional research is needed.
  • Reiki is not recommended as the sole treatment approach for potentially serious medical conditions, and should not delay the time it takes to consult with a healthcare professional or receive established therapies. Use cautiously with psychiatric illnesses.
  • Relaxation therapy: Relaxation therapy includes self-control relaxation, paced respiration, and deep breathing. There is promising early evidence from human trials supporting the use of relaxation to reduce symptoms of depression,although effects appear to be short-lived. Better quality research is necessary before a firm conclusion can be drawn.
  • Avoid with psychiatric disorders such as schizophrenia/psychosis. Jacobson relaxation (flexing specific muscles, holding that position, then relaxing the muscles) should be used cautiously with illnesses like heart disease, high blood pressure, or musculoskeletal injury. Relaxation therapy is not recommended as the sole treatment approach for potentially serious medical conditions, and should not delay the time to diagnosis or treatment with more proven techniques.
  • Riboflavin (Vitamin B2): Riboflavin is a water-soluble vitamin, which is involved in many processes in the body, and is necessary for normal cell function, growth, and energy production. Adequate nutrient supplementation with riboflavin may be required for the maintenance of adequate cognitive function. Treatment with B-vitamins, including riboflavin, has been reported to improve depression in patients taking tricyclic antidepressants.
  • Avoid if allergic or hypersensitive to riboflavin. Since the amount of riboflavin a human can absorb is limited, riboflavin is generally considered safe. Riboflavin is generally regarded as being safe during pregnancy and breastfeeding. The U.S. recommended dietary allowance (RDA) for riboflavin in pregnant women is higher than for non-pregnant women; the RDA during pregnancy is 1.4 milligrams daily, and 1.6 milligrams during breastfeeding.
  • SAMe: S-adenosylmethionine, or SAMe, is normally formed in the body from the essential amino acid methionine. SAMe supplements are used in depression and mood disorders. SAMe has been studied for use in depression for many decades. However, the majority of trials that have been performed have significant methodological flaws limiting their clinical usefulness. A small number of randomized placebo controlled trials suggest an antidepressant effect that is greater than that observed with placebo. Although some studies have suggested that SAMe has a more rapid onset of action in depression than tricyclic antidepressants (TCAs), it is uncertain whether these effects result in improved patient outcomes. Large randomized placebo controlled trials that compare SAMe to other antidepressants such as Selective Serotonin Reuptake Inhibitors (SSRIs) are needed. Until these trials are available, it is difficult to justify the use of SAMe in patients with depression since there are many effective antidepressants available to this patient population.
  • Caution should be used when taking SAMe supplements as drug interactions are possible. Avoid if allergic or hypersensitive to SAMe. Use cautiously with diabetes and anxiety disorders, or in women in their third trimester of pregnancy. Avoid with bipolar disorder. Avoid during the first trimester of pregnancy or if breastfeeding.
  • St. John's wort: Studies of St. John's wort for severe depressive disorder have not provided clear evidence of effectiveness. Additionally, despite some promising early data, there is currently not enough evidence to recommend St. John's wort for Seasonal Affective Disorder (SAD). Additional study is needed.
  • In published studies, St. John's wort has generally been well tolerated at recommended doses for up to one to three months. The most common adverse effects include gastrointestinal upset, skin reactions, fatigue/sedation, restlessness or anxiety, sexual dysfunction (including impotence), dizziness, headache, and dry mouth. Caution is advised when taking St. John's wort, as numerous adverse effects including many drug interactions are possible. Drug interactions with St. John's wort can have severe consequences. One small study reported elevated thyroid stimulating hormone (TSH) levels to be associated with taking St. John's wort. St. John's wort should not be used if pregnant or breastfeeding, unless otherwise directed by a doctor.
