There are actually a lot of symptoms of depression that depressed people may actually posses but they don’t have to suffer from each and every one of them before you actually help them get diagnosed and be treated for this illness. Also, since symptoms of depression actually vary, the time of their “attacks” varies as well.

Here are some common examples of symptoms of depression:

Prolonged period of sadness or not feeling “up to it,”  people who are always feeling not in the mood, who’d rather mope around the house and feel sorry for one’s self is the best example for this symptom of depression.

Feels hopeless, perennial pessimist: speaking of feeling sorry for one’s self, another common symptom of depression is when a person actually feels like he/she has nothing to look forward to in his or her life. As for being the perennial pessimist, those who show this symptom of depression are usually very negative about things, again, the feeling of hopelessness comes in to mind.

Guilt-driven, loss of self-worth and helplessness: other symptoms of depression that can be easily seen on people who prefer to mope around all day long are these. Whenever a person feels so guilty over something, that actually makes one a very sad person who feels like he or she doesn’t deserve to be happy. Thus, the loss of self-worth, if that person feels like he or she isn’t worthy of being happy or enjoying one’s self then that’s clear tell-tale symptom of depression. Helplessness also contribute to being depressed, when assuming that things won’t simply go your way, it’s already a clear saying that you have absolutely no hope in your body at all.

Isn’t interested in finding or taking pleasure; just dropping the hobbies as well as the other things that one used to enjoy: this tell-tale symptom of depression just shows how depressed a person can be, if one is actually too sad to take pleasure even in the very things that one loves then that person is seriously lacking something, rather, that person might well have caught the depression bug.

Fatigue, always tired: people suffering from depression, since they’ve lost whatever interest in life that they may have had before are actually lacking of physical energy at all times, if one would prefer to just mope around, probably won’t even eat not get enough sleep, a depressed person may well be on their way to not just a mental illness but depression can actually be terrible for one’s physical health as well.

Having trouble concentrating, having bad memory and is indecisive: a person who is suffering from depression easily gives away this tell-tale symptom of depression. Wherein one’s lack of interest with regards to the outside world or for just about anything for that matter can lead to that person’s inability to lose track of things and actually not be able to remember things that happened or what other people said. Lack of interest actually makes depressed people very inattentive.

There are actually more symptoms of depression that can actually help you see if a person (or you) needs to be brought to the doctor to get some help when it comes to depression: lacking sleep, sleeping too much or waking up at wee hours of the morning are all symptoms of depression (if it happens on a daily basis), appetite loss as well as eating too much may show one’s lack of enthusiasm for life. Be weary of sudden weight loss or weight gain in those around you. Being suicidal, talking about death, about wanting to die is another clear indication that that person is depressed. Being restless and irritable and physical symptoms that are usually brought about by poor mental health such as headaches, digestive disorders and various body pains.

A lot of people who are exerting too much of their brain power usually exhaust not only their physical strength when engaging in various multi-tasking activities, they also tend to over extend their brains up to the point when it plainly needs some good old time for relaxation. A lot of busy people who seem to cannot fathom the idea of relaxing and taking time of from work, as well as their worries, tend to actually start having nervous breakdowns, anxiety depression and all sorts of mental illnesses that can cause a person’s sanity to go haywire, fortunately, if you’re one of those poor unfortunate ones who are unable to distress and is constantly worried and fussing over things, there are actually available cures and various treatments for treating anxiety depression.

Anxiety depression is actually characterized by all sorts of irregularities and erratic behavior from the person who is suffering from it, this is usuallu due to certain stress triggers that may tend to easily cause a person undue jitters and stress. Also, a lot of people who tend to get easily nervous over stressful activities are actually prone to having anxiety depression, its just a matter of being strong-willed when it comes to facing difficult and stress-prone activities. It may be pretty hard to overcome at first, but trying to be calm and cool in times of extreme pressure is what’ll actually save your mental health from going totally downward spiral.

When it comes to effectively curing one’s self from a mental illness, one must keep in mind that you have to be actually honest with yourself and assess what kind of depression or mental illness you actually have, go to reputable psychiatrist to get yourself diagnosed correctly as well as be able to get the right depression treatment for yourself. Here are the various types of depression:

Manic or Bipolar depression – characterized by sudden and extreme changes in one’s mood wherein one minute he or she is in an elevated state of euphoria while the
next minute (day or week) he or she is feeling to be in a personal hell.

