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Clinical Competence For BHT Back to Course Index


Clinical Competence for BHT




Mental Health Assessments 


The information that is obtained by mental health professionals in an initial psychological assessment is the cornerstone from which a comprehensive treatment plan can be developed.  The effectiveness of the treatment plan relies heavily on the information gathered such as issues, disorders, obstacles, strengths, willingness and abilities of the client.


There are several types of assessments including, mental health and addiction assessments for status, treatment, as well as professional assessments on individuals who have very emotionally challenging careers such as police officers or professionals who have crossed the professional boundaries and have been sanctioned by professional licensing boards, law enforcement or their employer.  During this course we will focus primarily on mental health and dually diagnosed mental health and addiction assessments.


While it is gratifying to focus on the end result of positive client changes that occur through treatment, it is crucial to have a functional baseline or clinical yardstick from which to begin.  Not only does this give the foundation for the treatment plan, but also highlights the improvements made as treatment moves along.  You must know where you came from to see how far youve come, so to speak.


Assessments are client centered by their very nature and specifically relate to the distress and difficulties that each client must endure.  The assessment usually consists of:


-A description of the current problem

-A complete medication history

-Mental status exam

-Alcohol and drug history

-Current living arrangements

-Support systems

-Psychiatric history


-Preliminary diagnosis


Usually a specific form is utilized.  This form is not universal, but usually created by the facility or professional.  It is the counselors responsibility to gain sufficient information regarding the client and the clients presenting concerns to establish an effective treatment strategy.


Many times objective diagnostic measurements are administered as a means of gaining more information about the clinical needs of the client so as to provide strong recommendations to the referral sources.  Assessments are best done face to face and in person.  This enables body language, tone and affect to be considered.



The Counselor and the Process 


Performing an evaluation, assessment and/or mental status exam involves observation, conversation and exploration.  As a professional conducting the assessment it is important to immediately start to perceive signals and make first impressions.  When listening to the client avoid stereotypes and consider the context.


The assessment should be geared to the age of the client.  There would be different questions and tools used for children, adults or seniors. 


A brief introduction with an explanation of what will be happening during the process can improve cooperation and reduce anxiety.  The professional can talk about how the assessment will be conducted, through questions, inventories, verbally, written or both.


After the assessment is complete the professional reviews all of the data that they have obtained from the assessment process, including and tests or inventories, if administered, to make a preliminary psychological diagnosis.  Frequently, the clinician will refer to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) for clarification of mental health disorder symptoms and criteria.


Mental health assessments and neuropsychological tests should always be conducted by a trained professional, such as a psychologist or other mental health practitioner.  Many tests and inventories have specific requirements and cannot be performed even by credentialed, licensed professionals.



Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5)


Getting the right treatment always depends on having the right diagnosis.  If symptoms are caught early it makes them easier to treat and less likely to come back in other areas of a clients life. The final diagnosis will frequently come from a psychiatrist or a licensed professional but it is important for the behavioral health technicians working with the client to also understand the criteria and terms.


During the assessment process the clinician is attempting to put together a preliminary diagnosis when symptoms are present.


The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) could require a course in itself, however this course will provide a brief overview.


The DSM 5, was updated in 2013 by the American Psychiatric Association. The DSM 5 has been referred to as the “bible” of psychiatric diagnosis because it provides definitions, symptoms and characteristics for mental disorders that are recognized by clinicians from around the world. Previous DSM manuals called for clinicians to evaluate individuals on five levels or axes.


  • Axis I identifies mental disorders
  • Axis II identifies personality disorders and mental retardation
  • Axis III identifies relevant physical diseases and conditions
  • Axis IV identifies the individuals psychosocial and environmental issues
  • Axis V is used by the clinician to assess an individual’s overall functioning based on the 100-point scale called the Global Assessment of Functioning (GAF).

DSM-5 combined the first three axes into one in order to eliminate the distinctions between diagnoses, which helps clinicians, researchers and insurance companies streamline information. Clinicians still evaluate patients for the last two axes, they just do it using different tools. 


The Mental Status Exam



The mental status exam is an important part of the clinical assessment process. It is a structured way of observing and describing a clients current state of mind, under the domains of appearance, attitude, behavior, mood and affect, speech, thought process, thought content, perception, cognition, insight and judgment.  There are some minor variations in the subdivision of the Mental Status Exam and the sequence and names of Mental Status Exam domains.


The purpose of the Mental Status Exam is to obtain a comprehensive cross-sectional description of the client’s mental state, which, when combined with the biographical and historical information of the psychiatric history, allows the counselor to make an accurate diagnosis and begin treatment planning.


The data is collected through a combination of direct and indirect means: unstructured observation while obtaining the biographical and social information and focused questions about current symptoms, situation and history.  Overall, the mental status exam contains more information observed by the professional, rather than symptoms reported by the client, with some exceptions.





-The clients presenting appearance includes their sex, chronological and apparent age, ethnicity, apparent height and weight (average, stocky, healthy, petite), any physical deformities (hearing impaired, injured


-Basic Grooming and Hygiene are noted. 


-Attire, the type and appropriateness of their dress and grooming.  For example, are they dressed appropriately for the weather?  Do they have accessories like glasses or a cane?


-Gait and Motor Coordination is also noted (awkward, staggering, shuffling, rigid, trembling with intentional movement or at rest), posture (slouched, erect), work speed, any noteworthy mannerisms or gestures are included in the notes.


Manner and Approach:


Important factors to consider and note include:


-Interpersonal characteristics and approach to the evaluation

     For example:



     -friendly and open


-Behavioral Approach

     For example:







     For example:

     -normal rate and volume




-Eye Contact

     For example:




-Expressive Language


-Receptive Language


-Recall and Memory

     For example:

     -able to explain recent and past events

     -recalls three words immediately after two rehearsals

      and then again after five minutes

     -able to recall your name after 30 minutes



Orientation, Alertness and Thought Processes:


-Orientation refers to their awareness of person, who they are; place, where they are; time, what year is it; presidents, who is the president of the United States; and your name.  This serves as reference for their cognitive functioning.


-Alertness describes whether the client is for example, sleepy, alert, tired, dull or highly distracted.  It indicates their focus and awareness.


-Overall coherence and concentration are important factors to note.  Thought process issues can include whether the client is difficult to understand regarding their line of reasoning.


-It is important to explore if the client is experiencing any hallucinations or delusions.  Most assessment forms will list these out in the form of checklists.  Some examples include auditory hallucinations, visual hallucinations and delusional parasitosis.  When lists such as this are presented it is vital to give examples such as, Do you ever experience voices that other people cant hear? (Auditory Hallucination)  Do you ever see people or things that others dont see? (Visual Hallucinations) Do you have the feeling that bugs are crawling on you? (Delusional Parasitosis, sometimes referred to as Morgellons and/or Formication).


-Other important factors to assess with regard to thought processes include judgment and insight.  How did the client make some of the decisions they have made?  How do they feel about the outcome?  These are crucial when moving forward with the treatment.  Also, intellectual ability and abstraction skills, such as What would I mean if I said I was feeling blue?  or how are dogs and cats similar? need to be addressed.


Mood and Affect:


-Mood can be explored by asking about how they feel most days, for example, happy, sad, despondent or euphoric.  Does this match how they are presenting?


-The clients affect refers to how they feel at any given moment.  If a clients affect is flat, but they are describing their favorite childhood memory that shows affect that is inconsistent with the content of the conversation.  Affect can be expressed by words such as restricted, blunted, inappropriate.


-To differentiate mood from affect think in terms of mood as the overall feeling most days and the affect as more of the in the moment presentation.


-Building rapport is one of the most fundamental dynamics between a counselor and a client.  Rapport refers to the establishing the ability to relate to others.  In a mental status exam rapport is frequently described by terms such as, easy to establish, initially difficult but easier over time, difficult to establish, tenuous, and easily upset.


