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| Meta Title | Information about Mental Illness and the Brain - NIH Curriculum Supplement Series - NCBI Bookshelf |
| Meta Description | 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. |
| Meta Canonical | null |
| Boilerpipe Text | Defining Mental Illness
1
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.
Mental Illness in the Population
2
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.
Mental Illness in Adults
Figure 1
Scientists estimate that one of every four people is affected by mental
illness either directly or indirectly.
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 in Children and Adolescents
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 Association
33
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.
Warning Signs for Mental Illness
3
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.
Diagnosing Mental Illness
3
Mental Health Professionals
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.
Mental Illnesses are Diagnosed by Symptoms
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.
Mental Illness and the Brain
4
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.
The Basics of Brain Function
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.
Figure 2
The neuron, or nerve cell, is the functional unit of the nervous system. The
neuron has processes called dendrites that receive signals and an axon that
transmits signals to another neuron.
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.
Figure 4
Neurons relay their information using both electrical signals and chemical
messages in a process called neurotransmission.
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.
Investigating Brain Function
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.
Figure 5
Scientists use a variety of imaging techniques to investigate brain structure
and function.
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.
The Causes of Mental Illnesses
5
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.
The Biology of Mental Illnesses
Figure 6
Scientists understand that mental illnesses are associated with changes in
neurochemicals. For example, in people who have depression, less of the
neurotransmitter serotonin (small circles) is released into the synaptic
space than in people who do not
(more...)
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.
Risk Factors for Mental Illnesses
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.
Treating Mental Illnesses
6
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
Figure 7
Medicines are one part of an effective treatment plan for mental
illnesses.
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
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 Stigma of Mental Illness
7
"The last great stigma of the twentieth century is the stigma of mental
illness."
—Tipper Gore, wife of the former U.S. Vice President
37
Figure 8
Words can hurt. Many derogatory words and phrases are used in relation to
mental illness. However, these words maintain the stereotyped image and not
the reality about mental illness. Try not to use these words, and encourage
students not to use them.
(more...)
"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.
The Consequences of Not Treating Mental Illness
8
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
Information about Specific Mental Illnesses
9
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
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
The symptoms of depression
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.
The causes of depression (depressive disorders)
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
Treating depression
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
Coping with depression
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
Suicide
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)
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 researcher
6
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 symptoms of ADHD
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-IV
5
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 causes of ADHD
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.
Treating 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
Coping with ADHD
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
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.
The symptoms of schizophrenia
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
The causes of schizophrenia
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
Treating schizophrenia
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.
Finding Help for Someone with Mental Illness
11
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:
http://www.nmha.org/nav/section/affiliate.cfm
.
The Additional Resources for Teachers section describes other online resources about
mental illnesses (page 53).
References
1.
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.
Booth B, Fellman W, Greenbaum J, Matlen T, Markel G, Morris H, Robin AL, Tzelepis A.
Myths about ADD/ADHD.
2001. Retrieved July 8, 2001, from
http://www
​.add.org/content/abc/myths
​.html
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Glossary
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.
acute
Refers to a disease or condition that has a rapid onset, marked intensity, and short duration.
antidepressant
A medication used to treat depression.
anxiety
An abnormal sense of fear, nervousness, and apprehension about something that might happen in the future.
anxiety disorder
Any 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).
autism
A 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.
axon
The long, fiberlike part of a neuron by which the cell carries information to target cells.
bipolar disorder
A 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.
cerebrum
The upper part of the brain that consists of the left and right hemispheres.
chronic
Refers to a disease or condition that persists over a long period of time.
cognition
Conscious mental activity that informs a person about his or her environment. Cognitive actions include perceiving, thinking, reasoning, judging, problem solving, and remembering.
conduct disorder
A 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.
delusion
A false belief that persists even when a person has evidence that the belief is not true.
dendrite
The 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.
disease
A synonym for illness. See illness.
disorder
An abnormality in mental or physical health. In this module, disorder is used as a synonym for illness.
dysthymia
A 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 therapy
See electroconvulsive therapy.
frontal lobe
One 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 matter
The portion of brain tissue that is dark in color. The gray matter consists primarily of nerve cell bodies, dendrites, and axon endings.
hallucination
The perception of something, such as a sound or visual image, that is not actually present other than in the mind.
hypothalamus
The part of the brain that controls several body functions, including feeding, breathing, drinking, temperature, and the release of many hormones.
illness
A 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 disorder
A 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.
mania
Feelings of intense mental and physical hyperactivity, elevated mood, and agitation.
manic-depression
See bipolar disorder.
