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Fred Severyn, MD

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Division of Emergency Medicine
University of Colorado Denver School of Medicine
Aurora, Colorado

Indeed infection x girl 960 mg bactrim otc, this approach prizes activist group MindFreedom staged a hunger strike and demanded B antibiotics for moderate acne order line bactrim. The organization issued a press release that chided Cruise for promoted this story? Following publication of the book antimicrobial lab coats buy generic bactrim 480mg online, model continue to head governmental agencies that determine Whitaker was invited to speak at the 2010 Alternatives Conference virus protection free discount bactrim 960 mg on line, an national research and policy agendas? In response antimicrobial nanomaterials buy bactrim 960 mg low price, MindFreedom launched a psychotropic medications lead to less severe virus lyrics purchase bactrim cheap online, chronic, and disabling protest and Whitaker was re-invited to speak, but with a catch: imme mental disorders, as opposed to the opposite? The psychiatrist noted in his remarks that he had never reduces mental health stigma, why has stigma not improved in the attended a conference at which a second keynote speaker was context of widespread promotion and increased public acceptance employed to discredit the ﬁrst (Whitaker, 2010c). As before, his ad tropic medications are less safe and effective than is commonly dress was immediately followed by an extended rebuttal from a psy acknowledged, on what basis should psychiatrists be granted the chiatrist (Whitaker, 2011). As instructed, Whitaker submitted his legal authority to involuntarily hospitalize and forcibly treat individ slides to the organizers months prior to the grand rounds, but he did uals with mental disorders? A vigorous dialog about these issues is currently taking place in a Following the grand rounds, a Boston radio show reported that number of online communities. Although the popular media has repudiated by oneofthe leadingpsychiatrydepartmentsin thecountry, traditionally promoted biomedical claims in an uncritical manner, many of Whitaker subsequent speaking engagements were canceled. For those whose professional, ﬁnancial, and ideological of intense public debate, with critical stories appearing in prominent interests depend on maintaining the widely accepted validity of the newspapers, national newscasts, popular websites, and in the scientif biomedical model of mental disorder, this dialog may be perceived ic literature (Dx Revision Watch, 2012). Unfortunately, each example of critical edged as scientiﬁcally premature or even fallacious by some of the very dialog cited above has occurred largely without open and honest individuals and organizations who promote them (see Tables 1 and 2). Deacon / Clinical Psychology Review 33 (2013) 846–861 It is my hope that this article will encourage critical examination of Bach, P. The use of acceptance and commitment therapy to prevent the rehospitalization of psychotic patients: A randomized controlled trial. Toward a uniﬁed treatment for terized by increasingly chronic and disabling mental disorders in the emotional disorders. Uniﬁed protocol for transdiagnostic treatment of emotional disorders: Therapist “biologically-based brain disease” causal attributions. Cognitive-behavioral rewarded with improved clinical tools or outcomes, and continuation therapy, imipramine, or their combination for panic disorder: A randomized of the status quo based on faith that neuroscience will eventually revo controlled trial. Treatment of acute psychosis without neuroleptics: long-anticipated but scientiﬁcally implausible discovery of biological Two-year outcomes from the Soteria Project. Perphenazine:Observationsontheclinicaleffectsof References a new tranquillizing agent in psychotic conditions. The chemical imbalance explanation of depression: American Psychiatric Association (2003b). Eye movement desensitization and reprocessing: A chronology sants “irresponsible and dangerous”. Can long-term treatment with antidepressant drugs worsen the Psychologist, 58, 1028–1043. National surveys of mental disorders: Are they researching scientiﬁc Progress in Neuro-Psychopharmacology & Biological Psychiatry, 15, 1593–1602. Psychiatry, the pharmaceutical industry, and the road to better Psychiatry, 40, 830–834. Randomized, placebo-controlled trial of exposure and ritual prevention, Psychiatry, 17,11–21. Psychiatric News (Retrieved February 18, England Journal of Medicine, 352, 2515–2523. Retrieved June 27, 2012, ators of treatment effects in randomized clinical trials. Serotonin and depression: A disconnect between the adver phrenia patients not on antipsychotic medications: A 15-year multifollow-up tisements and the scientiﬁc literature. The empirically validated treatments movement: A practitioner/ phobia: Basic mechanisms and clinical strategies. Cognitive neuroscience and depression: Legitimate versus ims/Global/Content/Corporate/Press%20Room/Top-Line%20Market%20Data%20&% illegitimate reductionism and ﬁve challenges. Testimony during the hearing, Mental Illness and brain disease: Medco Health Solutions (2011). Retrieved June 13, 2012, from Dispelling myths and promoting recovery through awareness and treatment. Translating scientiﬁcopportunity intopublichealthimpact: Astrategic Psychological Science, 5, 716–743. Retrieved hunger-strike/hunger-strike-debate/fast-for-freedom-statement February 18, 2012, from. Reply by scientiﬁc panel of the Fast for Freedom in illness-deﬁned-as-disruption-in-neural-circuits. The inﬂuence of corporate and political trends in the outpatient diagnosis and treatment of bipolar disorder in youth. Three professional organization responses to third and ﬁnal Inform Yourself/About Mental Illness/About Mental Illness. Acute and longer-term outcomes in depressed outpatients requir take-over-obsessive-com;pulsive-disorder/complete. The catecholamine hypothesis of affective disorders: A review National Institute on Alcohol Abuse and Alcoholism (2012). The prospective course of rapid-cycling bipolar disorder: Findings from National Institute on Drug Abuse (2010). Evolution of public attitudes about mental illness: A systematic review and Norberg, M. National trends in the out Double-blind comparison of ﬁrst and second-generation antipsychotics in patient treatment of children and adolescents with antipsychotic drugs. Archives early-onset schizophreniaandschizo-affectivedisorder:Findingsfromthetreatment of General Psychiatry, 63, 679–685. Assessment of a multi-assay, serum-based biological diagnostic test for major New York: Harper & Row. More on the brain disease model of sertraline, and their combination for children and adolescents with obsessive– mental disorders. Reductionism in the psychology of the eighties: Can biochemistry World Mental Health Surveys. Journal of the American Medical Association, 291, eliminate addiction, mental illness, and pain? Mental health: A report of the ment industry to convince us we are out of control. The signiﬁcance of dopaminereceptor blockade for the action of disease like any other? National survey of psychotherapy training in psychiatry, psychology, and of American science. Retrieved June 29, pression, anxiety, and conduct problems in youth: A randomized effectiveness 2012, from. This is an open-access article distributed under the terms of the Creative Commons License creativecommons. Reproduction is permitted for personal, noncommercial use, provided that the article is in whole, unmodified, and properly cited. However, over the past twenty years, treatment has evolved to a more