-Facial and Emotional Expressions, described by terms such as, relaxed, tense, smiled, laughed, became insulting, yelled, happy, sad, alert, day-dreamy, angry, smiling, distrustful/suspicious, tearful when discussing such and such are important factors in this area.

-No assessment would be complete without addressing any history of or current suicidal and/or homicidal Ideation.  Again using terms such as ideation, are for the report only.  When talking with a client you would ask, have you ever thought about hurting yourself?  If the client reports ideation the next step would be to explore if they have a clear plan and intent, no clear plan, but intent, or no plan and no intent.  More simply put, You have told me that you have thought about hurting yourself within the last week.  Have you thought about how you would do this and do plan carry these thoughts out?

The clients risk for violence, responses to failure, impulsivity and anxiety are also important mood and affect areas.


Scales and Instruments Used in Assessments

There are hundreds of instruments created to streamline the assessment process.  Some are for mental health, some for addictions, many for dual diagnosis of both mental health and addictions, some for geriatric clients, some for adults and others for children.  The following are samples of popular instruments.


The Functional Assessment of Mental Health and Addiction Scale (FAMHA)


The Functional Assessment of Mental Health and Addiction scale (FAMHA) was specifically designed to meet criteria for both mental health issues and addictions.


Dually diagnosed clients have multiple service needs in mental health, addiction treatment, and medical interventions.  Thus, functional assessments like the FAMHA are the key to not only measuring the outcomes of treatments on a broad scale, but crucial to the clinician’s full understanding of patient’s individual needs.


The FAMHA is not the only scale of this type, but will give the learner an overview of information gathered for the dually diagnosed individual. 


Description of the FAMHA:

The scale describes the population types as:

-Mentally Ill Substance Users (MISU)

-Substance Using Mentally Ill (SUMI)

-Medically Compromised – Substance Using Patients (MCSU)

The scale assesses these individuals across a broad range of symptom and functional domains.  The 46 items of the scale document functional deficits across all biopsychosocial functional domains in such a way as to capture the current state of overall functioning, whilst demonstrating specific areas of need. The 46 items subdivided into 6 biopsychosocial dimensions:


1. Socio-legal

2. SocialCommunity Living

3. SocialInterpersonal Skills

4. Mood

5. Psychological Functioning

6. Physical Functioning.


In addition to the dimensional scales, data as to the patients primary and secondary drug of choice, alcohol consumption, prior mental health and addiction treatment episodes, demographics, and current medical, mental health and addiction diagnoses are also collected to add to the clarity of the diagnostic profile. It is expected that continued statistical analysis, including factor analyses of further trials, will yield more refined, discrete scale dimensions and add to the overall utility of the instrument.


It can be used as both an indicator of current functioning for diagnostic assessment and as a repeated measure to demonstrate the changes that occur to patients throughout the clinical cycle.

Because the term dual diagnosis is somewhat broad and misleading (for example; mental illness and learning disabilities are dual diagnoses). The distinction between MISU, SUMI, and MCMU patients has a significant impact on the selection and use of a variety of intervention techniques and strategies.

Development of the Scale

The FAMHA was developed with a variety of criteria in mind.  It was felt that the FAMHA should not only assess the obvious symptom categories of major mental illness and addiction, but should also:


1.               include functional domains that are deemed important for community based treatment clinics;

2.               demonstrate reliability and validity;

3.               possess sensitivity to treatment-related change;

4.               be appropriate and relevant to the dually diagnosed population that it functionally assesses;

5.               be a useful tool for treatment planning and clinical governance;

6.               have low administration costs;

7.               be relatively easy to use by all levels of clinical staff.


The current version of the FAMHA meets all of these criteria and can be administered in as little as 8 minutes by a trained, experienced rater.


The FAMHA uses a seven point, three way anchored Likert-like scale, ranging from extremely dysfunctional symptoms or behaviors (Score 1) to normative levels of these behaviors and symptoms (Score 7).



The Addiction Severity Index (ASI)

The ASI is the possibly the most widely used measure of substance abuse in the field. This is a semi-structured interview designed to provide important information about aspects of the life of patients that may contribute to their substance-abuse problems. The Addiction Severity Index (ASI) provides a general overview of substance-abuse problems rather than a focus on one particular area (200 questions on 7 subscales). 


The interview is based on the idea that addiction to drugs or alcohol is best considered in terms of the life events that preceded, occurred at the same time as, or resulted from the substance-abuse problem. The ASI focuses on seven functional areas, or subscales, that have been widely shown to be affected by the substance abuse: medical status, employment and support, drug use, alcohol use, legal status, family and social status, and psychiatric status. Each of these areas is examined individually by collecting information regarding the frequency, duration, and severity of symptoms of problems both historically over the course of the patient’s lifetime and more recently during the thirty days prior to the interview. Within each of the problem areas, the ASI provides both a 10-point, interviewer-determined severity rating of lifetime problems as well as a multi-item composite score (computer-calculated) that indicates the severity of the problems in the past thirty days.


The ASI is widely used clinically for assessing substance-abuse patients at the time of their admission for treatment. It takes about an hour to gather the basic information that forms the first step in the development of a patient profile for subsequent use by the staff in planning treatment.

The ASI also examines psychosocial functioning (medical, legal, employment, psychological, and social/family), which is crucial to understanding alcohol dependency.


Millon Clinical Multi-axial Inventory


The Millon Clinical Multi-axial Inventory is a true/false questionnaire that takes less than 30 minutes for an average person to complete. It is designed to reveal personality traits or characteristics of a person and is considered to be very useful in that it can reveal aspects of a person to assist in making a diagnosis more quickly than a traditional clinical interview. Like the DSM, there are several versions of this test, and only the most recent is considered valid.


Beck Depression Inventory

The Beck Depression Inventory is a test that is designed to be used alongside the DSM in order to clarify a diagnosis of depression. While this is a possible use, this test is mainly used to evaluate the effectiveness of treatments for depression. This test uses weighted ratings and asks questions regarding the typical symptoms of depression such as depressed mood, poor self-image and withdrawing socially. This test is updated to match the current DSM.


Minnesota Multiphasic Personality Inventory


The Minnesota Multiphasic Personality Inventory is a very common test that is used by clinicians to differentiate between potential diagnoses as well as to plan and evaluate treatment. However, this is a very popular test and is commonly used outside of clinical settings as well, such as penal institutions and human resources departments. This test is found to be remarkably accurate at predicting treatment outcomes. Like most psychiatric tests, there are several versions of the MMPI.

Again, different tools have different requirements per what type of professional can administer it.  There are a vast number of tools available.

A mental health assessment is done to explore alcohol and drug issues mental health problems, such as anxiety, depression, schizophrenia, as well as to help distinquish between mental and physical health problems.  An assesment should be done by a qualified, trained professional.  The information obtained is crucial to the correct diagnosis and effective treatment planning.


Treatment Plans


In mental health, the treatment plan refers to a written document that outlines the progression of therapy. A treatment plan may be highly formalized or may consist of loosely handwritten notes, depending on the documentation requirements of the insurance company and facility, the preference of the therapist and the severity of the presenting problem. No matter how formalized, however, the treatment plan is always subject to change as therapy progresses.


The treatment plan generally consists of four parts:


  •         Presenting Problem -A brief description of the main issue or issues
  •         Goals of Therapy – An annotated list of both the overall goal(s) and the interim goal(s) of therapy
  •         Methods – A short, annotated list of the techniques that will be used to achieve the goals
  •         Time Estimate – A brief estimate of the length of time and/or number of sessions needed

The client should always be involved in developing the treatment plan, although this is generally accomplished through informal discussion of the situation. Many therapists present a written copy of the treatment plan to the client, although others feel that this can add artificiality to the therapeutic relationship. A copy of the plan, however, should always be available upon request.