Postpartum depression – characterized by a prolonged sadness and a feeling of emptiness by a new mother wherein physical stress during child birth, an uncertain sense of responsibility towards the new born baby can be just some of the possible factors why some new mother go through this.

Dysthimia – characterized by a slight similarity with depression, although this time, it’s been proven to be a lot less severe, but of course with any case, should be treated immediately.

Cyclothemia – characterized by a slight similarity with Manic or Bipolar depression wherein the individual suffering from this mental illness may occasionally suffer from severe changes in one’s moods.

Seasonal Affective Disorder – characterized by falling in a rut only during specific seasons (i.e. Winter, Spring, Summer or Fall) studies however, prove that more people
actually fall in to a rut more during the Winter and Fall seasons and lastly, Mood swings, wherein a person’s mood may shift from happy to sad to angry in just a short time.

But the type of depression that has actually been proven to be quite common among people is anxiety depression, which is actually characterized by the state of being overly anxious about things. Anxiety, a supposedly normal behavior that’ll actually help a person adjust more to a certain stressful activity like first date jitters or a grueling exam the following day. Anxiety actually helps you get psyched up towards facing certain “difficult situations”; anxiety therefore is actually a good thing. Anxiety depression however, is simply the opposite, not to be easily dismissed as a “case of the nerves”; Anxiety depression is in actuality an illness that can be caused from the biological makeup of an individual, or in other words, a hereditary illness.

Also, there are actually various types of Anxiety depression, each having its own unique characteristics. Take for example Generalized Anxiety Disorder or GAD, this kind of Anxiety depression is a lot more complicated than the average Anxiety depression, in spite of possibly being a day-to-day habit for those who suffer this kind of Anxiety depression, Generalized Anxiety Disorder actually makes the individual quite more paranoid than usual, anxiety attacks are more frequent, even absurd at times. They can even be anxious even when there’s no apparent reason that calls for them to behave in such a way. People suffering from Generalized Anxiety Disorder actually shows a lot of symptoms, from lack of sleep, to being unable to relax, getting tired easily, cannot concentrate on what they’re doing and even suffering from depression.  This kind of Anxiety depression is still curable; just a little work will actually do the trick.

Consult a reputable cognitive behavior therapist who’ll help give the individual the therapy that he or she needs to help him or her loosen up, also prescribed medicines are sort of a must to help these individuals battle anxiety attacks, help them calm down and relax.

1. What are the signs that I may be depressed and therefore might need medication?

Most of us feel temporarily discouraged or “down” at times. This brochure is about treatment for a very different kind of depression. If you are experiencing this kind of depression, you may have been feeling sad, irritable or depressed most of every day for weeks, if not months. Activities or people you used to enjoy might not seem interesting anymore. You might stop attending class and feel tired all the time. You might find you have increased or decreased appetite, or you might find that you have lost or gained weight. A couple of days of insomnia, sleeping all day, or wanting to “just stay in bed” occasionally happen for us all. But when this happens consistently over a period of weeks it suggests a more serious problem.

If you’re depressed, you may have difficulty concentrating or making decisions. Friends may comment that you’re extra “sensitive” or crying a lot. When you are this depressed, it is not unusual to feel hopeless and helpless, as if you’re “stuck in a dark hole” and can’t get out. Other people may notice you no longer seem to care about your responsibilities or your appearance. You may think about death a lot and even consider killing yourself. These are all signs of a serious depression.
Signs of Depression:

* Sad Mood
* Sleep Problems
* Appetite Change
* Concentration Loss
* Suicidal Thoughts

2. Is depression a sign of personal “weakness”?

Depression is one of the most common concerns of students coming to the Counseling and Mental Health Center. It is not a sign of personal weakness. Abraham Lincoln, Queen Victoria and Winston Churchill are only a few of the strong people history suggests struggled with depression. It’s not a condition that you can will or wish away. People suffering from depression cannot merely expect to “pull themselves together” and get better. Without treatment, symptoms of depression may persist or get worse. With treatment, you may begin to experience significant relief within four to six weeks.
You’re not alone. Many university students experience depression.

3. Shouldn’t I be able to feel better without taking medication? Don’t other people get through this without medication?

Eventually, some people will feel better, even without treatment. Unfortunately, “feeling better” can take a year or more, and if untreated, depression can get worse and seriously interfere with your ability to study, work and enjoy relationships. Depression can also be a life-threatening illness when there is a risk of suicide. Medication will not “fix” everything, but it may help lighten your mood and help you to function so that you can begin working through other problems.