mental illness
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.
mental retardation
A 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.
myelin
A 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.
neurosis
A 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.
neurotransmission
The process that occurs when a neuron releases neurotransmitters that relay a signal to another neuron across the synapse.
neurotransmitter
A 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 disorder
A 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 disorder
An 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.
phobia
An 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 gland
An 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.
positron
A 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 neuron
The neuron that receives messages from other neurons.
presynaptic neuron
The neuron that sends messages to other neurons by releasing neurotransmitters into the synapse.
psychiatrist
A 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.
psychiatry
The branch of medicine that deals with identifying, studying, and treating mental, emotional, and behavioral disorders.
psychologist
A 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.
psychosis
A serious mental disorder in which a person loses contact with reality and experiences hallucinations or delusions.
psychotherapy
A 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.
receptor
A molecule that recognizes specific chemicals, including neurotransmitters and hormones, and transmits the message into the cell on which the receptor resides.
relapse
The reoccurrence of symptoms of a disease.
reuptake pump
The large molecule that carries neurotransmitter molecules back into the presynaptic neuron from which they were released. Also referred to as a transporter.
risk
The chance or possibility of experiencing harm or loss.
risk factor
Something that increases a person's risk or susceptibility to harm.
schizophrenia
A 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.
serotonin
A 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.
stigma
A negative stereotype about a group of people.
St. John's wort
An 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.
symptom
Something that indicates the presence of a disease.
synapse
The site where presynaptic and postsynaptic neurons communicate with each other.
synaptic space
The intercellular space between a presynaptic and postsynaptic neuron. Also referred to as the synaptic cleft.
syndrome
A group of symptoms or signs that are characteristic of a disease. In this module, the word syndrome is used as a synonym for illness.
transporter
A 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.
ventricle
One of the cavities or spaces in the brain that are filled with cerebrospinal fluid.
vesicle
A membranous sac within an axon terminal that stores and releases neurotransmitters.
Footnotes
1
Relevant to Lessons 1, 2, and 5
2
Relevant to Lesson 3.
3
Relevant to Lessons 2, 3, 4, and 5.
4
Relevant to Lessons 1, 2, and 4.
5
Relevant to Lessons 2, and 3.
6
Relevant to Lessons 4 and 5.
7
Relevant to Lessons 1, 2, 3, 4, and 5.
8
Relevant to Lessons 4 and 5.
9
Relevant to Lessons 2, 3, 4, 5, and 6.
10
In 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.
11
Relevant to Lessons 1, 2, 3, 4, 5, and 6. |
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# Information about Mental Illness and the Brain
## Defining Mental Illness[1](https://www.ncbi.nlm.nih.gov/books/NBK20369/#A746)
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.
## Mental Illness in the Population[2](https://www.ncbi.nlm.nih.gov/books/NBK20369/#A747)
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r44)
> Few U.S. families are untouched by mental illness.
### Mental Illness in Adults
[](https://www.ncbi.nlm.nih.gov/books/NBK20369/figure/A738/?report=objectonly "Figure 1")
#### [Figure 1](https://www.ncbi.nlm.nih.gov/books/NBK20369/figure/A738/?report=objectonly)
Scientists estimate that one of every four people is affected by mental illness either directly or indirectly.
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r4), [25](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r25), [44](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r44)
- 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 in Children and Adolescents
Mental illness is not uncommon among children and adolescents. Approximately 12 million children under the age of 18 have mental disorders.[4](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r4) The National Mental Health Association[33](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r33) 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.
## Warning Signs for Mental Illness[3](https://www.ncbi.nlm.nih.gov/books/NBK20369/#A748)
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r4) 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.
## Diagnosing Mental Illness[3](https://www.ncbi.nlm.nih.gov/books/NBK20369/#A748)
### Mental Health Professionals
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.
### Mental Illnesses are Diagnosed by Symptoms
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r5) 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.
## Mental Illness and the Brain[4](https://www.ncbi.nlm.nih.gov/books/NBK20369/#A749)
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.
### The Basics of Brain Function
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.
[](https://www.ncbi.nlm.nih.gov/books/NBK20369/figure/A739/?report=objectonly "Figure 2")
#### [Figure 2](https://www.ncbi.nlm.nih.gov/books/NBK20369/figure/A739/?report=objectonly)
The neuron, or nerve cell, is the functional unit of the nervous system. The neuron has processes called dendrites that receive signals and an axon that transmits signals to another neuron.
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.