Common Mental Health Diagnosis


There are many different conditions that are recognized as mental illnesses. The more common types include:


Anxiety disorders: People with anxiety disorders respond to certain objects or situations with fear and dread, as well as with physical signs of anxiety or nervousness, such as a rapid heartbeat and sweating. An anxiety disorder is diagnosed if the person’s response is not appropriate for the situation, if the person cannot control the response, or if the anxiety interferes with normal functioning. Anxiety disorders include generalized anxiety disorder, post-traumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD), panic disorder, social anxiety disorder, and specific phobias.


Mood disorders: These disorders, also called affective disorders, involve persistent feelings of sadness or periods of feeling overly happy, or fluctuations from extreme happiness to extreme sadness. The most common mood disorders are depression, mania, and bipolar disorder.


Psychotic disorders:  Psychotic disorders involve distorted awareness and thinking. Two of the most common symptoms of psychotic disorders are hallucinations — the experience of images or sounds that are not real, such as hearing voices — and delusions — false beliefs that the ill person accepts as true, despite evidence to the contrary. Schizophrenia is an example of a psychotic disorder.


Eating disorders: Eating disorders involve extreme emotions, attitudes, and behaviors involving weight and food. Anorexia nervosa, bulimia nervosa and binge eating disorder are the most common eating disorders.


Impulse control and addiction disorders: People with impulse control disorders are unable to resist urges, or impulses, to perform acts that could be harmful to themselves or others. Pyromania (starting fires), kleptomania (stealing), and compulsive gambling are examples of impulse control disorders. Alcohol and drugs are common objects of addictions. Often, people with these disorders become so involved with the objects of their addiction that they begin to ignore responsibilities and relationships.


Personality disorders: People with personality disorders have extreme and inflexible personality traits that are distressing to the person and/or cause problems in work, school, or social relationships. In addition, the person’s patterns of thinking and behavior significantly differ from the expectations of society and are so rigid that they interfere with the person’s normal functioning. Examples include antisocial personality disorder, obsessive-compulsive personality disorder, and paranoid personality disorder.


Substance Abuse


The DSM 5 recognizes substance-related disorders resulting from the use of 10 separate classes of drugs: alcohol; caffeine; cannabis; hallucinogens (phencyclidine or similarly acting arylcyclohexylamines, and other hallucinogens, such as LSD); inhalants; opioids; sedatives, hypnotics, or anxiolytics; stimulants (including amphetamine-type substances, cocaine, and other stimulants); tobacco; and other or unknown substances. Therefore, while some major groupings of psychoactive substances are specifically identified, the use of other or unknown substances can also form the basis of a substance-related or addictive disorder.

The activation of the brain’s reward system is central to problems arising from drug use; the rewarding feeling that people experience as a result of taking drugs may be so profound that they neglect other normal activities in favor of taking the drug. While the pharmacological mechanisms for each class of drug are different, the activation of the reward system is similar across substances in producing feelings of pleasure or euphoria, which is often referred to as a “high.”

The DSM 5 recognizes that people are not all automatically or equally vulnerable to developing substance-related disorders and that some people have lower levels of self-control that predispose them to develop problems if they’re exposed to drugs.

There are two groups of substance-related disorders: substance-use disorders and substance-induced disorders.

  • Substance-use disorders are patterns of symptoms resulting from the use of a substance that you continue to take, despite experiencing problems as a result.
  • Substance-induced disorders, including intoxication, withdrawal, and other substance/medication-induced mental disorders, are detailed alongside substance use disorders.


Criteria for Substance Use Disorders

Substance use disorders span a wide variety of problems arising from substance use, and cover 11 different criteria:

  1. Taking the substance in larger amounts or for longer than you’re meant to.
  2. Wanting to cut down or stop using the substance but not managing to.
  3. Spending a lot of time getting, using, or recovering from use of the substance.
  4. Cravings and urges to use the substance.
  5. Not managing to do what you should at work, home, or school because of substance use.
  6. Continuing to use, even when it causes problems in relationships.
  7. Giving up important social, occupational, or recreational activities because of substance use.
  8. Using substances again and again, even when it puts you in danger.
  9. Continuing to use, even when you know you have a physical or psychological problem that could have been caused or made worse by the substance.
  10. Needing more of the substance to get the effect you want (tolerance).
  11. Development of withdrawal symptoms, which can be relieved by taking more of the substance.



Severity of Substance Use Disorders

The DSM 5 allows clinicians to specify how severe or how much of a problem the subst

ance use disorder is, depending on how many symptoms are identified. Two or three symptoms indicate a mild substance use disorder; four or five symptoms indicate a moderate substance use disorder, and six or more symptoms indicate a severe substance use disorder. Clinicians can also add “in early remission,” “in sustained remission,” “on maintenance therapy,” and “in a controlled environment.”



Substance intoxication, a group of substance-induced disorders, detail the symptoms that people experience when they are “high” from drugs. Disorders of substance intoxication include:

  • Marijuana intoxication
  • Cocaine intoxication
  • Methamphetamine intoxication (stimulants)
  • Heroin intoxication (opioids)
  • Acid intoxication (other hallucinogen intoxication or “acid trip”)
  • Substance intoxication delirium

Substance/Medication-Induced Mental Disorders

Substance/medication-induced mental disorders are mental problems that develop in people who did not have mental health problems before using substances, and include:

  • Substance-induced psychotic disorder
  • Substance-induced bipolar and related disorders
  • Substance-induced depressive disorders
  • Substance-induced anxiety disorders
  • Substance-induced obsessive-compulsive and related disorders
  • Substance-induced sleep disorders
  • Substance-induced sexual dysfunctions
  • Substance-induced delirium
  • Substance-induced neurocognitive disorders


Relapse Triggers and High Risk Situations 


Any activity that threatens an individuals abstinence or sense of control is considered high-risk. This includes people, places and circumstances that were previously associated with use, as well as any behavior that increases the probability of use.  Research has found that negative emotional states such as anger, frustration and boredom account for 35% of all relapses; interpersonal conflicts account for about 16%; and social pressure account for 20%.


Triggers are generally sensory based, they cause an immediate reaction in a person and create an urge to use.  Triggers for an alcoholic might include non-alcoholic beer, cigarettes or meeting a former using buddy.  Triggers for a cocaine addict might include flour, a razor blade, straws, or going to a place where he/she formerly used.


Another relapse trigger that is often overlooked or under estimated is the ritual that a user followed during his/her earlier use.  Addicts have explained their ritual as like being on automatic pilot where the urge or anticipation masks conscious awareness of what is occurring.  Rituals have also been compared to a preoccupation.  This preoccupation is a thought without the behavior, whereas a ritual is a behavior without thoughts; consequently, a ritual can be defined as a set of habits which are automatic and key automatic responses within an individual.  It follows that ritualistic use of a mind-altering chemical substance is a procedure repeated customarily or automatically and needs to be evaluated for its potential to trigger a high risk situation.  This may be any event or process that a person followed consistently during pre-treatment chemical use.  It can be as simple as driving on a street where a former dealer lived or stashing or allocating money for a specific purpose.  Most people follow a ritual of using but some may not be conscious of their process.  For example, the concept of Thank God its Friday is part of the overall using environment; consequently, it may be part of an individuals trigger to initiate use at a particular place or time.



Relapse symptoms


It is important for the using community to be aware of high risk situations that could trigger a relapse.  It is equally important for them to be aware of symptoms that often precede a relapse.  Denial is also a critical issue with relapse.  Just as addicts will not admit that they have a problem, a recovering addict will often deny the impulses, urges and cravings to use again after being drug free for a period of time.  It is also possible that the client may not be fully aware of what he/she is feeling, but that he/she may recognize certain symptoms that could serve as warning signs for a possible relapse.  



