She was so excited when his proposal finally came. Things were going to be different now. Valerie's fiancé, a police officer and war veteran, promised to get his act together, and they'd be married in a few months. He would get off the booze and off the couch. He would see someone about his depressed mood. But the promises were empty. Paul drove to the beach, sat in the deserted parking lot, placed a gun to his head, and pulled the trigger. No note, no explanation. His pain was over and hers had just begun. She was wracked with guilt wondering why she didn't see it coming.

During any one-year period, more than 19 million Americans - 10% of the population - suffer from a depressive illness.¹ And 15% of depressed patients attempt suicide, very often using a firearm. In an interview, Laurie Flynn, the executive director of the National Alliance for the Mentally Ill, said, "It is easier and cheaper to get a gun and kill yourself than to get treatment."²

In the U.S., 31,484 people died by suicide in 2003 (the last year for which we have national statistics). That's one lost life every 17 minutes. The number of suicide attempts - 25 times higher than actual suicides - is downright frightening. It's no wonder that suicide is ranked as the 11th leading cause of death in America.³

The picture becomes gloomier when you add cases not included in these official suicide statistics: the misclassifications of the cause of death, accidents of undetermined cause, and the so-called "chronic suicides." Chronic suicides are deaths that result through the use of alcohol and other substances and consciously poor adherence to medical regimens for diabetes, obesity, hypertension, and other illnesses.

On the bright side, a Senate committee convened in 1998 to hold the first Congressional hearings on suicide. For the first time ever, the Surgeon General made preventing suicide one of his priorities. The health care community has plenty to tackle when it comes to preventing suicide.

Who's Vulnerable?

Aged Population: Older people attempt suicide less often than do younger people, but are more likely to complete the act. Although they account for only 10% of the population, older people account for 25% of suicides. Sadly, loneliness is the most common reason cited by older adults who consider suicide.⁴ Depressive symptoms are found in about 15% of all older adult community residents and nursing home patients. And although advanced age itself is not considered a risk factor for depression, being widowed and having a chronic medical illness make people vulnerable to depressive disorders.

Illness: Of the approximately 80 persons who complete suicide each day in the United States,³ about 25% to 75% suffer from a chronic disease.⁴ Contact with a primary care provider by suicide victims during the time leading up to suicide is remarkably common. In a review of 40 studies 45% of suicide victims had a primary care visit within a month of suicide. Compared to younger adults, the elderly who visited primary care had the highest rates of suicide following an office visit. In some cases these patients may have acted in response to a diagnosis or negative news about their health during the physician visit.⁵

Other Triggers: Separation, rejection, unemployment, legal troubles, and illness are all associated with suicide. The common thread in these events is loss and alienation. Suicide occurs more frequently in people who are socially isolated and have a family history of suicide or suicide attempt. In addition, the loss of a purpose, a core belief, or meaning can have profound repercussions on a person's sense of safety and trust.

Highly significant psychiatric factors related to suicide include substance abuse, depressive disorders, schizophrenia, and other mental disorders, such as anxiety. Almost 95% of all people who commit or attempt suicide have a diagnosed mental disorder.⁴ Depressive disorders account for 80% of this figure and many of these patients have been dually diagnosed with alcohol dependency. The suicide risk for people with depressive disorders is nearly 15%. Almost 15% of all alcohol-dependent people commit suicide, 80% of whom are men.⁶

Those who have made a prior attempt are also quite vulnerable. About 40% of depressed patients who commit suicide have made a previous attempt. The risk is greatest within three months of the first try. In outpatients, most depressed patients had a history of therapy. However, less than half were receiving psychiatric treatment at the time of the suicide attempt. Those in treatment often had suboptimal care, including subtherapeutic doses of antidepressants.⁴

Men commit suicide more than four times as often as women do. The lethality of the method of suicide chosen by men is reflected in their higher completion rate. Common methods include firearms, hanging, and jumping from high places. Women are three times more likely to attempt suicide than men, but choose less lethal methods, such as overdosing on psychoactive substances or poison. The lethality of the suicide plan is pivotal to the potential "success" of the plan. In evaluating the risk for suicide, the details of a plan (if any) and access to a lethal means of self-harm are components of the assessment.³

Marriage lessens the risk of suicide and having children further decreases the risk.⁴ Single, never-married people register an overall rate of nearly double that for married persons. Previously married persons, however, show sharply higher rates than do people who never married.