4. How does an antidepressant work?

Depression is an illness in which factors such as genetics, chemical changes in the body and external events may play an important role. Research suggests that depression may be linked to changes in the functioning of brain chemicals called neurotransmitters. Current research focuses on the serotonin, norepinephrine and dopamine systems. Certain genetic factors and changes in body hormones have also been implicated in some depressive conditions. These complex biological changes can produce profound changes in your mood and behavior. Antidepressants are thought to correct some of the chemical imbalances present in a depressive illness.

5. Is there a blood test for depression?

The diagnosis of depression is based on the recognition of certain characteristic signs and symptoms affecting your mood state, thinking patterns and physical well-being. At present, there is no blood test that can confirm or eliminate the diagnosis of depression.

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6. How long will I have to take a medication?

You and your treatment professional(s) will meet regularly after medication is prescribed to assess any changes and/or concerns and to evaluate how the medication is working for you. Typically, people take antidepressant medications for eight to twelve months or longer. While it is often tempting to stop taking the medication when you feel better, it is important to continue until you and your doctor agree your depression is treated. Stopping the medication early can result in the return of your original symptoms. You may be asked to gradually decrease or “taper off” the medication. “Tapering off” is particularly important with some medications to allow your body an adjustment period.

7. Will the depression come back when I stop taking medication?

In the majority of cases, depression is an illness that can be effectively treated with medication and counseling. However, there is always a chance that your depression may return once a medication is stopped. Continuing antidepressants and/or therapy for the recommended time period minimizes this possibility. Unfortunately, in a small number of cases, depression reoccurs after treatment is complete. Recognizing the signs of a new depressive episode and seeking treatment early are very important.

8. Is the medication addictive? Will I get “high”?

The currently prescribed medications that are approved for the treatment of depression are not considered addictive. Drug addiction implies that you would crave increasing amounts of a substance. While certain medications used in treating unusual forms of depression do have potentially addictive qualities, these medications are not considered standard antidepressants and are not the subject of this brochure. Although antidepressants are not addictive, you may experience some symptoms that lead you to wonder whether you are getting “high.” Early on in treatment, antidepressants may cause you to feel unusually energized, especially compared to your previous state. As with most prescription medications, there are also potential drug side effects with antidepressants. Feeling “high” or intoxicated suggests an unusual reaction to your medication, an interaction with another medication, complications from drug or alcohol use, or other unwanted side effects. In addition, some patients with manic-depressive illness may experience an unwanted episode of euphoria. Should you experience any of these problems, contact your psychiatrist immediately.
Antidepressants are not addictive.

9. Will the medication change my personality?

Medication will not change who you are as a person, your unique personal characteristics, or your life circumstances. The goal of antidepressant therapy is to allow you to work toward positive changes in your mood state and thinking patterns. Antidepressant medication assists people in experiencing the full range of human emotions without feeling overwhelmed. Although these positive changes may seem like personality changes, most often they are a sign that you are recovering your ability to react to people and situations in a non-depressed way. Sometimes antidepressant medication produces temporary side effects that feel like negative changes in personality. In particular, you may feel less emotionally sensitive or less “intense” than you did before taking medication. In the event that this occurs and is distressing for you, don’t hesitate to discuss your concerns with your counselor and psychiatrist. Refer to question #12 in this brochure to learn more about potential side effects.

10. What might my doctor ask me to do before prescribing medication?

The first step is usually an appointment with a psychiatrist to discuss your depressive symptoms. Your psychiatrist may ask the same questions you have already been asked by another professional. While you may find this repetition frustrating, keep in mind that questions are repeated so that your doctor can gain a thorough understanding of your symptoms, medical history, medication use, and drug or alcohol use. For female patients it will also be important to discuss the issues of pregnancy and birth control use since medication may be potentially harmful to a fetus or nursing infant. Since certain drugs, as well as some medical conditions, can produce depressive symptoms, you may also be referred to another physician for a complete physical exam and laboratory tests.

11. How will my doctor choose which medication to prescribe?

There are approximately 20 antidepressants currently available and approved for the treatment of depression. Antidepressants are generally classified by the chemical properties of the drug and the way in which they are thought to work. Groups of medication your doctor may refer to include: Selective Serotonin Reuptake Inhibitors (SSRIs), Tricyclic Antidepressants (TCAs) or Monamine Oxidase Inhibitors (MAOIs). Some clinicians may refer to medications discovered in the last 10 to 15 years as “new” medications and those medications which have been available in the last 30 years as “older” medication. Like shoe sizes, not every medication is the right fit for every individual; a medication that worked well for a friend may not be the best match for you.