Relapse Symptoms


  • Lack of commitment to sobriety
  • Over confidence
  • Repeated proclamations of Ill never use again
  • Isolation
  • Preoccupation with self
  • Easily irritated
  • Loss of motivation / dont care attitude
  • Less involvement with support groups
  • Non-responsive attitude
  • Rejects help
  • Hypochondriac
  • False statements
  • Increased use of non-prescription medications
  • Loss of self confidence
  • Strong bias / unreasonable resentments
  • Emotional overload
  • Focus on loneliness, frustration, anger and stress
  • Attempts at controlled use
  • Loss of control


Relapse Prevention

A comprehensive relapse prevention technique includes an approach where high risk situations were assessed and then coping strategies were developed for each situation.  The following factors were analyzed for each situation:


Self efficacy: individuals perception of his/her ability to cope with a situation.


Expectation: what is the consequence to the user of a specific behavior.


Attribute: why an individual exhibits a specific behavior.


Decision making: methodology used when the individual chooses a specific action.


Once this analysis is complete, the following intervention strategies can be employed:


Self-monitoring: maintaining a log of substance use or urges to use.  Additional information such as intensity of urge and coping strategy employed may also be documented.


Direct observation: individual rates the degree of temptation due to high-risk situations.  The individual may respond to an imaginary past episode or a fantasy about a past episode and then describe what he/she may have done differently to avoid future encounters.


Coping skills: this analytical tool is used to document the clients ability to cope once a trigger or high risk behavior is encountered.  This helps the individual to identify strengths and weaknesses and helps the client focus on areas that need improvement.


Decision Matrix: the matrix is used to document the consequences of a specific decision or action.  It may be used to gather immediate, as well as delayed consequences and can document both positive and negative outcomes.


Behavior commitment: this tool is intended to establish limits on use in the event of a slip.  It is also a commitment to seek help at the first indication of use to prevent a full-scale relapse.

Reminder ques – they are used to key specific action in the event of strong urge.


It follows that a primary goal of any relapse prevention program is to enable the individual to cope with future, inevitable urges to use.  The initial step is to identify the coping strategies that can be used in high risk situations.  It is also important to discuss an implementation plan for how these skills will be used.  Some have referred to this process as setting up a self-management program.  According to Ricky George (1990), The goals of self-management programs are to teach the individual how to anticipate and cope with the problem of relapse.  This approach generally combines behavioral skills training, cognitive interventions and lifestyle changes to help the individual modify their behavior.


The most frequently applied relapse prevention method is the cognitive-behavioral approach.  The primary feature of this approach is that it acknowledges the individual may have had little or no control over becoming addicted (disease concept) but has total responsibility for management of his/her recovery.


Keys to Avoiding Relapse:


        High Activity Level


        To do lists (guides activities for each day).


        Goal setting / acknowledge and reward success.


        Individual reward system (work toward a specific, individualized reward (i.e.,  new car, trip, clothes, etc.).


        Plan pleasurable activities, as well as work (hobbies, travel, read, etc.).


        Plan self improvement activities (items that will help the individual feel good about themselves)

        Exercise / active lifestyle

        Nutrition program

        Rest / relaxation time

        Manage stress

        Think positive


        Avoidance of high risk situations / activities

        Places / events where previously used

        Avoid social functions that have an AOD focus

        Avoid things that have triggered previous relapses

        Avoid former using buddies.


    Develop mind-management techniques – Block negative thought processes.  The mind always leads the physical act (i.e. an individual should think positive regarding an activity before they do the activity): consequently, if we could train our minds to detect wrong thinking (about use and abuse of AOD) then we could alter or disrupt those thoughts and focus on different things or thought processes to avoid actually relapsing.


      Avoid over confident feeling like I am in control and I have this AOD problem licked – generally, overconfidence leads to high risk behavior and poor decision making.


      Avoid out-of-balance emotional states.  Either feeling too good (overconfident) or too bad (depression) can lead to resumption of use.


      Forgetting or rationalizing away the pain and anguish of the former lifestyle.  Our minds will sometimes focus only on the pleasurable aspects of a former activity and completely mask (or forget) the negative consequences.  At times, individuals are convinced that returning to use would be wonderful (taste, feeling, emotions, etc.) And when they actually use they become deeply depressed as the reality of their actual use is realized.  The mind is a wonderful thing, but it too must be monitored and trained and one must realize that the mind can be misleading in some cases.


      Think positive; act positive; surround yourself with positive people – remember the little engine that said I can.





Medications treat the symptoms of mental disorders. They cannot cure the disorder, but they make people feel better so they can function.


Contemporary psychopharmacology marked the beginning of the use of psychiatric drugs to treat psychological illnesses. It brought with it the use of opiates and barbiturates for the management of acute behavioral issues in patients. In the early stages, psychopharmacology was primarily used for sedation. Then with the 1950s came the establishment of chlorpromazine for psychoses, lithium carbonate for mania, and then in rapid succession, the development of tricyclic antidepressants, monoamine oxidase inhibitors, benzodiazepines, among other antipsychotics and antidepressants.



What medications are used to treat schizophrenia?


Antipsychotic medications are used to treat schizophrenia and schizophrenia-related disorders. Some of these medications have been available since the mid-1950’s. They are also called conventional “typical” antipsychotics. Some of the more commonly used medications include:


        Chlorpromazine (Thorazine)

        Haloperidol (Haldol)

        Perphenazine (generic only)

        Fluphenazine (generic only)


In the 1990’s, new antipsychotic medications were developed. These new medications are called second generation, or “atypical” antipsychotics.


One of these medications was clozapine (Clozaril). It is a very effective medication that treats psychotic symptoms, hallucinations, and breaks with reality, such as when a person believes he or she is the president. But clozapine can sometimes cause a serious problem called agranulocytosis, which is a loss of the white blood cells that help a person fight infection. Therefore, people who take clozapine must get their white blood cell counts checked every week or two. This problem and the cost of blood tests make treatment with clozapine difficult for many people. Still, clozapine is potentially helpful for people who do not respond to other antipsychotic medications.


Other atypical antipsychotics were developed. All of them are effective, and none cause agranulocytosis. These include:


        Risperidone (Risperdal)

        Olanzapine (Zyprexa)

        Quetiapine (Seroquel)

        Ziprasidone (Geodon)

        Aripiprazole (Abilify)

        Paliperidone (Invega)


The antipsychotics listed here are some of the more common medications used to treat symptoms of schizophrenia.  There are others used, as well.


Note: The FDA issued a Public Health Advisory for atypical antipsychotic medications. The FDA determined that death rates are higher for elderly people with dementia when taking this medication.


A review of data has found a risk with conventional antipsychotics as well. Antipsychotic medications are not FDA-approved for the treatment of behavioral disorders in patients with dementia.


What are the side effects?


Some people have side effects when they start taking these medications. Most side effects go away after a few days and often can be managed successfully. People who are taking antipsychotics should not drive until they adjust to their new medication. Side effects of many antipsychotics include:



        Dizziness when changing positions

        Blurred vision

        Rapid heartbeat

        Sensitivity to the sun

        Skin rashes

        Menstrual problems for women


Atypical antipsychotic medications can cause major weight gain and changes in a person’s metabolism. This may increase a person’s risk of getting diabetes and high cholesterol.  A person’s weight, glucose levels, and lipid levels should be monitored regularly by a doctor while taking an atypical antipsychotic medication.


Typical antipsychotic medications can cause side effects related to physical movement, such as:



        Persistent muscle spasms




Long-term use of typical antipsychotic medications may lead to a condition called tardive dyskinesia (TD). TD causes muscle movements a person can’t control. The movements commonly happen around the mouth. TD can range from mild to severe, and in some people the problem cannot be cured. Sometimes people with TD recover partially or fully after they stop taking the medication.


Every year, an estimated 5 percent of people taking typical antipsychotics get TD. The condition happens to fewer people who take the new, atypical antipsychotics, but some people may still get TD. People who think that they might have TD should check with their doctor before stopping their medication.


How are antipsychotics taken and how do people respond to them?


Antipsychotics are usually pills that people swallow, or liquid they can drink. Some antipsychotics are shots that are given once or twice a month.