Chronic Disease Adds to the Risk

Depression may result when severe physical and cognitive impairments prevent the patient from enjoying life and engaging in the activities that previously had brought pleasure and meaning. The lack of purpose in life may lead to thoughts of death and actual suicide.

Physical illness is an independent risk factor both for depression and suicide.⁴ Consider, for example, that depressive symptoms are commonly exhibited in patients with neurological problems. Parkinson's disease, Alzheimer's disease, epilepsy, cerebrovascular accidents, and tumors are conditions that are often cited as culprits in depression.⁷ In cerebral vascular accidents (CVA), 10% to 27% of Americans who suffer a first or recurrent stroke experience major depression.⁸

Just as chronic illness can lead to depression, depression affects the course and duration of chronic illness. Studies suggest that depressed patients who also suffer from diabetes are more likely to develop diabetic complications than those without depression.⁹ One landmark study demonstrated that women with metastatic breast cancer who had group psychotherapy had lower levels of depression and lived twice as long as women who did not have this intervention.¹⁰ Because depressed patients lack energy and motivation, they are not likely to take the time and effort to eat well, exercise, or foster meaningful interpersonal relationships. They also are unlikely to engage in regular health care activities such as checking blood sugar or keeping medical appointments.

Diseases of the central nervous system (CNS) tend to raise the risk of suicide. Epilepsy, multiple sclerosis, head injury, Huntington's disease, and dementia top the list. While mood disturbances are associated with these disorders, the endocrine disorders (i.e. Cushing's disease, Klinefelter's syndrome, and porphyria), cardiovascular diseases, and HIV/AIDS are also associated with an increased suicide risk.

Cirrhosis and peptic ulcer, more commonly associated with alcohol dependency, also are linked with increased suicide risk. Two urological conditions - prostatic hypertrophy, treated with prostatectomy, and renal disease, treated with dialysis - are associated with risk of suicide.⁴

Cancer patients, too, are at a greater risk for suicide. The highest risk factors for suicide attempts in cancer patients are the site of the disease (head and neck, pancreas, and lungs), a poor prognosis, and suboptimal pain relief.⁵ These cancer patients may view suicide as a viable relief from pain, disfigurement, dependency, loss of body integrity, or quality of life. For some, suicide may be enacted earlier in the disease process in anticipation of misery and physical demise. Of men with cancer who commit suicide, 50% of them do so within one year of receiving the diagnosis. Of women with cancer who commit suicide, 70% of them have malignancies involving the breasts or reproductive organs.¹¹

Factors associated with physical illness that contribute to suicide, suicide attempts, and depression are loss of mobility, especially when physical activity is important to the individual, whether it be in his or her occupation or recreation; disfigurement; and intractable pain.¹¹ While about one in 20 American adults experiences major depression in a given year, the number rises dramatically to about one in three who have survived a heart attack. Certain types of medications, such as antihypertensives that may cause mood-related side effects, can contribute to an increased risk for suicide.¹²

A Word About Pain: Approximately 60% of patients with depression report pain symptoms at the time of diagnosis. The presence of a depressive disorder increases the risk of musculoskeletal pain, headache, and chest pain. A multidisciplinary approach including psychopharmocology and psychotherapy as well as pain management is essential in treating patients who have depression concomitant with chronic pain. Patients suffering with severe pain who have no previous history of depression are also at risk for suicide when ending their life is viewed as the only viable option to relieving the unrelenting physical misery.¹³

Valerie, like many loved ones of those who suffer from depression and suicidal thoughts, was likely too connected to the situation with her fiancé to view his condition objectively or in its entirety. Family members may want so desperately for the depressed patient to be OK that they minimize or even deny the existence of this serious problem. In hindsight one can see Valerie's fiancé experienced a number of suicide risk factors. Just being male puts him at risk. Plus he was using alcohol, which lowers inhibition and thereby increases the chances of an impulsive act like shooting oneself. Further, this patient worked in law enforcement, which gave him access to, and experience with firearms. The fact that Valerie's fiancé was not receiving any treatment for his depressive symptoms placed him at considerable risk for suicide.