target-directed approach. As we are presented with an ever increasing number of treatment options, the timing and combinations of therapeutic agents used becomes ever more complex in the age of personalized care, but we are hopeful that ultimately this will lead to improved patient outcomes. Breast cancer traditionally has been classified cers, and is associated with poor clinical outcomes into three different subtypes based on the presence or and aggressive tumor progression (18 21). The exact mechanism of action is not fully un cancer cases; while approximately 20% of breast can derstood. In this article, we will or progression of the disease due to trastuzumab re review the most promising novel biologic agents un sistance (43). The most plus trastuzumab plus docetaxel group (control common adverse events of grade 3 or higher was group) and 402 to pertuzumab plus trastuzumab plus neutropenia (61 of 107 women in group A, 48 of 107 in docetaxel group (pertuzumab group). The primary group B, one of 108 in group C, and 52 of 94 in group end point was independently assessed progres D) and febrile neutropenia (eight, nine, none, and sion-free survival, and secondary end points included seven, respectively) (72). Further the NeoSphere trial assessed the effect of per clinical studies are required to determine the clinical tuzumab and trastuzumab plus chemotherapy in relevance of this medication. The fusion pro groups: group A received trastuzumab and docetaxel, tein is conformed by two human single-chain variable group B received pertuzumab, trastuzumab and fragment (scFv) antibodies linked to a modified hu docetaxel, group C received pertuzumab and man serum albumin (78). However, in tumor cells ized study to compare the efficacy and safety of gem lacking homologous recombination. Results of cytopenia being the most common grade 3 or 4 toxici a phase I trial conducted by Kummar et al. Olaparib with temozolamide in preclinical solid tumor models was well tolerated, with grade 1-2 nausea, fatigue and (113). A phase I trial of rucaparib combined with te vomiting being the most commonly observed adverse mozolomide in advanced solid tumors was conduct reactions (95). A recent ules of olaparib: olaparib 400 mg once daily (cohort 1) study recruited 39 patients with multiple malignan vs. As such, rapamycin, along with result of adverse toxicities did so due to pneumonitis. Patients were stratified, based on letrozole and everolimus both inhibit estro the presence of visceral metastasis and prior sensitiv gen-induced breast cancer proliferation, and that ity to endocrine therapy, and received daily oral these two agents in combination act synergistically to everolimus (10mg) or placebo combined with ex augment their anti-tumor activity even further (125). Patients re progression, unacceptable toxicity, or withdrew from ceived 4 months of neoadjuvant letrozole combined the study. The termined by clinical palpation, favored the everolimus median age of the enrolled patients was 62, with 56% group 68. All three rozole or anastrozole, 48% had previously received cases of pneumonitis resolved shortly after discon tamoxifen, 16% had previously received fulvestrant, tinuing everolimus. Pneumonitis dated data was recently reported at the 2011 San An occurred more frequently than expected; 11 of 33 pa tonio Breast Cancer Symposium. There received either ganitumab or placebo, combined with are currently three trials involving cixutumumab exemestane or fulvestrant, per investigator’s choice. Breast cancer patients in more than 5% of the patients were transaminitis the cohort expansion group received 120 mg/kg/day (10%), headache (7%), and fatigue (7%). Partial responses were when she received trastuzumab previously), depres seen in 9 of 41 (22%) patients in the phase 1 portion. Vorinostat positive breast cancer who had progressed on was combined with tamoxifen in 19 patients with trastuzumab (164). The only grade 3-4 tox nificant toxicities included two venous thromboem icities were grade 3 transaminits in a patient with liver bolic events and grade 3 fatigue in 3 patients. The metastasis, grade 3 vomiting, and grade 3 hypokale most common grade 2 toxicities included: fatigue, mia due to grade 1 diarrhea. The most common pain and diarrhea requiring dose reduction and grade 3-4 toxicities were: fatigue, dyspnea, diarrhea, asymptomatic and reversible elevation in serum am and lethargy. Certainly, this question will be the subject Concluding Remarks of future studies. However, if one uses the paradigm the paradigm for treating breast cancer has of choosing highly efficacious therapies which have changed rather dramatically over the last decade. One of the challeng tumor biology, but at the same time beneficial due to es, particularly in treating metastatic breast cancer, is the availability of a biomarker that can become a tar that even with improved systemic therapies, the dis get for successful therapy. As more drugs that target the availability of several less toxic targeted therapies specific pathways are developed, tumors develop which can drastically change the natural history of the means to evade these agents, particularly when there disease. In fact it speaks to how far we have come in is redundancy in most biologic processes. The ro treating breast cancer as not just one disease, as our bustness, evolvability, modularity, redundancy, di treatments will become “personalized” to specific versity, system control, tolerance, and plasticity are subtypes of the disease. We can tailor our therapy to hallmarks of network pathways (174) which will fur the presence of functional genes: molecular profiling ther lead to difficulties of individual compounds to be will become much more used in the near future and successfully used against cancer growth for longer more such targeted compounds may become reality. One potential strategy is to combine Much work is of course still needed to unfold the multiple drugs that hit biologically important path complex personalized networks of tumor prolifera ways at different places. We believe that more thorough preclin the authors have declared that no competing ical testing may help us make more informed deci interest exists. Lyon, France: International Agency new treatment paradigms that will continue to build for Research on Cancer; 2010. Trastuzumab emtansine in human epidermal on progress made over preceding two decades, and growth factor receptor 2-positive breast cancer: a review. Curr Opin further improve clinical outcomes and survival rates Oncol 2011;23:594–600. Biology, metastatic patterns, and treatment of comparing docetaxel plus trastuzumab with vinorelbine plus patients with triple-negative breast cancer. Human breast cancer: correlation of relapse and survival with amplifi 2007;110:965-972. Activity of the dual kinase inhibitor lapatinib tooncogene in human breast and ovarian cancer. Trastuzumab Emtansine: A Unique Antibody-Drug that targets the ErbB2/ErbB3 oncogenic unit and inhibits heregu Conjugate in Development for Human Epidermal Growth Factor Re lin-induced activation of ErbB3. Cancer Res 2009;69(24 Suppl): Ab preliminary results of a randomized, multicenter, open-label phase 2 stract5062. Temsirolimus, Interferon Alfa, or Both for actions, physiological outcomes, and clinical targets. J Clin Oncol 2010; 28: abstr1013 bination with Topotecan Hydrochloride in Adults with Refractory Solid 134. Cancer Res 2011 Sep 1;71(17):5626-34 itor everolimus in combination with trastuzumab and vinorelbine in 112. Baselga J, Tolaney S, Hart L, Gomez P, Gartner E, DeCillis A, Ruiz-Soto in combination with trastuzumab in patients (pts) with pretreated, lo R, Lager J, Burris H.