Symptoms of schizophrenia, such as feeling agitated and having hallucinations, usually go away within days. Symptoms like delusions usually go away within a few weeks. After about six weeks, many people will see a lot of improvement.


However, people respond in different ways to antipsychotic medications, and no one can tell beforehand how a person will respond. Sometimes a person needs to try several medications before finding the right one. Doctors and patients can work together to find the best medication or medication combination, and dose.


Some people may have a relapsetheir symptoms come back or get worse. Usually, relapses happen when people stop taking their medication, or when they only take it sometimes. Some people stop taking the medication because they feel better or they may feel they don’t need it anymore. But no one should stop taking an antipsychotic medication without talking to his or her doctor. When a doctor says it is okay to stop taking a medication, it should be gradually tapered off, never stopped suddenly.

How do antipsychotics interact with other medications?

Antipsychotics can produce unpleasant or dangerous side effects when taken with certain medications. For this reason, all doctors treating a patient need to be aware of all the medications that person is taking. Doctors need to know about prescription and over-the-counter medicine, vitamins, minerals, and herbal supplements. People also need to discuss any alcohol or other drug use with their doctor.


What medications are used to treat depression?


Depression is commonly treated with antidepressant medications. Antidepressants work to balance some of the natural chemicals in our brains. These chemicals are called neurotransmitters, and they affect our mood and emotional responses. Antidepressants work on neurotransmitters such as serotonin, norepinephrine, and dopamine.

The most popular types of antidepressants are called selective serotonin reuptake inhibitors (SSRIs). These include:


        Fluoxetine (Prozac)

        Citalopram (Celexa)

        Sertraline (Zoloft)

        Paroxetine (Paxil)

        Escitalopram (Lexapro)


Other types of antidepressants are serotonin and norepinephrine reuptake inhibitors (SNRIs). SNRIs are similar to SSRIs and include venlafaxine (Effexor) and duloxetine (Cymbalta). Another antidepressant that is commonly used is bupropion (Wellbutrin). Bupropion, which works on the neurotransmitter dopamine, is unique in that it does not fit into any specific drug type.


SSRIs and SNRIs are popular because they do not cause as many side effects as older classes of antidepressants. Older antidepressant medications include tricyclics, tetracyclics, and monoamine oxidase inhibitors (MAOIs). For some people, tricyclics, tetracyclics, or MAOIs may be the best medications.


What are the side effects?


Antidepressants may cause mild side effects that usually do not last long. Any unusual reactions or side effects should be reported to a doctor immediately.


The most common side effects associated with SSRIs and SNRIs include:


  •         Headache, which usually goes away within a few days.
  •         Nausea (feeling sick to your stomach), which usually goes away within a few days.
  •         Sleeplessness or drowsiness, which may happen during the first few weeks but then goes away. Sometimes the medication dose needs to be reduced or the time of day it is taken needs to be adjusted to help lessen these side effects.
  •         Agitation (feeling jittery)
  •         Sexual problems, which can affect both men and women and may include reduced sex drive, and problems having and enjoying sex.
  •         Tricyclic antidepressants can cause side effects, including:
  •         Dry mouth.
  •         Constipation.
  •         Bladder problems. It may be hard to empty the bladder, or the urine stream may not be as strong as usual. Older men with enlarged prostate conditions may be more affected.
  •         Sexual problems, which can affect both men and women and may include reduced sex drive, and problems having and enjoying sex.
  •         Blurred vision, which usually goes away quickly.
  •         Drowsiness. Usually, antidepressants that make you drowsy are taken at bedtime.


People taking MAOIs need to be careful about the foods they eat and the medicines they take. Foods and medicines that contain high levels of a chemical called tyramine are dangerous for people taking MAOIs. Tyramine is found in some cheeses, wines, and pickles. The chemical is also in some medications, including decongestants and over-the-counter cold medicine.


Mixing MAOIs and tyramine can cause a sharp increase in blood pressure, which can lead to stroke. People taking MAOIs should ask their doctors for a complete list of foods, medicines, and other substances to avoid. An MAOI skin patch has recently been developed and may help reduce some of these risks. A doctor can help a person figure out if a patch or a pill will work for him or her.


How should antidepressants be taken?


People taking antidepressants need to follow their doctors’ directions. The medication should be taken in the right dose for the right amount of time. It can take three or four weeks until the medicine takes effect. Some people take the medications for a short time, and some people take them for much longer periods. People with long-term or severe depression may need to take medication for a long time.


Once a person is taking antidepressants, it is important not to stop taking them without the help of a doctor. Sometimes people taking antidepressants feel better and stop taking the medication too soon, and the depression may return. When it is time to stop the medication, the doctor will help the person slowly and safely decrease the dose. It’s important to give the body time to adjust to the change. People don’t get addicted, or “hooked,” on the medications, but stopping them abruptly can cause withdrawal symptoms.


What medications are used to treat bipolar disorder?


Bipolar disorder, also called manic-depressive illness, is commonly treated with mood stabilizers. Sometimes, antipsychotics and antidepressants are used along with a mood stabilizer.


Mood stabilizers


People with bipolar disorder usually try mood stabilizers first. In general, people continue treatment with mood stabilizers for years. Lithium is a very effective mood stabilizer. It was the first mood stabilizer approved by the FDA in the 1970’s for treating both manic and depressive episodes.


Anticonvulsant medications also are used as mood stabilizers. They were originally developed to treat seizures, but they were found to help control moods as well. One anticonvulsant commonly used as a mood stabilizer is valproic acid, also called divalproex sodium (Depakote). For some people, it may work better than lithium.  Other anticonvulsants used as mood stabilizers are carbamazepine (Tegretol), lamotrigine (Lamictal) and oxcarbazepine (Trileptal).


What are the side effects?

Treatments for bipolar disorder have improved over the last 10 years. But everyone responds differently to medications. Different medications for treating bipolar disorder may cause different side effects. Some medications used for treating bipolar disorder have been linked to unique and serious symptoms, which are described below.


Lithium can cause several side effects, and some of them may become serious. They include:


        Loss of coordination

        Excessive thirst

        Frequent urination



        Slurred speech

        Fast, slow, irregular, or pounding heartbeat

        Hallucinations (seeing things or hearing voices that do not exist)

        Changes in vision

        Itching, rash

        Swelling of the eyes, face, lips, tongue, throat, hands, feet, ankles, or lower legs


If a person with bipolar disorder is being treated with lithium, he or she should visit the doctor regularly to check the levels of lithium in the blood, and make sure the kidneys and the thyroid are working normally.


Some possible side effects linked with valproic acid/divalproex sodium include:


        Changes in weight


        Stomach pain



        Loss of appetite

Valproic acid may cause damage to the liver or pancreas, so people taking it should see their doctors regularly.


Valproic acid may affect young girls and women in unique ways. Sometimes, valproic acid may increase testosterone (a male hormone) levels in teenage girls and lead to a condition called polycystic ovarian syndrome (PCOS).  PCOS is a disease that can affect fertility and make the menstrual cycle become irregular, but symptoms tend to go away after valproic acid is stopped.   It also may cause birth defects in women who are pregnant.

Lamotrigine can cause a rare but serious skin rash that needs to be treated in a hospital. In some cases, this rash can cause permanent disability or be life-threatening.


In addition, valproic acid, lamotrigine, carbamazepine, oxcarbazepine and other anticonvulsant medications (listed in the chart at the end of this document) have an FDA warning. The warning states that their use may increase the risk of suicidal thoughts and behaviors. People taking anticonvulsant medications for bipolar or other illnesses should be closely monitored for new or worsening symptoms of depression, suicidal thoughts or behavior, or any unusual changes in mood or behavior. People taking these medications should not make any changes without talking to their health care professional.


Other medications for bipolar disorder may also be linked with rare but serious side effects.


How should medications for bipolar disorder be taken?