Seeing the Warning Signs

People contemplating suicide often exhibit warning signs. The list of behaviors, thoughts, emotions, and circumstances when clustered warrant need for urgent mental health evalution.^6,14

• Talks about suicide.
• Increasing isolation; withdraws from friends and/or social activities.
• Loses interest in hobbies, work, school, and personal appearance.
• Trouble eating or sleeping.
• Preoccupation with death, dying, and morbid subjects.
• Attempted suicide before.
• Putting affairs in order, such as giving away prized possessions, drawing up a will, and writing goodbye or "forgive me" letters.
• Unnecessary risks; increases use of alcohol or drugs.
• Direct and indirect statements about dying, such as "I wish I were dead" or "I won't be here when you get back."
• Recent severe losses.
• Making a plan and getting the tools ready, including hoarding prescription drugs or obtaining flammable substances.
• A sudden improvement in mood, which may indicate the patient's relief that a decision has been made to commit suicide. Experiences drastic changes in behavior.

Categorizing the severity of the risk for suicide necessitates a differentiation between attempts, gestures, threats, and ideation.¹⁴ An attempt is an act intended to cause death. A gesture is an act intended to result in minimal self-harm. A threat is a statement of intent to commit suicide. Ideations are thoughts about one's intent to attempt suicide. In general, a person with vague ideas, but no actual plan, is at lower risk than a patient with a preoccupation with suicidal ideas, or who has a specific plan and the means to carry it out.

Determining Suicidality

Talking with a depressed person about suicide will not cause a person to become suicidal. Instead, it may foster a stronger therapeutic bond of care, afford the patient some relief, alleviate isolation and hopelessness, and create an avenue for intervention, advocacy, and education.¹⁴ Nurses need to be able to talk with their patients. A frank yet empathetic dialogue facilitates both the nursing assessment for suicidality and referral for appropriate intervention when required. Home-care nurses and other nurses who work in sites of care, without on-site psychiatric professionals, need to be especially versed in assessment skills and agency referral procedures. Further, the visiting nurse is instrumental because patients at risk for suicide and depression are likely to disclose to the care provider with whom they have regular contact and with whom they have developed a relationship.

Here are some ways to be helpful:¹⁴

• Upon identifying that the patient is depressed and possibly suicidal, be direct. Talk openly and matter-of-factly about suicide.
• Be willing to listen. Be nonjudgmental.
• Get involved. Become available. Show your interest and support.
• Offer hope that alternatives are available.
• Take action. Facilitate the removal of the means (guns, rope). (FYI: The nurse should not actually remove the firearm herself.)
• When appropriate, discuss with caregiver and family members ways to keep the patient from harming him- or herself.
• Become sensitive and attuned to patients' feelings. They may feel or think they can't stop the pain; can't think clearly; can't see a way out; can't get out of depression; can't get someone's attention.
• Refer to emergency psychiatric services if the patient is unable to contract not to harm him- or herself.

Identifying Depression in Any Setting

Studies in the primary care and ambulatory practice have found that physicians often fail to recognize depression in their patients.¹⁵ Despite compelling prevalence statistics of depression in cancer patients, strong evidence exists that physicians and nurses do not recognize depression in their oncology patients. In a study of six oncologists treating more than 1,000 patients, these physicians displayed a marked tendency to underestimate the level of depression in patients who were the most depressed.¹⁶ When other types of global distress (such as pain or anxiety) were present, symptoms such as crying and diagnosed depression most influenced the oncologists. Physicians' ratings of depression were most highly correlated with physicians' ratings of patients' anxiety and pain. The researchers commented that physician assessment might be improved if they were instructed to assess and probe for the more reliable core symptom of anhedonia (i.e., loss of interest or pleasure) and the cognitive symptoms of guilt, suicidal thinking, and hopelessness.

In the rare study conducted to determine nurses' ability to recognize depression in their patients, nurses greatly underrecognized moderate to severe depression (only 29% and 14%, respectively).¹⁷ The nurses' ratings for depression were more influenced by the detection of crying jags and by the solicitation of a depressed mood. The nurses failed to detect depression most of the time.

When Mood Goes Awry

Mood disorder generally refers to a number of depressive illnesses and conditions that range from mild transient episodes of depression to chronic debilitating illness.