[](https://www.ncbi.nlm.nih.gov/books/NBK20369/figure/A740/?report=objectonly "Figure 3")
#### [Figure 3](https://www.ncbi.nlm.nih.gov/books/NBK20369/figure/A740/?report=objectonly)
Diagram of a synapse.
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.
[](https://www.ncbi.nlm.nih.gov/books/NBK20369/figure/A741/?report=objectonly "Figure 4")
#### [Figure 4](https://www.ncbi.nlm.nih.gov/books/NBK20369/figure/A741/?report=objectonly)
Neurons relay their information using both electrical signals and chemical messages in a process called neurotransmission.
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.
### Investigating Brain Function
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.
[](https://www.ncbi.nlm.nih.gov/books/NBK20369/figure/A742/?report=objectonly "Figure 5")
#### [Figure 5](https://www.ncbi.nlm.nih.gov/books/NBK20369/figure/A742/?report=objectonly)
Scientists use a variety of imaging techniques to investigate brain structure and function.
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.
## The Causes of Mental Illnesses[5](https://www.ncbi.nlm.nih.gov/books/NBK20369/#A750)
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.
### The Biology of Mental Illnesses
[](https://www.ncbi.nlm.nih.gov/books/NBK20369/figure/A743/?report=objectonly "Figure 6")
#### [Figure 6](https://www.ncbi.nlm.nih.gov/books/NBK20369/figure/A743/?report=objectonly)
Scientists understand that mental illnesses are associated with changes in neurochemicals. For example, in people who have depression, less of the neurotransmitter serotonin (small circles) is released into the synaptic space than in people who do not [(more...)](https://www.ncbi.nlm.nih.gov/books/NBK20369/figure/A743/?report=objectonly)
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.
### Risk Factors for Mental Illnesses
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.
## Treating Mental Illnesses[6](https://www.ncbi.nlm.nih.gov/books/NBK20369/#A751)
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
[](https://www.ncbi.nlm.nih.gov/books/NBK20369/figure/A744/?report=objectonly "Figure 7")
#### [Figure 7](https://www.ncbi.nlm.nih.gov/books/NBK20369/figure/A744/?report=objectonly)
Medicines are one part of an effective treatment plan for mental illnesses.
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r2)
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
**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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r3)
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r3)
## The Stigma of Mental Illness[7](https://www.ncbi.nlm.nih.gov/books/NBK20369/#A752)
> "The last great stigma of the twentieth century is the stigma of mental illness."
>
> —Tipper Gore, wife of the former U.S. Vice President[37](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r37)
[](https://www.ncbi.nlm.nih.gov/books/NBK20369/figure/A745/?report=objectonly "Figure 8")
#### [Figure 8](https://www.ncbi.nlm.nih.gov/books/NBK20369/figure/A745/?report=objectonly)
Words can hurt. Many derogatory words and phrases are used in relation to mental illness. However, these words maintain the stereotyped image and not the reality about mental illness. Try not to use these words, and encourage students not to use them. [(more...)](https://www.ncbi.nlm.nih.gov/books/NBK20369/figure/A745/?report=objectonly)
"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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r11)
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r11), [44](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r44) 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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r34) This is a substantial increase over the 38 percent of survey respondents in 1991 who recognized depression as a disease.
## The Consequences of Not Treating Mental Illness[8](https://www.ncbi.nlm.nih.gov/books/NBK20369/#A753)
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r45)
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r45) 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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r44) Depression in youth may predict more severe illness in adult life.[27](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r27) 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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r14)
> 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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r46) 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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r26) 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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r44)
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r3)
## Information about Specific Mental Illnesses[9](https://www.ncbi.nlm.nih.gov/books/NBK20369/#A754)
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
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r28) Nearly twice as many women as men have depression.[25](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r25) 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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r22)
#### The symptoms of depression
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r23), [27](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r27) They are
- **major depressive disorder**,[10](https://www.ncbi.nlm.nih.gov/books/NBK20369/#A755)
- **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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r27) 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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r44)
In children, depression lasts an average of seven to nine months with symptoms similar to those in adults.[44](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r44) 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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r44)
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r22) 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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r25) On average, untreated dysthymia lasts four years in children and adolescents.[44](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r44)
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r27)
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r29) 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.