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Strategic attacks on the adversary’s identifed centres of gravity will prevent them from executing a unifed strategy bacteria in florida waters bactrim 960 mg low price. The commander’s skill will be critical in allocating priorities to the diferent elements of the air campaign and thereafter in ensuring that adequate resources are made available to complete individual tasks virus 800000cb buy 960 mg bactrim free shipping. In the conduct of air campaigns antibiotic resistance in campylobacter jejuni buy bactrim 480mg low price, this will be an onerous task that will consume the commander’s entire attention and yet cannot be considered infallible virus and fever safe 480mg bactrim. Carefully balancing the air efort available and required will be an absolute necessity considering that air power assets are almost always scarce antibiotics given for ear infections purchase 960mg bactrim with visa, especially during actual combat operations antibiotics invented buy generic bactrim 480 mg on line. In pre-confict situations, ofensive air power must only be employed when it is certain that such actions will be advantageous to achieving the strategic long-term objectives of the campaign. When faced with an adversary air force of equal calibre, and if the advantages that would be gained by such actions are dubious, it would be prudent to carry out holding actions and recalibrate one’s own ofensive plans before executing them. More than in other military forces, attrition can become untenable in the case of air power for two reasons. First, the long gestation period required to feld a sufciently competent force with the required capabilities and, second, the difculty in obtaining 354 Strategic Situations sufcient equipment and personnel to reinforce a unit or force that has sufered high attrition. Terefore, air commanders must be able to identify the theatres wherein the air campaign must be carefully conducted at just the required level—without any surge etc. This is a command decision that will have to be based on professional mastery of the art of air campaign planning. Attrition Trench warfare in the Western Front from September 1914 to November 1918 is a classic example of a strategy of attrition being adopted by both sides in a campaign. On 1 July 1916 the British Army sufered 60,000 casualties during the frst hours of the Battle of the Somme. The concept of strategic bombardment was seen as a way of avoiding such horrendous casualties in future wars. However, the early theorists of air power including Douhet, Trenchard and Mitchell did not consider the extremely high casualty rate sufered by aviators during World War One. One reason may have been that many of British aircrew shot down were listed as casualties in the regiment that they had served in prior to joining the Royal Flying Corps. Consequently, the early theories on the application of air power did not include any consideration of the very high casualty rates that would be sufered by airmen in the future. This would mean that the entire campaign would have to be conducted under an unfavourable air situation, which may not be tenable in most cases. Air campaign planning to deal with an air force that is superior in ‘size’ is perhaps the most difcult. The air commander will have to determine the theatre or area of operation that is most vital for the adversary—identifed by analysing their intention—and then seize the initiative in that area by obtaining control of the air and vigorously denying the adversary manoeuvre opportunities. This may have to be done at the cost of depleting other areas of air power capabilities and, therefore, such decisions will have to be made at the strategic level of joint command. Under these circumstances, the air commander’s decision planning and conduct of the air campaign is crucial to the success of the broader joint campaign. Exploit the enemy’s unpreparedness; Attack when they are unaware; Take unexpected paths. The skilled commander travels by unexpected routes and strikes at the enemy at their points of weakness, taking advantage of the adversary’s unpreparedness. Speed has two distinct elements and is applicable at two diferent levels in the context of warfare. One, in the physical domain where manoeuvres have to be carried out efectively in the battlespace as fast as possible while maintaining the cohesiveness of the force at all times; and, two, in the cognitive domain, where the commander must be able to make decisions regarding the deployment of forces, execution of a pre-planned strategy and the way to counter adversary manoeuvre during the conduct of the confict. At the physical level, controlling the speed is mainly an operational and tactical level activity, although broader directions will emanate from the strategic level of command. In the cognitive domain, speed of the unfolding confict can only be mastered at the strategic level of command but the implications afect the activities of the force down to the tactical level, both in command and manoeuvres. This is because all conficts are a function of a whole of-government approach and decision-making at that level is ponderous at best. Sun Tzu advises to look for the time when the adversary is unprepared for battle and then attack at a time and place of one’s own choosing to catch them unawares. The element of surprise—unexpected paths—is considered a necessary contribution to improve the chances of success. One of the primary contributions of air power to contemporary confict is its ability to control the tempo of war. Controlling the tempo has further nuances in its application to a modern battlespace. A force that can operate at a tempo that is unsustainable for the adversary will always be victorious. Air power’s inherent characteristics—speed, responsiveness, reach, penetration, lethality—make it ideally suited to set and maintain the tempo of a confict. At the physical level, this could mean carrying out air operations at a pace faster than the adversary can efectively respond, thereby overwhelming their war-making capabilities. The essence here is relative speed; that is, one’s own actions must be faster than those of the adversary but need not be at the fastest pace that one’s own forces are capable of creating. In applying air power efectively, tempo can be controlled by any or a combination of saturation strikes that overwhelm the adversary air defences, control of the air to a degree that unsustainable attrition is inficted on the adversary, concerted interdiction that leaves the adversary surface forces stranded for supplies and reinforcements, and efective and overwhelming contribution to joint fres to support troops in contact. This concept has applicability from the tactical combat between two individual air assets to the grand strategic decision-making process of the nation. It is in mastering and controlling the tempo of operations that the decision making ability of a commander is tested to the utmost, and controlling the tempo to suit one’s own requirements is critical to the success of the campaign. Decision Superiority: An Air Force Concept Paper, Air Power Development Centre, 2008 In contemporary air campaign terms, Sun Tzu’s advice to exploit the adversary’s unpreparedness and act when they are unaware, in unexpected ways, is an exhortation to carry out well-planned pre-emptive strikes on the adversary’s identifed centres of gravity. For air power, this stanza is about decision superiority of commanders at all levels, controlled tempo of manoeuvre in the battlespace, neutralisation of the adversary’s centres of gravity and retaining the element of surprise. An optimum combination of these four elements in an air force will make it unbeatable in confict. Tempo is applicable to both physical and cognitive domains Air power has the ability to control the tempo of war in both the domains Pre-emptive air strikes must be considered a viable option to be exercised in confict scenarios 358 Strategic Situations Ofensive Campaigns Generally this is the Tao of Invasion: Deep penetration brings cohesion; the enemy will not prevail. Cherish the troops, avoid overexertion So their strength of the Spirit merges and accumulates. Thrust the Force where there is no escape, They will meet death without desertion. The further the force penetrates into hostile territory, the greater its unity and so the greater its invincibility. Sufcient productive land must be appropriated to ensure adequate provisions for the entire force. By consolidating energy, saving strength and keeping movements and operational plans secret, the force can become unfathomable to the adversary. If the force is placed in a location from where there is no escape, they will not fee even when faced with death. Having faced death, the ofcers and men will fear no pitfall, exerting themselves to the utmost to hold frm and fght to the end if there is