Depressed mood is the hallmark of all mood disorders. No one can escape life's ups and downs - periods of sadness and disappointment. However, patients suffering from a mood disorder are consumed with depression and possess a negative view of themselves, their future, and the world.¹⁸

Mood disorders have been recognized since ancient times. In the Old Testament, the story of King Saul describes a depressive syndrome. Hippocrates used the terms "mania" and "melancholia" to describe mental disturbances. Currently, the two major mood disorders officially recognized and described in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) are Major Depressive Disorder and Bipolar I Disorder.¹⁹

The causes of mood disorders are varied and complex, and may include psychosocial, genetic, and biological factors, either alone or in combination. The life event most often associated with a person's later development of depression is the loss of a parent before age eleven.^4,20 The environmental stressor most often associated with the onset of an episode of depression is the loss of a spouse.

Nurses may also come into contact with women suffering from postpartum depression or premenstrual dysmorphic disorder, and men and women with seasonal affective disorder, substance-induced mood disorder, recurrent and brief depressive disorder, and dysthymia, to name a few. Dysthymia is a less acutely disabling depressive disorder than major depression but is often more long-term. Sad mood must be present for most of the day more days than not for at least two years for a diagnosis to be made.¹⁹ Individuals may not function "at full speed" or "up to par." They can and do experience episodes of major depression.

Beyond Sadness - Major Depression and Bipolar Disorder

Major Depression: People with major depression have a number of symptoms nearly every day, most of the day, for at least two weeks.¹⁹ These symptoms must include at least one of the following and must represent a change from previous functional status: anhedonia (loss of interest or pleasure in things once enjoyed, such as family, shopping, sex, television, hobbies, grooming, or eating), or feeling sad, blue, down in the dumps, or empty.

To establish the diagnosis, the patient must have one of these core symptoms and at least four of the symptoms listed below or both of these core symptoms and at least three other symptoms from the list below. In either case, these symptoms must represent a change from previous functioning:

• Excessive guilt or remorse, feelings of worthlessness.
• Thoughts of suicide, death, or other morbid thoughts.
• Problems concentrating, thinking, remembering, or making decisions.
• Insomnia - trouble sleeping or sleeping too much, early morning awakening.
• Loss of energy/vitality or feeling tired all the time, feeling slowed down.
• Observable psychomotor agitation or retardation.
• Increase or decrease in appetite, weight change of 5% in a month's time.

Every sign and symptom needs to be evaluated for its contribution to the whole picture. Look at concurrent illnesses and other plausible causes. For example, appetite changes may be caused by gastrointestinal problems or cancer.

In addition, nurses need to be sensitive to how a patient may communicate the experience of his or her physical and emotional states. Having persistent physical and/or psychological symptoms that do not respond to treatment (such as headaches, aches and pains, stomach and bowel problems, anxiety and worry, and sexual problems) may be the language in which this particular patient conveys a mood disorder.⁶

Bipolar: Bipolar disorder is typically a chronic, recurring condition¹⁹ that is characterized by alternating cycles of depression and elation. The cycles can come on suddenly or gradually. When in the depressed phase, people with bipolar disorder can experience all of the symptoms of major depression and require treatment. Monitor them very carefully. When the bipolar patient experiences a manic state, mood is elevated and expansive. Manic episodes are actually defenses against profound underlying sadness and despair.

When in the manic phase, the person customarily exhibits the following:

• Inappropriate elation.
• Inappropriate irritability.
• Severe insomnia; increased talking.
• Grandiose notions; poor judgment.
• Disconnected and racing thoughts.
• Increased sexual desire; inappropriate social behavior.
• Markedly increased energy.
• Impulsively spending large sums of money

A mania-like state can be produced medically by certain drugs such as antidepressants or by CNS events such as steroids, bronchodilators, alcohol, cocaine, amphetamines, or decongestants.

When It Looks Like Depression, It Is Depression

Health care professionals must consider a wide range of conditions that may account for depression as a presenting symptom or complaint. Whenever depression is suspected, consider adjustment disorders in the differential diagnosis. The predominant manifestations of Adjustment Disorder with Depressed Mood are tearfulness, depressed mood, and hopelessness, which result from a stressor. Typically, a marked impairment in social or occupational functioning is apparent. The precipitating stress need not be unusual or severe. The person may be feeling a natural emotional reaction (sadness, disappointment, frustration), but exhibits a prolonged and complicated reaction. Retirement, failing to achieve occupational goals, and becoming a parent are often associated with adjustment disorders.¹⁹

A single stressor, like divorce, or multiple stressors, such as financial insecurity compounded by a physical health crisis, can precipitate adjustment disorders. Stressors can be recurrent (e.g., difficulty breathing each winter due to chronic obstructive pulmonary disease) or continuous (e.g., living with an alcoholic family member).