#### The causes of depression (depressive disorders)
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r44) 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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r22)
> 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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r13) PET imaging has also shown that depressed patients have lower neurotransmitter receptor binding potential in some areas of the brain.[48](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r48) 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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r42)
#### Treating depression
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r23)
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r44) 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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r1)
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r44)
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r23) 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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r31)
#### Coping with depression
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r23)
#### Suicide
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r22), [25](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r25) Over 90 percent of these people had a mental illness, typically either a depressive disorder or a substance-abuse disorder.[25](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r25) 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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r22)
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r44) 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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r44)
### Attention Deficit Hyperactivity Disorder (ADHD)
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r25) Although ADHD is usually associated with children, the disorder can persist into adulthood.[19](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r19) One researcher[6](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r6) 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 symptoms of ADHD
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r19) 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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r18), [30](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r30), [44](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r44)
The DSM-IV[5](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r5) 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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r19)
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 causes of ADHD
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r7), [19](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r19) 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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r24) 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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r44) 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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r8) 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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r9) 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.
#### Treating 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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r40) Nine out of 10 children improve while taking one of these drugs.[19](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r19)
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r24)
> 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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r24)
#### Coping with ADHD
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
Schizophrenia affects approximately 1 percent of the population, or 2.2 million U.S. adults. Men and women are equally affected.[25](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r25), [32](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r32) 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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r21) 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.
#### The symptoms of schizophrenia
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r32) 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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r5)
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r5)
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r44)
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r32) 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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r44)
#### The causes of schizophrenia
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r20), [36](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r36)
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r44) 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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r12) 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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r38), [39](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r39), [41](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r41) 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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r47) 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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r43)
#### Treating schizophrenia
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r44)
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r32)
People who manage schizophrenia best combine medication with psychosocial rehabilitation (life-skills training).[17](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r17) 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.
## Finding Help for Someone with Mental Illness[11](https://www.ncbi.nlm.nih.gov/books/NBK20369/#A756)
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: *<http://www.nmha.org/nav/section/affiliate.cfm>.*
The Additional Resources for Teachers section describes other online resources about mental illnesses (page 53).
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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
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National Institute of Mental Health. The numbers count: Mental disorders in America. 2001a. Retrieved July 3, 2001, from
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26\.
National Institute of Mental Health. The impact of mental illness on society. 2001b. Retrieved June 27, 2001, from
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National Institute of Mental Health. The invisible disease: Depression. 2001d. Retrieved June 27, 2001, from
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National Institute of Mental Health. Bipolar disorder. 2001e. Retrieved July 17, 2001, from
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National Institute of Mental Health. Attention deficit hyperactivity disorder. 2001f. Retrieved June 27, 2001, from
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National Institute of Mental Health. Information about St. John’s wort. 2001g. Retrieved July 13, 2001, from
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National Institute of Mental Health. When someone has schizophrenia. 2001h. Retrieved June 28, 2001, from
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National Mental Health Association. Did you know? Retrieved July 3, 2001, from
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National Mental Health Association. Depression survey reveals dramatic changes in public opinion: Disease or state of mind? 2001. Retrieved July 18, 2001, from
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National Research Council. National Science Education Standards. Washington, DC: National Academies Press; 1996.
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Pearlson GD. Neurobiology of schizophrenia. Annals of Neurology. 2000;48:556–566. \[[PubMed: 11026439](https://pubmed.ncbi.nlm.nih.gov/11026439)\]
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Pfizer Inc. Mental illness stigma and bias assailed at historic White House conference. Pfizer Views. 2000. Making News. Retrieved July 15, 2003, from
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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. \[[PubMed: 11437799](https://pubmed.ncbi.nlm.nih.gov/11437799)\]
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. \[[PubMed: 9337768](https://pubmed.ncbi.nlm.nih.gov/9337768)\]
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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
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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. \[[PubMed: 10982495](https://pubmed.ncbi.nlm.nih.gov/10982495)\]
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Stoll AL, Renshaw PF, Yurgelun-Todd DA, Cohen BM. Neuroimaging in bipolar disorder: What have we learned? Biological Psychiatry. 2000;15:505–517. \[[PubMed: 11018223](https://pubmed.ncbi.nlm.nih.gov/11018223)\]
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. \[[PMC free article: PMC58784](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC58784/)\] \[[PubMed: 11573002](https://pubmed.ncbi.nlm.nih.gov/11573002)\]
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Veggeberg SK. The big story in depression: What isn’t happening. Brainwork—The Neuroscience Newsletter. 1997. Retrieved July 3, 2001, from
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Weinberger D, Torrey EF, Berman K. Schizophrenia PET scan. 1990. Retrieved July 13, 2001, from
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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. \[[PubMed: 10986548](https://pubmed.ncbi.nlm.nih.gov/10986548)\]
## Glossary
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.
acute
Refers to a disease or condition that has a rapid onset, marked intensity, and short duration.