no other alternative. This subsection is regarding the conduct of an ofensive campaign—invasion—and in diferent stanzas Sun Tzu provides advice on penetrating the adversary’s territory to create superiority; the psychology of troops in battle, as well as how they should be prepared for combat operations; the various battle arrays; and the basic requirements for the employment of forces in ofensive actions. Sun Tzu believes that a separate philosophy, ‘Tao’, is essential for success in an ofensive campaign. This philosophy operates in two areas—one, at the confict arena, from the tactical through to the strategic level and, two, at the grand national security level of the nation. At the operational level of confict, when manoeuvring deep in adversary territory, two factors will bring about a greater unity and cohesion within the force. One, the brotherhood of shared danger and, two, a sense of being able to trust no-one but one’s own compatriots in hostile territory, even though the area may have been conquered. In hostile territory the commander must ensure that the concentration of force necessary to thwart any adversary counterattack is never diluted at the strategic level, since that is one of the greatest dangers that faces an invading force. The second strategic danger is of extended supply lines that could become a vulnerable centre of gravity of the invading forces. Sun Tzu advised the use of captured provisions and other material to avoid this situation and also to limit one’s own resource expenditure as far as possible. However, this can only be a short to medium-term solution to the logistic supply issue. While exploiting the adversary’s resource base, securing the supply line from one’s own home base must also be simultaneously accomplished. At the grand national security level, the consequences of invading another nation must be robustly debated and, in contemporary circumstances, should be attempted only as a last option. International reaction to such actions has the capacity to turn a brilliant military victory into strategic defeat for a nation that has not consciously created the diplomatic climate for other nations to accept, and maybe even support, the invasion. The military philosophy of ofensive action must be cognisant of these intangible factors that have a more than even chance of infuencing the fnal political outcome of an invasion. Decision superiority at the highest levels of government, ably supported by the strategic level of military command functioning with professional mastery, is irreplaceable as a critical factor in the success of an invasion. The third part is regarding the psychology of the force as a whole in confict, wherein Sun Tzu advises operational commanders to ensure that the troops are not overexerted so that their combined capabilities can be concentrated at the will of the strategic commander. The elements of surprise and, in a subtle manner, of deception are also introduced in the development of concepts of operations that are ‘unfathomable’ to the adversary. Such concepts must be tailored to a particular context, but should reside within a broader extant framework, developed and tested at leisure and in great detail. The operational employment of the force in an ofensive campaign must be such that it is compelled to fght, if necessary to the death, to achieve mission aims that, in turn, will contribute to the campaign objectives. Although Sun Tzu advises to manoeuvre the troops into areas of danger, the underlying principle is to manipulate the psychology of the force by denying it the opportunity to withdraw. The commander has to be extremely skilled to identify the area where the force will be victorious if it operates diligently in a cohesive 360 Strategic Situations manner. An invading force must never be mistaken for a force that is suicidal in its tactics and operational ethos. Here, the competency of commanders at all levels is of great importance in identifying and exploiting the opportunities to be successful. In the application of air power in an ofensive campaign, two strategic level requirements stand out as fundamental to success—concentration of force and adequacy of logistic supply. Both these requirements can only be met if the appropriate characteristics of air power are adequately developed within the force as a whole. Although air power is essentially an ofensive capability, the structure of the force as a whole can be oriented either ofensively or defensively, depending on a number of factors. Planning and executing an ofensive campaign requires greater amount of skill from the commander than preparing a defensive stance. First and foremost, it is about achieving control of the air and maintaining it for the required duration. Control of the air is more difcult in an ofensive campaign because the airspace will be over adversary territory and therefore contested. Accordingly, the counter air campaign assumes the greatest importance and must be accorded the highest priority within the overall campaign plan. This requires a professional understanding of the joint campaign objectives and plans at the strategic level of command. Within the air campaign plan, identifcation of the centres of gravity and adequate concentration of force to neutralise them should be the base from which the rest of the plan is built. The second requirement is the adequacy of logistics supplies, which Sun Tzu solved by advising the use of resources from conquered territory. This is not a possibility in the application of modern air power and, therefore, logistic planning prior to the commencement of the ofensive is vital to the success of the entire campaign. Such planning must also consider the security of these supply lines, which might necessitate a greater expenditure of air power resources in having to airlift the supplies if surface transportation is not secure. Concerns regarding supply chain security can also force the ofensive elements of the force to operate from safer home bases. This in turn will require longer transit times and deliver reduced time ‘on target’, with its associated increase in the quantum of air power assets required to fulfl all the requirements. In ofensive air campaigns, adequacy of logistics and the security of the supply chain are the Achilles heels. Obviously, then, the logistics system must be in harmony, both with the economic system of the nation and with the tactical concepts and environment of the combat forces. Eccles I believe that the task of bringing the force to the fghting point, properly equipped and well-formed in all that it needs is at least as important as the capable leading of the force in the fght itself … In fact, it is indispensable, and the combat between hostile forces is more in the preparation than the fght. General Sir John Monash An ofensive air campaign, whether against a sovereign nation or a non-state entity with no legal standing, has repercussions that can only be contained at the grand strategic level of government. Terefore, it is necessary for the decision to initiate the campaign to be taken at that level with a full and clear understanding of the direct impact and the rippling secondary efects that such actions will create. Further, even with the technological advances that make ofensive air attacks extremely accurate, other factors such as faulty intelligence can lead to collateral damage. Under the current international environment of ensuring discrimination, humaneness and proportionality in the application of lethal force, this is not an acceptable situation. The government must have a strong belief in the correctness of the ofensive action being conducted and must let the air campaign unfold without political interference. Breaking the rhythm of the planned campaign can lead to its failure, with greater and more disastrous consequences for the entire campaign. Humane Warfare the truth is that war in the past has often been soulless—it has involved the destruction of much of the cultural heritage of the societies that have been involved. The Second World War saw the destruction of some of the great architectural treasures of old Europe: the old city of Warsaw; the monastery at Monte Casino (the mother of European monasticism); as well as museums and art galleries which stored the glory of European art. In one fre in Berlin, 434 old masters were destroyed including works by Caravaggio, Titian and Veronese. The advice not to overexert the force is particularly relevant to air power, especially for smaller air forces. In ofensive operations, the air force will be employed at a much higher tempo than when carrying out purely defensive measures and, therefore, the possibility of overextending the capability generation capacity of the force is an ever-present danger. The air commander must carefully nurture the forces and avoid attrition as far as possible so that concentration of force can be achieved when needed.