Your psychiatrist will consider potential adverse effects of medication. The goal of treatment is to effectively eliminate depression with a medication that produces minimal problems or adverse effects. Unfortunately, an “ideal” medication that does not pose some potential problem or risk is not yet available. Side effects are generally mild and decrease with time. Research is focusing on more selective medications for depression that produce fewer and less problematic side effects. It is important that you ask your doctor about any concerns you might have about a medication or its potential side effects.

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12. What are the possible side effects of antidepressant medication?

Antidepressants are a relatively safe treatment option in otherwise healthy individuals being treated for depression. Like most prescribed (and some over-the-counter medications), antidepressants may cause mild, and usually temporary side effects in some people. Most of the time, side effects are mild, manageable and disappear over time. Common side effects include nausea, loose stools or constipation, dizziness, drowsiness, nervousness, sleep changes, dry mouth, headache and blurred vision. Some people experience a change in sexual interest or functioning. While more severe problems are less common, they are possible.

Your doctor or pharmacist will have information sheets that outline a range of potential side effects. Each time you meet with your doctor for follow-up sessions, she or he will ask about your response to the medication and check for problematic effects. Unusual side effects or those that could interfere with your ability to work or study should be reported to your doctor immediately so that changes in the medication can be made. Most side effects are reversible and gradually disappear after a medication is stopped.

13. How long will it be before the medication helps me? How will I know that the medication is working?

All antidepressants take time to work. Don’t be discouraged if you don’t feel better right away. Therapeutic response typically occurs within two to four weeks after treatment is started, although some people feel better sooner. It is not unusual for your friends and family to notice signs of improvement before you do. When the medication begins to work, you may find yourself increasingly able to accomplish things and enjoy life in a way that is more “normal” for you. If you do not respond to one medication, your doctor may recommend a change of dosage or a change to other medication(s).

Each person is unique in his or her response to medication. Treatment of depression is an ongoing process, with your doctor monitoring and “fine tuning” your medication, depending on how it is working for you.

Each person is unique in his or her response to medication.

14. Can I take other medications along with antidepressants?

An important question! Sometimes when antidepressants are taken in combination with other drugs, the chances of side effects or drug interactions increase. It is very important to consult with your prescribing physician, particularly about allergy medications. Be sure to tell your doctor about any medications you use, even over-the-counter or “natural” vitamins and herbal products.

15. Will the medication interfere with my birth control pills?

There is no evidence that antidepressants decrease contraceptive protection. However, like other medications, antidepressants are potentially harmful to the fetus if you are or become pregnant.

16. Are there “natural” substances I can use to treat depression?

There has been a great deal of publicity about herbal preparations such as St. John’s Wort for the treatment of depression. Unfortunately, in the United States there are currently no adequate studies to prove that this or other herbal remedies are an effective treatment, especially when compared to standard antidepressants for certain forms of clinical depression. In addition, herbal preparations may not have any significant impact on severe forms of depression. Currently it is not recommended that traditional antidepressants be mixed with herbal antidepressants. If you are curious about any new developments in the research on herbal preparations, talk with your psychiatrist before “self-medicating.”

17. How much will antidepressant medication cost?

Although the cost of medication may be difficult for some students to budget, the costs of not treating a depression are also high. You’ve invested considerable time and money to attend UT. Your ability to function in school, relationships and outside employment may be significantly affected by an untreated episode of depression. The average cost of medication for depression will be about $10 to $70 per month (taking one medication at the average dose level). Many insurance companies pay a portion of medication costs. You may be required to pay a “co-pay” (often $4 to $12) for your portion of the cost. Other insurance companies pay a certain percentage of the cost. You will need to check your individual insurance policy to find out what medication expenses are covered.

18. Why can’t I use alcohol when taking medication?

Did you know that alcohol itself is an extremely potent depressant? You certainly don’t want to feel more depressed! The use of alcohol and drugs can complicate the diagnosis and treatment of a depressive illness. Many depressive conditions are associated with the excessive use of alcohol and some drugs. Using drugs or alcohol can increase the risk of dangerous behaviors including suicide or cause complicated interactions with your prescribed medication. In sum, alcohol or drug use can reduce the effectiveness of your treatment, prolong your illness, and increase the risk of negative medication side effects.