antidepressant
A medication used to treat depression.
anxiety
An abnormal sense of fear, nervousness, and apprehension about something that might happen in the future.
anxiety disorder
Any 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).
autism
A 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.
axon
The long, fiberlike part of a neuron by which the cell carries information to target cells.
bipolar disorder
A 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.
cerebrum
The upper part of the brain that consists of the left and right hemispheres.
chronic
Refers to a disease or condition that persists over a long period of time.
cognition
Conscious mental activity that informs a person about his or her environment. Cognitive actions include perceiving, thinking, reasoning, judging, problem solving, and remembering.
conduct disorder
A 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.
delusion
A false belief that persists even when a person has evidence that the belief is not true.
dendrite
The 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.
disease
A synonym for illness. See illness.
disorder
An abnormality in mental or physical health. In this module, disorder is used as a synonym for illness.
dysthymia
A 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 therapy
See electroconvulsive therapy.
frontal lobe
One 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 matter
The portion of brain tissue that is dark in color. The gray matter consists primarily of nerve cell bodies, dendrites, and axon endings.
hallucination
The perception of something, such as a sound or visual image, that is not actually present other than in the mind.
hypothalamus
The part of the brain that controls several body functions, including feeding, breathing, drinking, temperature, and the release of many hormones.
illness
A 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 disorder
A 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.
mania
Feelings of intense mental and physical hyperactivity, elevated mood, and agitation.
manic-depression
See bipolar disorder.
mental illness
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.
mental retardation
A 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.
myelin
A 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.
neurosis
A 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.
neurotransmission
The process that occurs when a neuron releases neurotransmitters that relay a signal to another neuron across the synapse.
neurotransmitter
A 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 disorder
A 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 disorder
An 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.
phobia
An 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 gland
An 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.
positron
A 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 neuron
The neuron that receives messages from other neurons.
presynaptic neuron
The neuron that sends messages to other neurons by releasing neurotransmitters into the synapse.
psychiatrist
A 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.
psychiatry
The branch of medicine that deals with identifying, studying, and treating mental, emotional, and behavioral disorders.
psychologist
A 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.
psychosis
A serious mental disorder in which a person loses contact with reality and experiences hallucinations or delusions.
psychotherapy
A 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.
receptor
A molecule that recognizes specific chemicals, including neurotransmitters and hormones, and transmits the message into the cell on which the receptor resides.
relapse
The reoccurrence of symptoms of a disease.
reuptake pump
The large molecule that carries neurotransmitter molecules back into the presynaptic neuron from which they were released. Also referred to as a transporter.
risk
The chance or possibility of experiencing harm or loss.
risk factor
Something that increases a person's risk or susceptibility to harm.
schizophrenia
A 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.
serotonin
A 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.
stigma
A negative stereotype about a group of people.
St. John's wort
An 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.
symptom
Something that indicates the presence of a disease.
synapse
The site where presynaptic and postsynaptic neurons communicate with each other.
synaptic space
The intercellular space between a presynaptic and postsynaptic neuron. Also referred to as the synaptic cleft.
syndrome
A group of symptoms or signs that are characteristic of a disease. In this module, the word syndrome is used as a synonym for illness.
transporter
A 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.
ventricle
One of the cavities or spaces in the brain that are filled with cerebrospinal fluid.
vesicle
A membranous sac within an axon terminal that stores and releases neurotransmitters.
## Footnotes
1
Relevant to Lessons 1, 2, and 5
2
Relevant to Lesson 3.
3
Relevant to Lessons 2, 3, 4, and 5.
4
Relevant to Lessons 1, 2, and 4.
5
Relevant to Lessons 2, and 3.
6
Relevant to Lessons 4 and 5.
7
Relevant to Lessons 1, 2, 3, 4, and 5.
8
Relevant to Lessons 4 and 5.
9
Relevant to Lessons 2, 3, 4, 5, and 6.
10
In 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.
11
Relevant to Lessons 1, 2, 3, 4, 5, and 6.
[Copyright](https://www.ncbi.nlm.nih.gov/books/about/copyright/) © 2007-, BSCS.
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National Institutes of Health (US); Biological Sciences Curriculum Study. NIH Curriculum Supplement Series \[Internet\]. Bethesda (MD): National Institutes of Health (US); 2007. Information about Mental Illness and the Brain.