Medications should be taken as directed by a doctor. Sometimes a person’s treatment plan needs to be changed. When changes in medicine are needed, the doctor will guide the change. A person should never stop taking a medication without asking a doctor for help.


is no cure for bipolar disorder, but treatment works for many people. Treatment works best when it is continuous, rather than on and off. However, mood changes can happen even when there are no breaks in treatment. Patients should be open with their doctors about treatment. Talking about how treatment is working can help it be more effective.


It may be helpful for people or their family members to keep a daily chart of mood symptoms, treatments, sleep patterns, and life events. This chart can help patients and doctors track the illness. Doctors can use the chart to treat the illness most effectively.

Because medications for bipolar disorder can have serious side effects, it is important for anyone taking them to see the doctor regularly to check for possibly dangerous changes in the body.


What medications are used to treat anxiety disorders?


Antidepressants, anti-anxiety medications, and beta-blockers are the most common medications used for anxiety disorders.


Anxiety disorders include:


        Obsessive compulsive disorder (OCD)

        Post-traumatic stress disorder (PTSD)

        Generalized anxiety disorder (GAD)

        Panic disorder

        Social phobia.




Antidepressants were developed to treat depression, but they also help people with anxiety disorders. SSRIs such as fluoxetine (Prozac), sertraline (Zoloft), escitalopram (Lexapro), paroxetine (Paxil), and citalopram (Celexa) are commonly prescribed for panic disorder, OCD, PTSD, and social phobia. The SNRI venlafaxine (Effexor) is commonly used to treat GAD. The antidepressant bupropion (Wellbutrin) is also sometimes used. When treating anxiety disorders, antidepressants generally are started at low doses and increased over time.


Some tricyclic antidepressants work well for anxiety. For example, imipramine (Tofranil) is prescribed for panic disorder and GAD. Clomipramine (Anafranil) is used to treat OCD. Tricyclics are also started at low doses and increased over time.


MAOIs are also used for anxiety disorders. Doctors sometimes prescribe phenelzine (Nardil), tranylcypromine (Parnate), and isocarboxazid (Marplan). People who take MAOIs must avoid certain food and medicines that can interact with their medicine and cause dangerous increases in blood pressure. For more information, see the section on medications used to treat depression.


Benzodiazepines (anti-anxiety medications)


The anti-anxiety medications called benzodiazepines can start working more quickly than antidepressants. The ones used to treat anxiety disorders include:


        Clonazepam (Klonopin), which is used for social phobia and GAD

        Lorazepam (Ativan), which is used for panic disorder

        Alprazolam (Xanax), which is used for panic disorder and GAD.

        Buspirone (Buspar) is an anti-anxiety medication used to treat GAD


Unlike benzodiazepines, however, it takes at least two weeks for buspirone to begin working.


Clonazepam, listed above, is an anticonvulsant medication.




Beta-blockers control some of the physical symptoms of anxiety, such as trembling and sweating. Propranolol (Inderal) is a beta-blocker usually used to treat heart conditions and high blood pressure. The medicine also helps people who have physical problems related to anxiety. For example, when a person with social phobia must face a stressful situation, such as giving a speech, or attending an important meeting, a doctor may prescribe a beta-blocker. Taking the medicine for a short period of time can help the person keep physical symptoms under control.


What are the side effects?


The most common side effects for benzodiazepines are drowsiness and dizziness. Other possible side effects include:


        Upset stomach

        Blurred vision






Possible side effects from buspirone (BuSpar) include:








        Trouble sleeping


Common side effects from beta-blockers include:



        Cold hands




In addition, beta-blockers generally are not recommended for people with asthma or diabetes because they may worsen symptoms.


How should medications for anxiety disorders be taken?


People can build a tolerance to benzodiazepines if they are taken over a long period of time and may need higher and higher doses to get the same effect. Some people may become dependent on them. To avoid these problems, doctors usually prescribe the medication for short periods, a practice that is especially helpful for people who have substance abuse problems or who become dependent on medication easily. If people suddenly stop taking benzodiazepines, they may get withdrawal symptoms, or their anxiety may return. Therefore, they should be tapered off slowly.


Buspirone and beta-blockers are similar. They are usually taken on a short-term basis for anxiety. Both should be tapered off slowly. Talk to the doctor before stopping any anti-anxiety medication.


What medications are used to treat ADHD?


Attention deficit/hyperactivity disorder (ADHD) occurs in both children and adults. ADHD is commonly treated with stimulants, such as:


        Methylphenidate (Ritalin, Metadate, Concerta, Daytrana)

        Amphetamine (Adderall)

        Dextroamphetamine (Dexedrine, Dextrostat).

        In 2002, the FDA approved the nonstimulant medication atomoxetine (Strattera) for use as a treatment for ADHD. In February 2007, the FDA approved the use of the stimulant lisdexamfetamine dimesylate (Vyvanse) for the treatment of ADHD in children ages 6 to 12 years


What are the side effects?


Most side effects are minor and disappear when dosage levels are lowered. The most common side effects include:


        Decreased appetite. Children seem to be less hungry during the middle of the day, but they are often hungry by dinnertime as the medication wears off.


        Sleep problems. If a child cannot fall asleep, the doctor may prescribe a lower dose. The doctor might also suggest that parents give the medication to their child earlier in the day, or stop the afternoon or evening dose. To help ease sleeping problems, a doctor may add a prescription for a low dose of an antidepressant or a medication called clonidine.

        Stomachaches and headaches


Less common side effects. A few children develop sudden, repetitive movements or sounds called tics. These tics may or may not be noticeable. Changing the medication dosage may make tics go away. Some children also may appear to have a personality change, such as appearing “flat” or without emotion. Talk with your child’s doctor if you see any of these side effects.


How are ADHD medications taken?


Stimulant medications can be short-acting or long-acting, and can be taken in different forms such as a pill, patch, or powder. Long-acting, sustained and extended release forms allow children to take the medication just once a day before school. Parents and doctors should decide together which medication is best for the child and whether the child needs medication only for school hours or for evenings and weekends too.



ADHD medications help many children and adults who are hyperactive and impulsive. They help people focus, work, and learn. Stimulant medication also may improve physical coordination. However, different people respond differently to medications, so children taking ADHD medications should be watched closely.


Are ADHD medications safe?

Stimulant medications are safe when given under a doctor’s supervision. Some children taking them may feel slightly different or “funny.”


Some parents worry that stimulant medications may lead to drug abuse or dependence, but there is little evidence of this. Research shows that teens with ADHD who took stimulant medications were less likely to abuse drugs than those who did not take stimulant medications.


FDA warning on possible rare side effects


In 2007, the FDA required that all makers of ADHD medications develop Patient Medication Guides. The guides must alert patients to possible heart and psychiatric problems related to ADHD medicine. The FDA required the Patient Medication Guides because a review of data found that ADHD patients with heart conditions had a slightly higher risk of strokes, heart attacks, and sudden death when taking the medications. The review also found a slightly higher risk (about 1 in 1,000) for medication-related psychiatric problems, such as hearing voices, having hallucinations, becoming suspicious for no reason, or becoming manic. This happened to patients who had no history of psychiatric problems.


The FDA recommends that any treatment plan for ADHD include an initial health and family history examination. This exam should look for existing heart and psychiatric problems.


The non-stimulant ADHD medication called atomoxetine (Strattera) carries another warning. Studies show that children and teenagers with ADHD who take atomoxetine are more likely to have suicidal thoughts than children and teenagers with ADHD who do not take atomoxetine. If your child is taking atomoxetine, watch his or her behavior carefully. A child may develop serious symptoms suddenly, so it is important to pay attention to your child’s behavior every day. Ask other people who spend a lot of time with your child, such as brothers, sisters, and teachers, to tell you if they notice changes in your child’s behavior. Call a doctor right away if your child shows any of the following symptoms:


        Acting more subdued or withdrawn than usual

        Feeling helpless, hopeless, or worthless

        New or worsening depression

        Thinking or talking about hurting himself or herself

        Extreme worry


        Panic attacks

        Trouble sleeping


        Aggressive or violent behavior

        Acting without thinking

        Extreme increase in activity or talking

        Frenzied, abnormal excitement

        Any sudden or unusual changes in behavior


Which groups have special needs when taking psychiatric medications?