  • Tai Chi: Tai chi is a system of movements and positions believed to have developed in 12th Century China. Tai chi techniques aim to address the body and mind as an interconnected system, and are traditionally believed to have mental and physical health benefits to improve posture, balance, flexibility and strength. Preliminary research suggests that tai chi may help alleviate depression. Patients may experience improved mood as a result of tai chi practice. Additional research is needed.
  • Avoid with severe osteoporosis or joint problems, acute back pain, sprains, or fractures. Avoid during active infections, right after a meal, or when very tired. Some believe that visualization of energy flow below the waist during menstruation may increase menstrual bleeding. Straining downwards or holding low postures should be avoided during pregnancy, and in patients with inguinal hernias. Some tai chi practitioners believe that practicing for too long or using too much intention may direct the flow of chi (qi) inappropriately, possibly resulting in physical or emotional illness. Tai chi should not be used as a substitute for more proven therapies for potentially serious conditions. Advancing too quickly while practicing tai chi may increase the risk of injury.
  • Therapeutic touch: Therapeutic touch may offer some benefits when used with standard therapies to treat depression. More research is needed.
  • Therapeutic touch is believed to be safe for most people. Therapeutic touch should not be used for potentially serious conditions in place of more proven therapies. Avoid with fever or inflammation, and on body areas with cancer.
  • Valerian: There is currently not enough available scientific evidence on the use of valerian for depression.
  • Use with caution if allergic to members of the Valerianaceaefamily. Avoid if driving or operating heavy machinery, as it may cause drowsiness. Avoid with liver disease. Avoid if pregnant or breastfeeding.
  • Vitamin B6 (Pyridoxine): Some research suggests that pyridoxine supplementation alone or in combination with high doses of other B vitamins may help with depression. Pyridoxine helps increase the "calming" neurochemicals serotonin and gamma amino butyric acid (GABA) levels in the blood, possibly benefiting people in dysphoric mental states. Well-designed clinical trials are needed to confirm potential benefit. Vitamin B6 may be found in a multivitamin or a B-complex vitamin supplement.
  • Avoid if sensitive or allergic to any vitamin B6 product ingredients. Some individuals seem to be particularly sensitive to vitamin B6 and may have problems at lower doses. Avoid excessive dosing. Vitamin B6 is likely safe when used orally in doses not exceeding the recommended dietary allowance (RDA). The RDA for pregnant women is 1.9 milligrams per day. For relief of severe nausea in early pregnancy, 30-75 milligrams has been used daily. There is some concern that high-dose pyridoxine taken by a pregnant mother can cause seizures in a newborn. The RDA in breastfeeding women is 2 milligrams per day. Use cautiously if pregnant or breastfeeding.
  • Vitamin D: In limited available study, vitamin D was found to be better than light therapy in the treatment of seasonal affective disorder (SAD). Further studies are necessary to confirm these findings.
  • Avoid if allergic or hypersensitive to vitamin D or any of its components. Vitamin D is generally well-tolerated in recommended doses; doses higher than recommended may cause toxic effects. Use cautiously with hyperparathyroidism (overactive thyroid), kidney disease, sarcoidosis, tuberculosis, and histoplasmosis. Vitamin D is safe in pregnant and breastfeeding women when taken in recommended doses.
  • Fair negative scientific evidence:
  • Psychotherapy: Several studies suggest that patients with psychotic depression are probably not good candidates for psychotherapy and that medication remains the optimal treatment. More research is needed to determine how psychotherapy may be of benefit in psychotic depression.
  • Psychotherapy cannot always resolve mental or emotional conditions. Psychiatric drugs are sometimes needed. In some cases, symptoms may get worse if the proper medication is not taken. Not all therapists are qualified to work with all problems. Use cautiously with serious mental illness or some medical conditions because some forms of psychotherapy may stir up strong emotional feelings and expression. Psychotherapy may help with post-partum depression, but is not a substitute for medication that may be needed in severe cases.