### In this Page
- [Defining Mental Illness](https://www.ncbi.nlm.nih.gov/books/NBK20369/#A571)
- [Mental Illness in the Population](https://www.ncbi.nlm.nih.gov/books/NBK20369/#A572)
- [Warning Signs for Mental Illness](https://www.ncbi.nlm.nih.gov/books/NBK20369/#A590)
- [Diagnosing Mental Illness](https://www.ncbi.nlm.nih.gov/books/NBK20369/#A601)
- [Mental Illness and the Brain](https://www.ncbi.nlm.nih.gov/books/NBK20369/#A604)
- [The Causes of Mental Illnesses](https://www.ncbi.nlm.nih.gov/books/NBK20369/#A607)
- [Treating Mental Illnesses](https://www.ncbi.nlm.nih.gov/books/NBK20369/#A619)
- [The Stigma of Mental Illness](https://www.ncbi.nlm.nih.gov/books/NBK20369/#A626)
- [The Consequences of Not Treating Mental Illness](https://www.ncbi.nlm.nih.gov/books/NBK20369/#A631)
- [Information about Specific Mental Illnesses](https://www.ncbi.nlm.nih.gov/books/NBK20369/#A632)
- [Finding Help for Someone with Mental Illness](https://www.ncbi.nlm.nih.gov/books/NBK20369/#A737)
- [References](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.s1)
- [Glossary](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_glossary.s1)
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| Readable Markdown | ## Defining Mental Illness[1](https://www.ncbi.nlm.nih.gov/books/NBK20369/#A746)
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.
## Mental Illness in the Population[2](https://www.ncbi.nlm.nih.gov/books/NBK20369/#A747)
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r44)
> Few U.S. families are untouched by mental illness.
### Mental Illness in Adults
[](https://www.ncbi.nlm.nih.gov/books/NBK20369/figure/A738/?report=objectonly "Figure 1")
#### [Figure 1](https://www.ncbi.nlm.nih.gov/books/NBK20369/figure/A738/?report=objectonly)
Scientists estimate that one of every four people is affected by mental illness either directly or indirectly.
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r4), [25](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r25), [44](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r44)
- 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 in Children and Adolescents
Mental illness is not uncommon among children and adolescents. Approximately 12 million children under the age of 18 have mental disorders.[4](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r4) The National Mental Health Association[33](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r33) 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.
## Warning Signs for Mental Illness[3](https://www.ncbi.nlm.nih.gov/books/NBK20369/#A748)
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r4) 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.
## Diagnosing Mental Illness[3](https://www.ncbi.nlm.nih.gov/books/NBK20369/#A748)
### Mental Health Professionals
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.
### Mental Illnesses are Diagnosed by Symptoms
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r5) 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.
## Mental Illness and the Brain[4](https://www.ncbi.nlm.nih.gov/books/NBK20369/#A749)
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.
### The Basics of Brain Function
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.
[](https://www.ncbi.nlm.nih.gov/books/NBK20369/figure/A739/?report=objectonly "Figure 2")
#### [Figure 2](https://www.ncbi.nlm.nih.gov/books/NBK20369/figure/A739/?report=objectonly)
The neuron, or nerve cell, is the functional unit of the nervous system. The neuron has processes called dendrites that receive signals and an axon that transmits signals to another neuron.
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.
[](https://www.ncbi.nlm.nih.gov/books/NBK20369/figure/A740/?report=objectonly "Figure 3")
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.
[](https://www.ncbi.nlm.nih.gov/books/NBK20369/figure/A741/?report=objectonly "Figure 4")
#### [Figure 4](https://www.ncbi.nlm.nih.gov/books/NBK20369/figure/A741/?report=objectonly)
Neurons relay their information using both electrical signals and chemical messages in a process called neurotransmission.
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.
### Investigating Brain Function
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.
[](https://www.ncbi.nlm.nih.gov/books/NBK20369/figure/A742/?report=objectonly "Figure 5")
#### [Figure 5](https://www.ncbi.nlm.nih.gov/books/NBK20369/figure/A742/?report=objectonly)
Scientists use a variety of imaging techniques to investigate brain structure and function.
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.
## The Causes of Mental Illnesses[5](https://www.ncbi.nlm.nih.gov/books/NBK20369/#A750)
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.
### The Biology of Mental Illnesses
[](https://www.ncbi.nlm.nih.gov/books/NBK20369/figure/A743/?report=objectonly "Figure 6")
#### [Figure 6](https://www.ncbi.nlm.nih.gov/books/NBK20369/figure/A743/?report=objectonly)
Scientists understand that mental illnesses are associated with changes in neurochemicals. For example, in people who have depression, less of the neurotransmitter serotonin (small circles) is released into the synaptic space than in people who do not [(more...)](https://www.ncbi.nlm.nih.gov/books/NBK20369/figure/A743/?report=objectonly)
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.