Psychiatric medications are taken by all types of people, but some groups have special needs, including:


        Children and adolescents

        Older adults

        Women who are pregnant or may become pregnant.

        Children and adolescents


Most medications used to treat young people with mental illness are safe and effective. However, many medications have not been studied or approved for use with children. Researchers are not sure how these medications affect a child’s growing body. Still, a doctor can give a young person an FDA-approved medication on an “off-label” basis. This means that the doctor prescribes the medication to help the patient even though the medicine is not approved for the specific mental disorder or age.


For these reasons, it is important to watch young people who take these medications. Young people may have different reactions and side effects than adults. Also, some medications, including antidepressants and ADHD medications, carry FDA warnings about potentially dangerous side effects for young people.


More research is needed on how these medications affect children and adolescents. In addition to medications, other treatments for young people with mental disorders should be considered.


Psychotherapy, family therapy, educational courses, and behavior management techniques can help everyone involved cope with the disorder.


Older adults


Because older people often have more medical problems than other groups, they tend to take more medications than younger people, including prescribed, over-the-counter, and herbal medications. As a result, older people have a higher risk for experiencing bad drug interactions, missing doses, or overdosing.


Older people also tend to be more sensitive to medications. Even healthy older people react to medications differently than younger people because their bodies process it more slowly. Therefore, lower or less frequent doses may be needed.


Sometimes memory problems affect older people who take medications for mental disorders. An older adult may forget his or her regular dose and take too much or not enough. A good way to keep track of medicine is to use a seven-day pill box, which can be bought at any pharmacy. At the beginning of each week, older adults and their caregivers fill the box so that it is easy to remember what medicine to take. Many pharmacies also have pillboxes with sections for medications that must be taken more than once a day.


Women who are pregnant or may become pregnant


The research on the use of psychiatric medications during pregnancy is limited. The risks are different depending on what medication is taken, and at what point during the pregnancy the medication is taken. Research has shown that antidepressants, especially SSRIs, are safe during pregnancy. Birth defects or other problems are possible, but they are very rare.


However, antidepressant medications do cross the placental barrier and may reach the fetus. Some research suggests the use of SSRIs during pregnancy is associated with miscarriage or birth defects, but other studies do not support this.20 Studies have also found that fetuses exposed to SSRIs during the third trimester may be born with “withdrawal” symptoms such as breathing problems, jitteriness, irritability, trouble feeding, or hypoglycemia (low blood sugar).

Most studies have found that these symptoms in babies are generally mild and short-lived, and no deaths have been reported. On the flip side, women who stop taking their antidepressant medication during pregnancy may get depression again and may put both themselves and their infant at risk.


In 2004, the FDA issued a warning against the use of certain antidepressants in the late third trimester. The warning said that doctors may want to gradually taper pregnant women off antidepressants in the third trimester so that the baby is not affected.   After a woman delivers, she should consult with her doctor to decide whether to return to a full dose during the period when she is most vulnerable to postpartum depression.


Some medications should not be taken during pregnancy. Benzodiazepines may cause birth defects or other infant problems, especially if taken during the first trimester. Mood stabilizers are known to cause birth defects. Benzodiazepines and lithium have been shown to cause “floppy baby syndrome,” which is when a baby is drowsy and limp, and cannot breathe or feed well.


Research suggests that taking antipsychotic medications during pregnancy can lead to birth defects, especially if they are taken during the first trimester. But results vary widely depending on the type of antipsychotic. The conventional antipsychotic haloperidol has been studied more than others, and has been found not to cause birth defects.

After the baby is born, women and their doctors should watch for postpartum depression, especially if they stopped taking their medication during pregnancy. In addition, women who nurse while taking psychiatric medications should know that a small amount of the medication passes into the breast milk. However, the medication may or may not affect the baby. It depends on the medication and when it is taken. Women taking psychiatric medications and who intend to breastfeed should discuss the potential risks and benefits with their doctors.


Decisions on medication should be based on each woman’s needs and circumstances. Medications should be selected based on available scientific research, and they should be taken at the lowest possible dose. Pregnant women should be watched closely throughout their pregnancy and after delivery.



What medications are used to treat substance dependence?


Medications can be used to help treat alcohol abuse and dependence. Some medicines reduce withdrawal symptoms during detoxification. Other medicines help you stay sober during the long process of recovery.




Medicines most often used to treat withdrawal symptoms during detoxification include:


        Antianxiety medicines (benzodiazepines such as diazepam), which treat withdrawal symptoms such as delirium tremens (DTs).

        Seizure medicines to reduce or stop severe withdrawal symptoms during detoxification.

        Medicines for recovery

        Medicines used to help you stay sober during recovery include:

        Disulfiram (Antabuse), which makes you sick to your stomach when you drink.

        Naltrexone (ReVia, Vivitrol), which interferes with the pleasure you get from drinking.

        Acamprosate (Campral), which may reduce your craving for alcohol.

        Topiramate (Topamax), which may help treat alcohol problems.



Risk Assessment


The Choice of Suicide:

There are three necessary and sufficient conditions for a suicidal event to occur:


1) There must be sufficient psychological pain.


2) The wish to die must be greater than the wish to live.


3) A self-injury method must be available.

Let’s look at each of these individually.


Psychological Pain:


Current/Acute suicidal thoughts and/or intent

History of mental illness

Intensity of current depressive symptoms

Current treatment regimen and response

 Recent life stressors (separation, loss)

Alcohol and drug use patterns

Psychotic symptoms

Current living situation (support system)


Thousands of theorists have tried to answer the question of why people kill themselves.  Geo Stone, Suicide and Attempted Suicide summarizes the reasons best in three words: to stop pain.

Psychological pain can include a myriad of issues.  Although most depressed people are not suicidal, most suicidal people are depressed. Depression, stress and grief can be suffocating.  It can seem as though there is no viable way out of the problems, short of escaping into death.  Even more unnerving is the statistics that show those who cannot differentiate between long-term problems and situational problems.  A suicide in response to a long term, chronic problem is distressing.  A suicide in response to a single event such as failing a test or not making the team is heartbreaking.


The Wish To Die Must Be Greater Than The Wish To Live:

All behavior has a positive intention.  Not all behavior is positive, but on some level the desired outcome has a positive motive.  When assessing the potential for suicide in a patient it is difficult to ascertain their level of commitment.  An understanding of where a patient is coming from is necessary to understand what positive intention their behavior has.  One night a ship’s captain saw the lights of what he thought was an approaching ship heading directly toward the vessel he was commanding.  He ordered his communications officer to blink a message to the approaching ship:  Change your course 10 degrees south.  A reply came back instantly, Change your course 10 degrees north.  The captain fired back, I’m a captain, change your course south.  Another reply cam back quickly, Well, I’m a seaman 1st class, change your course north.  Infuriated, the ship’s captain signaled back sharply, Dammit, I’ll say one last time, change your course south.  I’m on a battleship!  The immediate volley came back, and I say change your course north; I’m in a lighthouse! (author unknown). You have to determine where the person is emotionally to make an assessment of how safe they are.  What is a challenge to one person is unbearable to another. 


All gestures and attempts are serious.  Some of the issues to take into account in determining how much should be done to ensure someone’s safety include looking at whether they have made previous attempts, how lethal were those attempts and is the attempt a means to simply end life or change it somehow.  An emotional pay off does not make the behavior less dangerous or the attempt less serious, but there would other avenues in treatment that should be addressed.  