Adjustment disorders are distinct from bereavement.⁴ Bereavement is natural and normal and can be displayed by any or all of the following: sadness, tearfulness, and feelings of loss accounted for by the loss of an important person, role function, living situation, or way of life. Grief and bereavement share many features with depression and adjustment disorders, such as tearfulness, loss of appetite, diminished interest in the world, and sadness. The striking feature that distinguishes grief and bereavement from depression is that fluctuations of mood are common in grief. People often describe grief coming in waves, washing over them, and then subsiding. Even in intense grief, moments of lightheartedness and happy reminiscences are possible. In depression, the mood disturbances are pervasive and unremitting. If mood fluctuations occur, they are relatively minor.

Seeing the Light

In ancient Phoenicia, the mentally ill were boarded on ships - The Ship of Fools - and set adrift to roam the seas in search of more hospitable harbors.⁷ In a figurative way, this practice may continue today when depressive illness is minimized, completely overlooked, or not seen as an illness.

Bipolar disorder and major depression are medical illnesses and must be treated. Likewise, adjustment disorders should also be treated because these conditions can develop into major depression when left untreated. Treatment for depression is important because:

• Most depressions are responsive to treatment. Between 80% to 90% of those suffering from serious depression can be effectively treated.²⁰
• Early treatment may prevent the depression from becoming severe or chronic.
• Thoughts of suicide are common in depression, and the risk of suicide is heightened if the depression is not treated.
• With successful treatment, thoughts of suicide often subside.
• A major depression can last for six months to a year, if not treated.
• If not treated, there is a greater chance of having a recurrent depression.
• Treatment can prevent recurrences of depression.
• Depression causes pain and suffering for the patient and family. Effective treatment helps ease the suffering and can alleviate emotional pain.
• Untreated depression can interfere with the patient's ability to effectively recover from other medical illnesses.

Several factors may interfere with diagnosis and treatment. The depressed patient may present with a myriad of physical complaints connected with the depressive illness, such as sleep disruption, weight loss, or poor appetite. This same patient may never actually report feeling depressed. Diagnosing depression in these cases can be a challenge. Many conditions can mimic depression or actually cause depression as a side effect of treatment. Establishing a diagnosis when multiple medical, pharmacological, and neurological factors are present can be difficult.

Defeating the Shame

For many individuals, depression is a sign of weakness or character defect. A stigma is sometimes attached to the diagnosis.²¹ Stigmatization can change a person's social identity. The individual may feel less accepted in social interactions, may be denied opportunities, and might end up with feelings of shame and self-loathing.²¹

The depressed patient may choose to keep his or her diagnosis confidential. Fear of being judged by others or shame at needing professional help may plague the patient. In some cases, a decision not to disclose the condition can result in less satisfying relationships, because the person is concealing a secret. And sometimes, keeping a secret isn't an option. Certain jobs require disclosure of a diagnosis or treatment for a mental illness, such as those requiring the use of heavy equipment or the operation of mass transportation.

Stigma, shame, or the humiliation of needing help can be so powerful that it can make patients nonadherent to medication regimens, fail to keep health care appointments, and not disclose their situation to loved ones, even though they may need help from the family. Patients and family members will need coaching, support, and guidance about upsetting and unpleasant encounters. Psychotherapy can provide strategies for coping, instill hope, and facilitate self-acceptance and self-awareness that lead to diminished feelings of shame, guilt, and self-loathing.

Nurses need to examine their own attitudes and feelings about mental illness. The real danger is that negative attitudes and emotions can interfere with the ability to identify and care for patients with depression. Workshops, empathy training, medical anthropology courses, individual or group psychotherapy, and other psychoeducational activities in nursing staff development and continuing education are useful in pinpointing the stigmas and core beliefs that may cause such interference.

Coping with Life's Ups and Downs

"Mild" depression that is short term is not considered a mental illness. Patients may seek advice from the nurse for their mild depression, which often accompanies crisis situations such as managing and accepting a medical diagnosis or caring for a loved one.

For patients feeling mildly depressed, regular exercise may help reduce the symptoms, as well as providing them with an opportunity to identify and talk about any source of sadness. Complementary and adjunctive therapies, such as reflexology, massage, guided imagery, art therapy, and yoga may prove beneficial.