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Based onstrated signiﬁcantly greater and earlier reduc on negative data antibiotics for vre uti safe 480mg bactrim, ziprasidone alone or as adjunc tions in manic and depressive symptoms in patients tive therapy antibiotic biogram buy bactrim amex, and adjunctive levetiracetam have with mixed episodes inadequately controlled with been added as not-recommended options for the divalproex (78) infection 2 bio war simulation purchase generic bactrim pills. The clinician must balance the desired effect of remission with the undesired effect of switching infection under the skin order bactrim 960mg free shipping. In this analysis antibiotics for acne doryx cheap 480mg bactrim with amex, lamotrigine antibiotic levo purchase cheapest bactrim, [per Texas Medication Algorithms (87)] versus paroxetine, aripiprazole, and lithium were not optimized treatment alone and found no signif signiﬁcantly different from placebo in improving icant differences between treatment groups. However, as cited in previous ever, given that this was an open-label study, and iterations, a meta-analysis of individual patient in the absence of further study details, recom data supported the eﬃcacy of lamotrigine mono mendations for adjunctive lithium use remain therapy (83). Non-respond ers in this trial entered a second phase in which Olanzapine + ﬂuoxetine. In addition, a post-hoc analysis of a second-line therapies): No changes from 2005 previously cited combination study (95) found that guideline (1). Add-on or switch therapy (alternate ﬁrst or second-line therapies): Olanzapine monotherapy. A (98) or as an adjunct (99) in patients with bipolar small (n = 20), open-label study provided addi depression. Similarly, when used as an Although there is level 1 evidence, the magnitude adjunct to lithium or divalproex, lurasidone of beneﬁt of olanzapine monotherapy was only signiﬁcantly reduced depressive symptoms, and modestly greater than that of placebo (95, 102). These data look very inner tension, which are not the core symptoms of promising and if clinical experience supports eﬃ depression (81). Patients receiving adjunctive patients who have psychotic bipolar depression, in chronotherapy experienced a signiﬁcantly greater those at high risk for suicide, and in those with reduction in depressive symptoms within 48 hours, signiﬁcant medical complications due to not drink which was sustained throughout the seven weeks. In an open trial, similar rates of response depression: and remission were observed in patients with bipolar depression (70% and 26%, respectively) and those Ziprasidone monotherapy. The trials have not yet been published, but concomitant anticonvulsants achieved comparable results are available at. While ziprasidone is not recommended with bipolar or unipolar depression (107, 108). Antidepressants with no signiﬁcant differences between treatment were not associated with a signiﬁcantly increased groups (level 2 negative) (119). Most negative studies of In a 16-week, prospective, open-label trial, antidepressants for bipolar depression to date have aripiprazole (add-on or monotherapy) was associ employed paroxetine as the antidepressant (91, 125, ated with a signiﬁcant decline in depressive symp 127). A meta-analysis of the eﬃcacy of antidepres toms over 16 weeks among 85 patients with bipolar sants in unipolar depression (128) suggested that depression who were unresponsive to other med clinically important differences exist between vari ications (lithium, anticonvulsants, or antipsychotic ous antidepressants in terms of eﬃcacy and accept agents) (level 3) (117). Given the above, we believe that the following Clinical questions and controversies conclusions and recommendations are warranted What is the role of antidepressants in patients with regarding the use of antidepressants for bipolar bipolar depression? Antidepressants are objective of tapering and discontinuing antidepres the most commonly used treatments for bipolar sants 6–8 weeks after full remission of depression; depression (122, 123) as clinicians continue to (ii) avoid the use of tricyclic antidepressants and believe that, based on their clinical experience, venlafaxine (131, 132) as they are associated with these are effective for bipolar depression. However, an increased risk of manic switch; (iii) antidepres the limited, but growing body of clinical trial data sants should not be used to treat a current mixed has not been consistent in supporting their role. In another study, paroxe several analyses, adherence was positively associ tine monotherapy (20 mg ⁄ day) was not superior to ated with higher satisfaction with medication, placebo in improving bipolar depressive symptoms monotherapy, a college degree, and fear of relapse, (125). It is unknown if higher doses of paroxetine and was negatively associated with illness factors would have been more effective. Both treatments demonstrated a Caucasian ethnicity, a previous manic episode, signiﬁcant beneﬁt in terms of mood stability and good social functioning (no work or social impair reduction of recurrence, but there were no differ ment, living independently or with family), outpa ences between the two treatments. Since the tient treatment, and being neither satisﬁed nor psychoeducation treatment was designed to be dissatisﬁed with life (146, 147). Among responders to long-term lithium programs demonstrated a longer time to recur therapy, the risk of recurrence was higher in those rence, fewer recurrences of any type, less time with atypical features (mainly mood-incongruent acutely ill, and fewer days of hospitalization during psychotic symptoms), inter-episodic residual symp 1–5 years of follow-up (158, 159). Mainte signiﬁcantly more effective than divalproex mono nance therapy for bipolar disorder: General principles therapy in preventing relapse during up to two (1)]. Combination therapy was not adjunctive therapy have been added as third-line signiﬁcantly more effective than lithium alone. Among patients followed for at least ﬁve that lithium, olanzapine, and aripiprazole had years, practically no patients were maintained signiﬁcant effects in the prevention of manic successfully on monotherapy with either drug. The analysis concluded atypical antipsychotic agents in preventing relapse that olanzapine may prevent manic episodes only in to any episode versus placebo (162). By contrast, another lithium or divalproex in patients with manic ⁄ mixed study of open-label continuation treatment, in 114 episodes and an inadequate response to lithium or patients with bipolar depression who were re divalproex (176). Several open-label and post-hoc analyses provide additional insight into the role of atypical antipsy Third-line options: chotic agents in the management of patients with mixed episodes or psychotic symptoms. At one year, a of ﬂexible-dosed ziprasidone (40–160 mg ⁄ day) worsening of mania was reported in 2. In a 24-week, open-label trial of signiﬁcantly longer with asenapine compared to adjunctive risperidone in 114 patients with mixed olanzapine (p = 0. In one analysis, there were associa review of risks and beneﬁts and a treatment tions of ﬂuoxetine with ventricular septal defects, plan for ongoing monitoring. The rate of major anomalies category X (1%) medication during pregnancy (primarily cardiovascular) in birth outcome among (190). The most frequently used psychotropic pregnant patients (n = 314) with ﬁrst trimester drugs were paroxetine, alprazolam, lorazepam, exposure was 4. In addition, please visit the congenital heart disease when compared to no Canadian Hospital for Sick Children Motherisk exposure (202). Therefore, in ciated with an increased risk for major congenital the following section, we will provide only a brief anomalies, but was associated with an increased update of some of the new data in patients with incidence of atrial septal defects. Psychotropic medications can be newborns associated with prenatal exposure to used in the second and third trimester if necessary. The If lithium is used during the second and third new drug labels now contain information about the trimester, the serum lithium levels should be potential risk for abnormal muscle movements and monitored closely because of changes in blood withdrawal symptoms including agitation, abnor volume during pregnancy, and the dose should be mal muscle