As a mental health counselor in the psychiatric hospital setting, I assessed several hundred suicide attempts.  I clearly remember only two individual who wanted to die over any other possible solution.  Those who are serious about suicide are not attention seeking, however there an unfortunate many that do use behavior to manipulate when they are void of other productive means.  Suicides can also occur as a person in need continues to up the ante with high-risk behaviors.


Ann and John have had a rocky relationship for years.  John seems to spend more and more time at the local bar hanging out with his friends.  Ann has tried to talk with him about how lonely she gets when he is away all of the time, but he just complains that she is nagging.  Ann ingest 10 Tylenol then calls 911.  John rushes to the E.R. and things improve between them for several weeks.  Over time John feels safe leaving Ann and actually begins to resent having to baby sit her emotions.  He begins to go out with the guys too often again.  They fight frequently, Ann leaves him several times, just to reconcile days later.  After a particularly bad fight, John storms out of the house.  He yells back at Ann for her not to wait up for him, as he has no intentions of coming home until he is ready.  Ann then takes 15 Tylenol and makes a superficial cut on her wrist as this cycle continues; these behaviors can result in an accidental suicide.




Method Availability

It is worthy of repeating, all statements, gestures, and attempts are serious.  In addition to this, it is a professionals goal to help a client in the lowest level of care necessary.  When making that determination, a factor that can give detail to where a client is at in the ideation of suicide is to ask if they have thought of killing themselves and if so how.  If the response is that they have thought about dying by shooting themselves and they do not have access to a gun, the situation is less threatening in the immediate than someone who plans on taking the readily available prescription drugs waiting in the bathroom.  At least, there is the potential for intervention time.


As noted by the American Foundation for Suicide, the factors that contribute any particular suicide are diverse and complex, so our efforts to understand it must incorporate many approaches. The clinical, neurobiological, legal and psychosocial aspects of suicide are some of the major lines of inquiry into suicide.


Danger Signs of Suicide:


The American Foundation for Suicide list the following as risk factors:


  • Past History of Attempted Suicide
    Between 20 and 50 percent of people who kill themselves had previously attempted suicide. Those who have made serious suicide attempts are at a much higher risk for actually taking their lives.
  • Psychiatric Disorders
    Substance Abuse, particularly when combined with depression
    Personality Disorders, especially Borderline, Antisocial
  • Genetic Predisposition
    Family history of suicide, depression, or other psychiatric illness. 
  • Neurotransmitters
    A clear relationship has been demonstrated between low concentrations of the serotonin metabolite 5-hydroxyindoleactic acid (5-HIAA) in cerebrospinal fluid and an increased incidence of attempted and completed suicide in psychiatric patients.
  • Impulsivity 
    Impulsive individuals are more apt to act on suicidal impulses
  • Demographics
    Sex: Males are three to five times more likely to commit suicide than females. 
    Age: Elderly Caucasian males have the highest suicide rates.


Overall the most common risk factors to address in a risk assessment include:


History of Suicide Attempts

Medical Seriousness of Previous Attempts

Acute Suicidal Ideation

Family History of Suicide

 Acute Overuse of Alcohol and or Other Drugs

       Alcoholism is a factor in about 30% of all completed suicides.

            Approximately 7 percent of those with alcohol dependence will die by




SAD PERSONS: a mnemonic for assessing suicide risk

S ex (male)

A ge (elderly or adolescent)

D epression


P revious suicide attempts

E thanol abuse

R ational thinking (psychosis)

S ocial supports lacking

O rganized plan

N o spouse (divorced, widowed, single)

S ickness (physical illness)


Other considerations noted by the American Foundation for Suicide  include:

         Intense Affective State in Addition to Depression
Immediate relief is sought.  The individual expresses desperation, rage, anxiety, guilt, hopelessness, or an acute sense of abandonment.

         Changes in Behavior and Speech

     Be alert to such statements as, my children would

     be better off with a happy mommy. Or my parents    

     would be happier if they didnt have me to deal

     with. Often those contemplating suicide talk as if

     they are saying signing off or going away. 


         Deterioration in level of functioning  

Work or schoolwork declines, increasing use of alcohol, other self-destructive behavior, loss of control, rage explosions.


Initial Management and Disposition:


There are many intervention strategies for professionals and loved ones to access to help those in need.  The following is intended to categorize patients to help with the determination of what is necessary. 


  • Ideation, Plan and Intent

  • Ideation, Plan, No Intent

  • Ideation, No Plan, No Intent

1.  Ideation, Plan and Intent


Hospitalization is necessary, especially if they have current psychosocial stressors and acces to lethal means. 



2.  Ideation, Plan, No Intent


In some circumstances, these clients can be treated in outpatient settings, especially if they have a solid support system and no access to a lethal means.  In some cases, hospitalization is necessary.


3.  Ideation, No Plan, No Intent


These clients should be evaluated carefully for psychosocial stressors.  With good support systems in place and no lethal means, they can generally be treated in outpatient.



Suicide Crisis Calls:

A suicidal patient may evoke significant strong emotions in a counselor, such as anger toward the client or fear of losing the client, of personal failure or professional consequences in preventing attempts


However, despite these emotions, mental health professionals can have a tremendous impact by arming themselves with the knowledge and skill to successfully treat depressed clients and prevent suicide.


David L. Conroy, PhD, makes the following recommendations for how to handle a caller who is suicidal.


 1.  Be yourself. The right words are unimportant. If you are

     concerned, your voice and manner will show it.

2.  Listen. Let the person unload despair, ventilate anger. If given an

     opportunity to do this, he or she will feel better by the end of the

     call. No matter how negative the call seems, the fact that it exists

     is a positive sign, a cry for help.

3.  Be sympathetic, non-judgmental, patient, calm, accepting. The caller has done the right thing by getting in touch with another person.

4.  If the caller is saying I’m so depressed, I cannot go on, ask The Question: Are you having thoughts of suicide?

5.  If the answer is yes, you can begin asking a series of further questions: Have you thought about how you would do it (PLAN); Have you got what you need (MEANS); Have you thought about when you would do it (TIME SET). 95% of all suicidal callers will answer no at some point in this series or indicate that the time is set for some date in the future. This will be a relief for both of you.

6.  Simply talking about their problems for a length of time will give suicidal people relief from loneliness and pent up feelings, awareness that another person cares, and a feeling of being understood. They also get tired — their body chemistry changes. These things take the edge off their agitated state and help them get through a bad night.

7.  Avoid arguments, problem solving, advice giving, quick referrals, belittling and making the caller feel that has to justify his suicidal feelings. It is not how bad the problem is, but how badly its hurting the person who has it.

8.  If the person is ingesting drugs, get the details (what, how much, alcohol, other medications, last meal, general health) and call Poison Control or 911.  A shift partner can call while you continue to talk to the person, or you can get the callers permission and do it yourself on another phone while the caller listens to your side of the conversation. If Poison Control recommends immediate medical assistance,

     ask if the caller has a nearby relative, friend, or neighbor who can assist with transportation or the ambulance. In a few cases the person will initially refuse needed medical assistance. Remember that the call is still a cry for help and stay with him in a sympathetic and non-judgmental way. Ask for his address and phone number in case he changes his mind. (Call the number to make sure its busy.) If your organization does not trace calls, be sure to tell him that.

9.  Do not go it alone. Get help during the call and debrief afterwards.

10.Your caller may be concerned about someone else who is suicidal. Just listen, reassure him that he or she is doing the right thing by taking the situation seriously, and sympathize with the stressful situation. With some support, many third parties will work out reasonable courses of action on their own. In the rare case where the third party is really a first party, just listening will enable you to move toward his or her problems. You can ask, Have you ever been in a situation where you had thoughts of suicide?



Suicide, in most cases, can be prevented. While some suicides occur without any precedence, most do not. The most effective way to prevent suicide is to learn how to recognize the signs of someone at risk, take those signs seriously and know how to respond to them.

Many of the catalysts for suicide are temporary; suicide is permanent.  Suicide is not a random or senseless act, but an unchangeable, extreme, solution.