### Risk Factors for Mental Illnesses
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.
## Treating Mental Illnesses[6](https://www.ncbi.nlm.nih.gov/books/NBK20369/#A751)
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
[](https://www.ncbi.nlm.nih.gov/books/NBK20369/figure/A744/?report=objectonly "Figure 7")
#### [Figure 7](https://www.ncbi.nlm.nih.gov/books/NBK20369/figure/A744/?report=objectonly)
Medicines are one part of an effective treatment plan for mental illnesses.
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r2)
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
**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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r3)
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r3)
## The Stigma of Mental Illness[7](https://www.ncbi.nlm.nih.gov/books/NBK20369/#A752)
> "The last great stigma of the twentieth century is the stigma of mental illness."
>
> —Tipper Gore, wife of the former U.S. Vice President[37](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r37)
[](https://www.ncbi.nlm.nih.gov/books/NBK20369/figure/A745/?report=objectonly "Figure 8")
#### [Figure 8](https://www.ncbi.nlm.nih.gov/books/NBK20369/figure/A745/?report=objectonly)
Words can hurt. Many derogatory words and phrases are used in relation to mental illness. However, these words maintain the stereotyped image and not the reality about mental illness. Try not to use these words, and encourage students not to use them. [(more...)](https://www.ncbi.nlm.nih.gov/books/NBK20369/figure/A745/?report=objectonly)
"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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r11)
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r11), [44](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r44) 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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r34) This is a substantial increase over the 38 percent of survey respondents in 1991 who recognized depression as a disease.
## The Consequences of Not Treating Mental Illness[8](https://www.ncbi.nlm.nih.gov/books/NBK20369/#A753)
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r45)
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r45) 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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r44) Depression in youth may predict more severe illness in adult life.[27](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r27) 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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r14)
> 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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r46) 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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r26) 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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r44)
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r3)
## Information about Specific Mental Illnesses[9](https://www.ncbi.nlm.nih.gov/books/NBK20369/#A754)
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
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r28) Nearly twice as many women as men have depression.[25](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r25) 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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r22)
#### The symptoms of depression
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r23), [27](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r27) They are
- **major depressive disorder**,[10](https://www.ncbi.nlm.nih.gov/books/NBK20369/#A755)
- **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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r27) 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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r44)
In children, depression lasts an average of seven to nine months with symptoms similar to those in adults.[44](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r44) 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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r44)
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r22) 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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r25) On average, untreated dysthymia lasts four years in children and adolescents.[44](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r44)
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r27)
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r29) 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.
#### The causes of depression (depressive disorders)
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r44) 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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r22)
> 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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r13) PET imaging has also shown that depressed patients have lower neurotransmitter receptor binding potential in some areas of the brain.[48](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r48) 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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r42)
#### Treating depression
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r23)
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r44) 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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r1)
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r44)
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r23) 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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r31)
#### Coping with depression
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r23)
#### Suicide
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r22), [25](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r25) Over 90 percent of these people had a mental illness, typically either a depressive disorder or a substance-abuse disorder.[25](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r25) 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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r22)
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r44) 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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r44)
### Attention Deficit Hyperactivity Disorder (ADHD)
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r25) Although ADHD is usually associated with children, the disorder can persist into adulthood.[19](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r19) One researcher[6](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r6) 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 symptoms of ADHD
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r19) 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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r18), [30](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r30), [44](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r44)
The DSM-IV[5](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r5) 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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r19)
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 causes of ADHD
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r7), [19](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r19) 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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r24) 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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r44) 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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r8) 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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r9) 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.
#### Treating 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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r40) Nine out of 10 children improve while taking one of these drugs.[19](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r19)
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r24)
> 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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r24)
#### Coping with ADHD
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
Schizophrenia affects approximately 1 percent of the population, or 2.2 million U.S. adults. Men and women are equally affected.[25](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r25), [32](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r32) 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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r21) 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.
#### The symptoms of schizophrenia
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r32) 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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r5)
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r5)
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r44)
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r32) 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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r44)
#### The causes of schizophrenia
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r20), [36](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r36)
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r44) 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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r12) 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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r38), [39](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r39), [41](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r41) 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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r47) 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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r43)
#### Treating schizophrenia
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r44)
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](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r32)
People who manage schizophrenia best combine medication with psychosocial rehabilitation (life-skills training).[17](https://www.ncbi.nlm.nih.gov/books/NBK20369/#mental_brain_references.r17) 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.