tone, tremor, sleepiness, breathing, and adjusted accordingly to maintain levels in the feeding diﬃculties in newborns. In a case-controlled series of and congenital malformations were greater in those 52 pregnancies, topiramate was associated with receiving higher doses versus lower doses; however, reduced birth weight but no decrease in gestational no signiﬁcant differences in neonatal outcomes age and no increase in structural defects (196). However, in one analysis postpartum period because of a lack of screening antidepressant use was associated with increased instruments designed speciﬁcally for use during this rates of pregnancy complications, including in period (206). Pregnancy risk American Academy of Lactation risk Agent categorya Pediatrics rating categoryb Thioridazine C N ⁄ Thiothixene C N ⁄ Triﬂuoperazine C Unknown, of concern N ⁄A Atypical antipsychotic agents Aripiprazole C N ⁄ Clozapine B Unknown, of concern L3 Olanzapine C N ⁄ Quetiapine C Unknown, of concern L4 Risperidone C N ⁄ Ziprasidone C Unknown, of concern L4 [Copyright (2008) Wolters Kluwer Health; reprinted with permission from (191)]. The optimal cut-off score was menopausal transition was associated with signif eight or more endorsed symptoms without the icantly more visits due to depressive symptoms and supplementary questions (sensitivity 88% and fewer euthymic visits compared to a comparison speciﬁcity 85%) (208). In a well-designed longitudinal study involving 344 pregnant women, there was an 8. The reader is referred to recent publications atric medications during lactation are also shown focusing speciﬁcally on differential diagnosis and in Table 6. Provided below is an overview of reductions in mania scores with risperidone versus current data of the eﬃcacy of atypical antipsy placebo (254). Similar results were seen in a small cohort mood stabilizer group included studies on topira study in which risperidone resulted in a faster and mate and oxcarbazepine, neither of which demon greater reduction of symptom scores versus divalp strated eﬃcacy as mood stabilizers. Hence, although it is premature to medication-associated weight gain was greater with conclude that atypical antipsychotic agents have atypical antipsychotic agents than with mood greater eﬃcacy than mood stabilizers in pediatric stabilizers (effect size 0. This negative trial patients that was previously cited in abstract form requires replication in light of the small sample has now been published (258). Adolescents also experienced demonstrated signiﬁcant improvements with lamo signiﬁcant changes in fasting glucose, total choles trigine monotherapy in both manic and depressive terol, triglycerides, alanine aminotransferase, and clinical endpoints (262, 263), and as an adjunct to prolactin. Several analyses have failed to tion, less favourable response to treatment, and detect a signiﬁcant association between dementia worse course of illness (283, 287, 288). This greater decrease in alcohol-related outcomes com suggests that quetiapine should be investigated in pared to placebo (324). An analysis of 98 patients from the acute ously described six-month, open-label trial sug open-label phase of this study found that these gested eﬃcacy for risperidone (333). Supporting this is one small (n = 17), 12-week feasibility study demonstrating that 41% of Divalproex. The negative compared to placebo, beginning at week one and results may be related to the slow titration of continuing through week eight. Interestingly, switch rates into hypo ⁄ mania were similar with paroxetine Psychotherapy: A post-hoc analysis of 20 patients and placebo. Although about 24% pared to unstructured support groups, with lasting experienced hypomania ⁄ subsyndromal hypoma beneﬁts for up to ﬁve years (346). Signiﬁcantly nia, this did not result in treatment discontinua fewer patients in the psychoeducation group expe tion. A 12-week, open-label trial assessed the beneﬁt of adding lamotrigine or Quetiapine. However, neither ﬂuoxe symptoms continued to improve over a 52-week tine nor lithium was signiﬁcantly better than placebo period, suggesting that the two negative acute in mean time to relapse (ﬂuoxetine 249. The lack short to detect a difference between lamotrigine of superiority of ﬂuoxetine over placebo in these and placebo. Similarly, a retrospective chart review studies may be related to a lack of statistical power reported that the majority of 31 patients with due to a smaller sample size. The mean dose of eﬃcacy and safety of antidepressants in real-world lamotrigine was 199 mg ⁄ day and the maximum settings. This was similar worsening of affective symptoms compared to only to the lifetime prevalence of 2. Clinicians should formulate maintenance therapy following their ﬁrst manic treatment plans based on patientsÕ presenting episode, the mean 12-month weight gain was symptoms, course of illness, previous treatment signiﬁcantly greater compared to healthy control responses, and family history. During short-term treatment, olanzapine orally disintegrating tablet was not Monitoring associated with any reduction in weight gain com Previous iterations of the guidelines provided rec pared to the standard tablet formulation (370). Post-hoc well as risk factors for cardiovascular disease such analyses of two studies found a modest increase in as overweight ⁄ obesity, diabetes, metabolic syn weight with adjunctive aripiprazole that was not drome, and dyslipidemia. Complete medical and signiﬁcantly different from that using lithium ⁄di laboratory investigations should be performed at valproex alone (372). When used as an adjunct to baseline, with ongoing monitoring for weight lamotrigine, aripiprazole plus lamotrigine was asso changes and adverse effects of medication. Metabolic syndrome and type 2 diabetes: Addi In addition, patients tested during a manic ⁄mixed tional data continue to demonstrate high rates of or depressed state showed exaggerated impairment diabetes and metabolic syndrome associated with on measures of verbal learning (383). Two cohort Additional data conﬁrm the potential for met studies have shown fewer cognitive impairments abolic disturbances with divalproex treatment. In a associated with quetiapine than with olanzapine or cohort study, divalproex was associated with risperidone (385, 387). As discussed in previous tive galantamine improved episodic memory per iterations of the guidelines, atypical antipsychotic formance; however, placebo improved processing agents, as well as lithium ⁄divalproex, can cause speed (389). Lipid proﬁles syndrome, or toxic epidermal necrolysis with should be monitored and appropriate lipid-lower lamotrigine, carbamazepine, and divalproex (390, ing medications prescribed as needed, according to 391). A 12-week trial demonstrated a statistically published recommendations for the management signiﬁcant reduction in the development of rashes of dyslipidemia. Antidepres grant ⁄ research support from or is on speaker ⁄ advisory boards for AstraZeneca Canada, BrainCells, Inc. When a ﬁrst-line treatment is Stanley Medical Research Institute, Genome Quebec, Nova Scotia Health Research Foundation, Neuroscience Research unsuccessful, clinicians are advised to try alterna Fund (Eli Lilly Canada); and research contract support from tive ﬁrst-line treatments before proceeding to Cephalon. Costs support from Pﬁzer and has served as a speaker for Purdue associated with attempted suicide among individuals with Pharma. Work Institutes of Mental Health; and receives royalties form impairment in bipolar disorder patients–results from a Random House, Inc. Understanding needs, interactions, treat nology Research and Development Project, Ministry of Health ment, and expectations among individuals affected by and Welfare of Korea, Janssen, Eli Lilly & Co. Self-esteem in remitted bipolar disorder ical Research Institute, AstraZeneca, Eli Lilly & Co. Bipolar Disord 2010; 12: SmithKline, and Wyeth; has received honoraria ⁄ speakers fees 585–592. J Clin Psychiatry 2011; 72: GlaxoSmithKline, Organon, Novartis, Mayne Pharma, and 502–508. Course and outcome after the ﬁrst manic episode in patients with bipolar disorder: prospective 12-month References data from the Systematic Treatment Optimization Program For Early Mania project. Longitudinal guidelines for the management of patients with bipolar course of bipolar I disorder: duration of mood episodes. Enhancing mul correlates of bipolar