Alcohol and drugs can make your depression worse.

19. What if I forget to take my pills on schedule?

This is something you’ll want to discuss with your doctor. In most cases, if you miss a dose of your medication, don’t take a double dose next time. Simply continue with the next scheduled dose and try not to miss again. If you miss several consecutive doses you may experience problems such as headache and nausea. Most importantly, if you often forget to take the medication, your recovery is likely to take longer.

20. How do I tell my family and friends?

Often the people who care about you are already aware of and concerned about the changes in your mood and energy levels. They may be very relieved that you are getting help. Since depression can leave you feeling exhausted or helpless, getting support from others at this time is very important. However, many people have never experienced a serious depression and have trouble fully understanding how disabling it can be. They might not mean to hurt you but they may say or do things that do hurt. It may help to share this brochure with those you most care about so that they can better understand and help you.

21. If I am taking medication, will I still need counseling?

For many people the combination of medication and psychotherapy is the most effective way to treat depression. While medication can help improve depressive symptoms, it can’t change the events, thoughts or behaviors that are problematic or distressing for you. Even before becoming depressed you may have been struggling with personal or family issues that affected how you felt about yourself and your relationships. Psychotherapy can help you begin to explore and resolve these concerns. Individual and/or group psychotherapy may also be recommended to assist you in improving self-esteem, relationship skills and strategies for managing stressful events. Good nutrition, good quality sleep and exercise are also important elements of your recovery. To feel better as quickly as possible, consider all the recommendations made to you by your counselor and your psychiatrist.

Article Source:Â http://www.utexas.edu/student/cmhc/booklets/meds/meds.html

Everyone, at various times in life, feels sad or blue. It’s normal to feel sad on occasion. Sometimes this sadness comes from things that happen in your life: you move to a different city and leave friends behind, you lose your job or a loved one dies. But what’s the difference between “normal” feelings of sadness and the feelings caused by clinical depression?

* How intense the mood is: depression is more intense than a simple bad mood.
* How long the mood lasts: a bad mood is usually gone in a few days, but depression lasts for two weeks or longer.
* How much it interferes with your life: a bad mood does not keep you from going to work or school or spending time with friends. Depression can keep you from doing these things and may even make it difficult to get out of bed.

While it’s normal for people to experience ups and downs during their lives, those who have depression experience specific symptoms daily for two weeks or more, making it difficult to function at work, at school or in relationships.

Depression is a treatable illness marked by changes in mood, thought and behavior. That’s why it’s called a mood disorder.

People of all ages, races, ethnic groups and social classes have depression. Although it can occur at any age, the illness often develops between the ages of 25 and 44. The lifetime prevalence of depression is 24 percent for women and 15 percent for men.
Bipolar Disorder: More Than A Mood Swing

Bipolar disorder (also known as manic depression) is a treatable illness marked by extreme changes in mood, thought, energy and behavior. It is known as bipolar disorder because a person’s mood can alternate between the “poles” of mania (high, elevated mood) and depression (low, depressed mood). This change in the mood or “mood swing” can last for hours, days, weeks or even months. These highs and lows are frequently seasonal. Many people who have bipolar disorder report feeling symptoms of depression more often in the winter and symptoms of mania more often in the spring.

Bipolar disorder affects more than two million adult Americans. Like depression and other serious illnesses, bipolar disorder can also adversely affect spouses, family members, friends and people in the workplace. It usually begins in late adolescence (often appearing as depression during teen years), although it can start in early childhood or as late as the 40s and 50s. An equal number of men and women develop this illness and it is found among all races, ethnic groups and social classes. Bipolar disorder tends to run in families.
Mood Disorders Are Treatable

The majority of people with mood disorders are able to find treatments that work. Talk therapy, medication or a combination of both help the person feel better and change situations in their life that may be contributing to their illnesses (substance abuse, bad relationships, etc.).

Depression

Depression is a treatable illness involving an imbalance of brain chemicals called neurotransmitters. It is not a character flaw or a sign of personal weakness. You can’t make yourself well by trying to “snap out of it.” Although it can run in families, you can’t catch it from someone else. The direct causes of the illness are unclear, however it is known that body chemistry can bring on a depressive disorder, due to experiencing a traumatic event, hormonal changes, altered health habits, the presence of another illness or substance abuse.