## Finding Help for Someone with Mental Illness[11](https://www.ncbi.nlm.nih.gov/books/NBK20369/#A756)
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: *<http://www.nmha.org/nav/section/affiliate.cfm>.*
The Additional Resources for Teachers section describes other online resources about mental illnesses (page 53).
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## Glossary
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.
acute
Refers to a disease or condition that has a rapid onset, marked intensity, and short duration.
antidepressant
A medication used to treat depression.
anxiety
An abnormal sense of fear, nervousness, and apprehension about something that might happen in the future.
anxiety disorder
Any 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).
autism
A 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.
axon
The long, fiberlike part of a neuron by which the cell carries information to target cells.
bipolar disorder
A 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.
cerebrum
The upper part of the brain that consists of the left and right hemispheres.
chronic
Refers to a disease or condition that persists over a long period of time.
cognition
Conscious mental activity that informs a person about his or her environment. Cognitive actions include perceiving, thinking, reasoning, judging, problem solving, and remembering.
conduct disorder
A 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.
delusion
A false belief that persists even when a person has evidence that the belief is not true.
dendrite
The 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.
disease
A synonym for illness. See illness.
disorder
An abnormality in mental or physical health. In this module, disorder is used as a synonym for illness.
dysthymia
A 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 therapy
See electroconvulsive therapy.
frontal lobe
One 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 matter
The portion of brain tissue that is dark in color. The gray matter consists primarily of nerve cell bodies, dendrites, and axon endings.
hallucination
The perception of something, such as a sound or visual image, that is not actually present other than in the mind.
hypothalamus
The part of the brain that controls several body functions, including feeding, breathing, drinking, temperature, and the release of many hormones.
illness
A 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 disorder
A 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.
mania
Feelings of intense mental and physical hyperactivity, elevated mood, and agitation.
manic-depression
See bipolar disorder.
mental illness
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.
mental retardation
A 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.
myelin
A 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.
neurosis
A 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.
neurotransmission
The process that occurs when a neuron releases neurotransmitters that relay a signal to another neuron across the synapse.
neurotransmitter
A 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 disorder
A 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 disorder
An 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.
phobia
An 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 gland
An 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.
positron
A 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 neuron
The neuron that receives messages from other neurons.
presynaptic neuron
The neuron that sends messages to other neurons by releasing neurotransmitters into the synapse.
psychiatrist
A 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.
psychiatry
The branch of medicine that deals with identifying, studying, and treating mental, emotional, and behavioral disorders.
psychologist
A 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.
psychosis
A serious mental disorder in which a person loses contact with reality and experiences hallucinations or delusions.
psychotherapy
A 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.
receptor
A molecule that recognizes specific chemicals, including neurotransmitters and hormones, and transmits the message into the cell on which the receptor resides.
relapse
The reoccurrence of symptoms of a disease.
reuptake pump
The large molecule that carries neurotransmitter molecules back into the presynaptic neuron from which they were released. Also referred to as a transporter.
risk
The chance or possibility of experiencing harm or loss.
risk factor
Something that increases a person's risk or susceptibility to harm.
schizophrenia
A 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.
serotonin
A 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.
stigma
A negative stereotype about a group of people.
St. John's wort
An 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.
symptom
Something that indicates the presence of a disease.
synapse
The site where presynaptic and postsynaptic neurons communicate with each other.
synaptic space
The intercellular space between a presynaptic and postsynaptic neuron. Also referred to as the synaptic cleft.
syndrome
A group of symptoms or signs that are characteristic of a disease. In this module, the word syndrome is used as a synonym for illness.
transporter
A 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.
ventricle
One of the cavities or spaces in the brain that are filled with cerebrospinal fluid.
vesicle
A membranous sac within an axon terminal that stores and releases neurotransmitters.
## Footnotes
1
Relevant to Lessons 1, 2, and 5
2
Relevant to Lesson 3.
3
Relevant to Lessons 2, 3, 4, and 5.
4
Relevant to Lessons 1, 2, and 4.
5
Relevant to Lessons 2, and 3.
6
Relevant to Lessons 4 and 5.
7
Relevant to Lessons 1, 2, 3, 4, and 5.
8
Relevant to Lessons 4 and 5.
9
Relevant to Lessons 2, 3, 4, 5, and 6.
10
In 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.
11
Relevant to Lessons 1, 2, 3, 4, 5, and 6. |
| Shard | 129 (laksa) |
| Root Hash | 7295144728021232729 |
| Unparsed URL | gov,nih!nlm,ncbi,www,/books/NBK20369/ s443 |