Saint John's Wort, whose botanical name is Hypericum perforatum, has become popular in treating mild depression - especially by those who have self-diagnosed a mild depressive mood and seek over-the-counter treatment. Some studies show efficacy equal to Imipramine or selective serotonin reuptake inhibitors (SSRIs) in treating mild and moderate depression. However, a recent analysis of all published research data resulted in inconsistent findings regarding the efficacy of Saint John's Wort. Further, it can interact with medications including retroviral and antiepileptic medications; serotonin syndrome may occur when used with sympathomimetics or antidepressants. Possible adverse effects from Saint John's Wort include nausea, headache, constipation, dry mouth, and dizziness. The Food and Drug Administration (FDA) does not regulate Saint John's Wort. Although sold in health-food stores and in pharmacies as a nutritional supplement over the counter, it should always be used under medical supervision.²²

Initiating an Effective Plan

The three basic types of treatment for major depression are medications, psychotherapy, and electroconvulsive therapy (ECT). They may be used singly or in combination. Psychotherapy helps to strengthen coping skills, gain insight into and resolve problems, improve personal relationships, and lessen harmful behaviors and ways of thinking. Psychotherapy may be short-term (10 to 20 weeks) or long-term if the depression is chronic and complicated by other mental illnesses, personality traits, and stressors. In particular, cognitive and interpersonal short-term therapy is often used. ECT is a highly effective treatment for severe depressive episodes, especially those including psychosis or suicidal thoughts. Studies show that combinations of regularly scheduled psychotherapy and adherence to medication regimens provide the most beneficial treatment for depression.¹⁸

When Medication Is Indicated

Antidepressants and psychotherapy are indicated for treatment of major depression. Antidepressant medications may be needed for a minimum of four to nine months after full remission, or perhaps indefinitely. Antidepressants are not habit-forming or addictive, nor are they "uppers" or stimulants.

Two major classes of antidepressants are the tricyclics (TCAs) and serotonin reuptake inhibitors (SSRIs). The first antidepressant medications, TCAs, were introduced during the 1950s. Since the advent of SSRIs that have fewer side effects, TCAs are less frequently prescribed. MAO inhibitors are another class less infrequently prescribed due to required dietary restrictions. Newer non-SSRIs have also become available (see table below for further information).¹⁸

In treating bipolar disorder, mood-stabilizing medications are required, alone or in combination with antidepressants. Lithium is a mood-stabilizing medication and remains the first line of psychopharmocology treatment for bipolar disorder Anticonvulsant medications such as valproate (Depakote) or carbamazepine (Tegretol) are also mood-stabilizers and are used for difficult-to-treat bipolar episodes. Valproate is the only FDA approved anticonvulsant for treatment of mania. Antianxiety and antipsychotic medications may also be used to treat bipolar symptoms. Antidepressant treatment alone places the bipolar patient at risk of switching into mania or hypomania or of developing rapid cycling.²³

Medications for Mood Disorders

The National Alliance for the Mentally Ill (NAMI) provides medication fact sheets.²⁴

For specific medication information, go to www.nami.org.

Stimulants (e.g., dexedrine or methylphenidate [Ritalin]) may be used for dying patients with a short life expectancy who can't wait the four to six weeks for the antidepressant effect of the other medications to commence.

Additionally, complementary and adjunctive supportive therapies can be very helpful if they are culturally appropriate and acceptable to the patient. These therapies include healing touch, aromatherapy, massage, reflexology, guided imagery, and meditation, among others.

Antidepressants

Fuller, MA, Sajatovic M. Lexi-Comp's Drug Information Handbook for Psychiatry. 5th ed. Hudson, OH: Lex-Comp: 2005

Brener, T & Doyle R.M. Nursing 2007 Drug Handbook. 27th ed. Phila, PA: Lippincott Williams & Wilkins; 2006.

*Serotonin syndrome occurs in patients taking two or more medications that increase CNS serotonin levels and is characterized by autonomic and neuromuscular changes including confusion, agitation, myoclonus, tachycardia, hyperreflexia, and muscle rigidity. This drug-related condition is usually mild but can be life threatening. Treatment involves discontinuing serotonin medications and treating symptoms.

Serotonin syndrome: Recognition and management. Noland, S. & Scoggin, J.A. www.uspharmacist.com/oldformat.asp?url=newlook/files/feat/acf2fa6.htm

Mood Stabilizers: Treatment of Bipolar Disorder