spectrum disorder in the world tiyear guideline concordance for bipolar disorder mental health survey initiative. Differences in prevalence and treatment of warning signs checklists for relapse in bipolar depression bipolar disorder among immigrants: results from an and mania: utility, reliability and validity. J Affect Disord 2011; 133: treatment for caregivers of patients with bipolar disorder. Clinician-assisted internet risk of suicide after ﬁrst hospital contact in mental based treatment is effective for depression: randomized disorder. Clarke G, Kelleher C, Hornbrook M, Debar L, Dickerson eﬃcacy and safety of intramuscular aripiprazole. Cogn Behav double-blind study of lorazepam versus the combination Ther 2009; 38: 222–234. Barnes E, Simpson S, Griﬃths E, Hood K, Craddock N, Pharmacotherapy 1998; 18: 57–62. Eﬃcacy of lorazepam and haloperidol for rapid tranquilization in a sodium valproate and haloperidol in the management of psychiatric emergency room setting. Comparative psychotic agitation: a randomized comparison of oral eﬃcacy and acceptability of antimanic drugs in acute treatment with risperidone and lorazepam versus intra mania: a multiple-treatments meta-analysis. Villari V, Rocca P, Fonzo V, Montemagni C, Pandullo P, and mood stabilizer eﬃcacy and tolerability in pediatric Bogetto F. Oral risperidone, olanzapine and quetiapine and adult patients with bipolar I mania: a comparative versus haloperidol in psychotic agitation. Bowden C, Gogus A, Grunze H, Haggstrom L, Ryba intramuscular injections of olanzapine, lorazepam, or kowski J, Vieta E. A 12-week, open, randomized trial placebo in treating acutely agitated patients diagnosed comparing sodium valproate to lithium in patients with with bipolar mania. J Clin Psychopharmacol 2001; 21: bipolar I disorder suffering from a manic episode. Eﬃcacy of study of the effectiveness and safety of intramuscular valproate versus lithium in mania or mixed mania: a olanzapine in the treatment of acute agitation in randomized, open 12-week trial.

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Participating in Clinical Research Clinical research is medical research that involves people like you infection kpc cheap 480mg bactrim fast delivery. People volunteer to participate in carefully conducted investigations that ultimately uncover better ways to treat antibiotics for sinus infection toddler cheap bactrim 480mg without a prescription, prevent antibiotic infusion order bactrim 480mg online, diagnose antibiotics and xanax side effects order 480mg bactrim free shipping, and understand human disease first line antibiotics for sinus infection trusted 960mg bactrim. Clinical research includes trials that test new treatments and therapies as well as long-term natural history studies antibiotics drug test 960mg bactrim free shipping, which provide valuable information about how disease and health progress. Please Note: Decisions about participating in a clinical trial and determining which ones are best suited for you are best made in collaboration with your licensed health professional. After the initial phone interview, you will come to an appointment at the clinic and meet with a clinician. This website is a searchable registry and results database of federally and privately supported clinical trials conducted in the United States and around the world. This information should be used in conjunction with advice from health professionals. Talk to your doctor about clinical trials, their benefts and risks, and whether one is right for you. Finding Help Mental Health Treatment Locator the Substance Abuse and Mental Health Services Administration provides this online resource for locating mental health treatment facilities and programs. The Mental Health Treatment Locator section of the Behavioral Health Treatment Services Locator lists facilities providing mental health services to persons with mental illness. Questions to Ask Your Doctor Asking questions and providing information to your doctor or health care provider can improve your care. Talking with your doctor builds trust and leads to better results, quality, safety, and satisfaction. We encourage you to reproduce this publication and use it in your eforts to improve public health. A diagnosis is made after getting information from you, your family members and friends. Bipolar disorder affects parts of the brain controlling emotion, thought and drive and is most likely caused by a complex set of genetic and environmental factors. Psychotherapy is often used with medications; a therapist can help you have a healthier lifestyle and learn about what triggers worsen the illness. Bipolar disorder Bipolar disorder is a treatable mood disorder in which people have extreme mood swings that include emotional highs (manias) and lows (depression) (Figure 1). Bipolar disorder was formerly called manic depression or manic depressive illness. These mood swings are more severe than normal ups and downs in mood and can last from a few days to several months. Bipolar disorder 4 Page 7 of 32 mc5155-03 Bipolar I disorder affects roughly one percent of the adult population and tends to run in families. The disorder also happens in children and teens (adolescents) but exact figures are not known. Noticing symptoms in children can be hard because they are often mistaken for disruptive disorders that are common in this age group. The disease involves an imbalance of brain chemicals in the areas of the brain that regulate emotion, thinking processes, and energy. Although the exact cause is not known, scientists believe you are more likely to have bipolar disorder if it runs in your family; the illness sometimes happens when you experience stressful events. Examples of such events might include a job promotion or serious relationship problem. If you have bipolar disorder you may not see how impaired you are when having a mood episode. If manic symptoms are left untreated, you can put yourself into unhealthy, illegal, or life-threatening situations because of potentially impaired judgment and impulsive behavior. Getting the necessary medical care can help avoid needless suffering for you, your family and your friends. Mania or a manic episode You are having a manic episode if your mood is unusually and persistently high or if you are unusually irritable for at least one week. This mood disturbance must be severe enough to disrupt your ability to function at home, work or school and be associated with many of these additional symptoms: Increased sexual drive In most severe cases, you may believe in things that are not true (delusions) and think you see, hear and smell things that are not real (hallucinations). In a hypomanic episode, the changes in your mood are not severe enough to keep you from functioning or to require that you be hospitalized. Bipolar disorder can be treated, and people with this illness can lead full and productive lives. Bipolar Disorder Bipolar disorder Bipolar disorder, also known as manic-depressive illness, is a brain disorder that causes unusual shifts in a person’s mood, energy, and ability to function. Different from the normal ups and downs that everyone goes through, the symptoms of bipolar disorder are severe. They can result in damaged relation ships, poor job or school performance, and even suicide. But there is good news: bipolar disorder can be treated, and people with this illness can lead full and productive lives. However, some people have their first symptoms during childhood, and some develop them late in life. It is often not recognized as an illness, and people may suffer for years before it is properly diagnosed and treated. Like diabetes or heart disease, bipolar dis order is a long-term illness that must be carefully managed throughout a per son’s life. It is an illness that is biological in its origins, yet one that feels psychological in the experience of it; an illness that is unique in conferring advantage and pleasure, yet one that brings in its wake almost unendurable suffering and, not infrequently, suicide. Bipolar disorder causes dramatic mood swings—from overly “high” and/or irritable to sad and hopeless, and then back again, often with periods of nor mal mood in between. Denial that anything is wrong A manic episode is diagnosed if elevated mood occurs with 3 or more of the other symptoms most of the day, nearly every day, for 1 week or longer. Chronic pain or other