Prevention
  • The individual suffering from bipolar disorder should reduce stress and try to develop regular sleep patterns. Sleep disturbances may signal the early phase of a manic or depressive episode.
  • Limit or avoid common stimulants, such as caffeine and certain over-the-counter medications (pseudoephedrine or Sudafed®). Nervousness and anxiety may occur when using these, possibly triggering a manic episode. Some dietary supplements may also cause nervousness and anxiety, such as weight loss supplements that contain stimulants like caffeine, Citrus aurantium, green tea, and synephrine.
  • Learn to recognize the early warning signs and triggers of a bipolar relapse. Warning signs of relapse vary from patient to patient, and may include thoughts of death (or sudden optimism), or slight changes in sleep patterns (a common indicator), mood, energy, self-esteem, sexual interest, concentration, and willingness to take on new projects, and dress or grooming.
  • The individual with bipolar disorder should avoid using drugs and alcohol.

Author information
  • This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).

Bibliography
  1. American Academy of Child and Adolescent Psychiatry. . Accessed March 2, 2009.
  2. American Psychiatric Association. . Accessed March 2, 2009.
  3. National Alliance on Mental Health. . Accessed March 2, 2009.
  4. National Institute of Mental Health. . Accessed March 2, 2009.
  5. Natural Standard: The Authority on Integrative Medicine. Copyright © 2009. . Accessed March 2, 2009.

Causes
  • A variety of physical, genetic, environmental, and emotional factors seem to be involved in causing bipolar disorder.
  • Genetic Factors: As stated in risk factors, a gene has been linked with developing bipolar illness.
  • Neurotransmitters: Some studies suggest that a low or high level of neurotransmitters such as serotonin, norepinephrine, or dopamine may cause bipolar disorder. Studies have found evidence that a change in the sensitivity of the receptors on nerve cells to these neurotransmitters may be one issue, along with an imbalance in the amounts of neurotransmitters. Head trauma may cause chemical imbalances and result in bipolar disorder. Balancing neurotransmitters with drug therapy is the current focus for treatment of bipolar disorder.
  • Medications: High levels of digoxin, a common heart medication used for congestive heart failure (CHF), can also give rise to mania due to a toxic buildup of the drug in the body. Medications that have been reported to cause symptoms of bipolar include amphetamines, baclofen, bromocriptine, captopril, cimetidine, cocaine, corticosteroids (including adrenocorticotropic hormone or ACTHa), cyclosporine, disulfiram, hallucinogens, hydralazine, isoniazid, levodopa, methylphenidate, opiates and opioids such as phencyclidine (PCP), procarbazine, procyclidine and yohimbine.
  • Other causes: Stress (both physical and emotional), drug abuse (such as cocaine and methamphetamine), and mood changes that happen with the seasons (seasonal affective disorder or SAD), may trigger bipolar symptoms. Stress causes increases in the hormone cortisol, which may lead to neurochemical imbalances.

Risk factors
  • Bipolar disorder tends to run in families. A family history of depression appears to exist in 80 to 90% of cases of bipolar disorder. More than two-thirds of people with the disorder have a close relative with it or with depression. Recent research has identified a gene (DISC1) that is linked with developing bipolar disorder. This same gene may also influence the chances of getting schizophrenia and major depression.
  • Having certain coexisting medical conditions, or taking certain medications, may increase the risk for a manic syndrome. Conditions that have been linked with causing symptoms of bipolar disorder include attention deficit hyperactivity disorder (ADHD), acquired immunodeficiency syndrome (AIDS), extrapyramidal diseases or diseases of the nerves dealing with movement (Huntington's Disease, Parkinson's Disease), central nervous system infections (general paresis, viral encephalitis), cerebral neoplasms, cerebral trauma, cerebrovascular accidents, dialysis dementia, kidney problems, Kleine-Levin syndrome (the need for excessive sleep), Klinefelter's syndrome (genetic abnormality which increases risk of diseases), multiple sclerosis (MS, an inflammatory disease of the muscular system), pellagra (a vitamin B3 or niacin deficiency), Pick's disease (rare brain disease leading to dementia), postpartum mania (mania after having a baby), stroke, temporal lobe epilepsy, thyroid diseases, Wilson's disease (accumulation of copper), and Vitamin B12 deficiency.

Copyright © 2011 Natural Standard (www.naturalstandard.com)


The information in this monograph is intended for informational purposes only, and is meant to help users better understand health concerns. Information is based on review of scientific research data, historical practice patterns, and clinical experience. This information should not be interpreted as specific medical advice. Users should consult with a qualified healthcare provider for specific questions regarding therapies, diagnosis and/or health conditions, prior to making therapeutic decisions.

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