persistent bodily symptoms that are not caused by physical illness or injury. Thoughts of death or suicide, or suicide attempts A depressive episode is diagnosed if 5 or more of these symptoms last most of the day, nearly every day, for a period of 2 weeks or longer. Hypo mania may feel good to the person Severe mania who experiences it and may even be associated with good functioning Hypomania (mild to moderate mania) and enhanced productivity. Thus even when family and friends learn Normal/ to recognize the mood swings as balanced mood possible bipolar disorder, the person Mild to moderate may deny that anything is wrong. Sometimes, severe episodes of mania or depression include symp toms of psychosis (or psychotic symptoms). Common psychotic symptoms are hallucinations (hearing, seeing, or otherwise sensing the presence of things not actually there) and delusions (false, strongly held beliefs not influenced by logical reasoning or explained by a person’s usual cultural concepts). Psychotic symptoms in bipolar disorder tend to reflect the extreme mood state at the time. For example, delusions of grandiosity, such as believing one is the President or has special powers or wealth, may occur during mania; delusions of guilt or worthlessness, such as be lieving that one is ruined and penniless or has committed some terrible crime, may appear during depression. People with bipolar disorder who have these symptoms are sometimes incorrectly diagnosed as having schizophrenia, an other severe mental illness. It may be helpful to think of the various mood states in bipolar disorder as a spectrum or continuous range. At one end is severe depression, above which is moderate depression and then mild low mood, which many people call “the blues” when it is short-lived but is termed “dysthymia” when it is chronic. Then there is normal or balanced mood, above which comes hypomania (mild to moderate mania), and then severe mania. In some people, however, symptoms of mania and depression may occur to gether in what is called a mixed bipolar state. Symptoms of a mixed state often include agitation, trouble sleeping, significant change in appetite, psychosis, and suicidal thinking. A person may have a very sad, hopeless mood while at the same time feeling extremely energized. Bipolar disorder may appear to be a problem other than mental illness—for instance, alcohol or drug abuse, poor school or work performance, or strained interpersonal relationships. Therefore, a di agnosis of bipolar disorder is made on the basis of symptoms, course of illness, and, when available, family history. It seems as though my mind has slowed down and burned out to the point of being vir tually useless…. Others say, “It’s only temporary, it will pass, you will get over it,” but of course they haven’t any idea of how I feel, although they are certain they do. Hypomania: At first when I’m high, it’s tremendous… ideas are fast… like shooting stars you follow until brighter ones appear…. All shyness disap pears, the right words and gestures are suddenly there… uninteresting peo ple, things become intensely interesting. Your marrow is infused with unbeliev able feelings of ease, power, well-being, omnipotence, euphoria… you can do anything… but, somewhere this changes. Mania:The fast ideas become too fast and there are far too many… over whelming confusion replaces clarity… you stop keeping up with it—memory goes. Anyone who is thinking about committing suicide needs immediate attention, preferably from a mental health professional or a physician. Therefore, recognizing bipolar disorder early and learning how best to manage it may de crease the risk of death by suicide. Ei ther way, it is important to understand that suicidal feelings and actions are symptoms of an illness that can be treated. Be tween episodes, most people with bipolar disorder are free of symptoms, but as many as one-third of people have some residual symptoms. A small percentage of people experience chronic unremitting symptoms despite treatment. When 4 or more episodes of illness occur within a 12-month period, a person is said to have rapid-cycling bipolar disorder. Some people experi ence multiple episodes within a single week, or even within a single day. Rapid cycling tends to develop later in the course of illness and is more common among women than among men. People with bipolar disorder can lead healthy and productive lives when the illness is effectively treated. Without treatment, however, the natural course of bipolar disorder tends to worsen. Over time a person may suffer more fre quent (more rapid-cycling) and more severe manic and depressive episodes than those experienced when the illness first appeared. Unlike many adults with bipolar disorder, whose episodes tend to be more clearly defined, children and young adolescents with the illness often experi ence very fast mood swings between depression and mania many times within a day. Older adolescents who develop the illness may have more classic, adult-type episodes and symptoms. Bipolar disorder in children and adolescents can be hard to tell apart from other problems that may occur in these age groups. For example, while irri tability and aggressiveness can indicate bipolar disorder, they also can be symp toms of attention deficit hyperactivity disorder, conduct disorder, oppositional defiant disorder, or other types of mental disorders more common among adults such as major depression or schizophrenia. Children or adolescents with emotional and behavioral symptoms should be carefully evaluated by a mental health professional. Any child or ado lescent who has suicidal feelings, talks about suicide, or attempts suicide should be taken seriously and should receive immediate help from a mental health specialist. Scientists are learning about the possible causes of bipolar disorder through several kinds of studies. Most scientists now agree that there is no single cause for bipolar disorder—rather, many factors act together to produce the illness. Studies of identical twins, who share all the same genes, indicate that both genes and other factors play a role in bipo lar disorder. If bipolar disorder were caused entirely by genes, then the identi cal twin of someone with the illness would always develop the illness, and research has shown that this is not the case. But if one twin has bipolar disor der, the other twin is more likely to develop the illness than is another sibling. But scientists expect that the advanced research tools now being used will lead to these discoveries and to new and better treatments for bipolar disorder. Brain-imaging studies are helping scientists learn what goes wrong in the brain to produce bipolar disorder and other mental illnesses. There is evidence from imaging studies that the brains of people with bipolar disorder may differ from the brains of healthy individu als. As the differences are more clearly identified and defined through research, scientists will gain a better understanding of the underlying causes of the illness, and eventually may be able to predict which types of treatment will work most effectively. Most people with bipolar disorder—even those with the most severe forms—can achieve substantial stabilization of their mood swings and related symptoms with proper treatment. A strategy that combines medication and psychosocial treat ment is optimal for managing the disorder over time. In most cases, bipolar disorder is much better controlled if treatment is contin uous than if it is on and off. But even when there are no breaks in treatment, mood changes can occur and should be reported immediately to your doctor. The doc tor may be able to prevent a full-blown episode by making adjustments to the treatment plan. Working closely with the doctor and communicating openly about treatment concerns and options can make a difference in treatment effectiveness. In addition, keeping a chart of daily mood symptoms, treatments, sleep pat terns, and life events may help people with bipolar disorder and their families to better understand the illness. Medications Medications for bipolar disorder are prescribed by psychiatrists—medical doctors (M. While primary care physicians who do not specialize in psychiatry also may prescribe these medications, it is recommended that people with bipolar disorder see a psychiatrist for treatment.

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