Symptoms

• Prolonged sadness or unexplained crying spells
• Significant changes in appetite and sleep patterns
• Irritability, anger, worry, agitation, anxiety
• Pessimism, indifference
• Loss of energy, persistent lethargy
• Feelings of guilt, worthlessness
• Inability to concentrate, indecisiveness
• Inability to take pleasure in former interests, social withdrawal
• Unexplained aches and pains
• Recurring thoughts of death or suicide

Most psychiatric illnesses cannot currently be cured although recovery may occur. While some have short time courses and only minor symptoms, many are chronic conditions which can have a significant impact on a patients’ quality of life and even life expectancy, and as such may be thought to require long-term or life-long treatment. Effectiveness of treatment for any given condition is also variable from individual to individual.

Psychiatry in professional practice

Psychiatrists are medical doctors and are certified in treating mental illness using the biomedical approach to mental disorders including the use of medications. Psychiatrists may also go through significant training to conduct psychotherapy, psychoanalysis, and/or cognitive behavioral therapy, but it is their medical training that differentiates them from clinical psychologists and other psychotherapists. Psychiatric nurses and psychiatric social workers are also involved in the professional practice of psychiatry, with the former having limited prescription rights in some countries and the latter having a legal role in committing people to psychiatric facilities in some countries. A high proportion of patients presenting to general practice report mental health problems and family physicians frequently prescribe psychiatric medication and sometimes refer patients for psychiatric assessment.

Some departments of psychiatry, especially those with academic links, may have the name of “Psychological Medicine,” which should not be confused with Medical Psychology, Health Psychology or Clinical Psychology.

As part of their evaluation of the patient, psychiatrists, Physician Assistants, and Nurse Practitioners are the only mental health professionals who may conduct physical examinations, order and interpret laboratory tests and EEGs, and may order brain imaging studies such as CT or CAT, MRI, and PET scanning. A medical professional must evaluate the patient for any medical problems or diseases that may be the cause of the mental illness, although findings of relevant brain abnormalities, for example via CAT scans, may be uncommon [1]

In addition to psychiatrists who practice clinically, some only perform research and/or work in an academic setting. These psychiatrists may only hold research degrees or a combination of psychiatry doctorates (such as an M.D. and Ph.D.).

Subspecialties

The field of psychiatry itself can be divided into various subspecialties. These include:

* Child and adolescent psychiatry
* Adult psychiatry
* Psychiatry of Old Age (Psychogeriatrics)
* Learning disability
* Behavioral medicine
* Consultation-liaison psychiatry
* Emergency psychiatry
* Addiction psychiatry
* Forensic psychiatry

Some psychiatric practitioners specialize in helping certain age groups; child and adolescent psychiatrists work with children and teenagers in addressing psychological problems. Those who work with the elderly are called geriatric psychiatrists, or in the UK and Australia, psychogeriatricians. Those who practise psychiatry in the workplace are called industrial psychiatrists in the US (occupational psychology is the name used for the most similar discipline in the UK). Psychiatrists working in the courtroom and reporting to the judge and jury (in both criminal and civil court cases) are called forensic psychiatrists, who also treat mentally disordered offenders and other patients whose condition is such that they have to be treated in secure units.

Other psychiatrists and mental health professionals in the field of psychiatry may also specialize in psychopharmacology, neuropsychiatry, eating disorders, and early psychosis intervention.

See also: meta-semantics

Treatment overview

In general, psychiatric treatments have changed over the past several decades (see History section, below). In the past, psychiatric patients were often hospitalized for six months or more, with some cases involving hospitalization for many years. Today, most psychiatric patients are managed as outpatients. If hospitalization is required, the average hospital stay is around two to three weeks, with only a small number of cases involving long-term hospitalization.

Individuals with mental illness are commonly referred to as patients but may also be called clients or more recently consumers. They may come under the care of a psychiatric physician or other psychiatric practitioners by various paths, the two most common being self-referral or referral by a primary-care physician. Alternatively, a patient may be referred by hospital medical staff, by court order, involuntary commitment, or, in the UK and Australia, by sectioning under a mental health law.

Initial assessment

Whatever the circumstance of their patient’s referral, a psychiatrist first assesses their patient’s mental and physical condition. This usually involves interviewing the patient and often obtaining information collated from other sources such as other health and social care professionals, relatives, associates, law enforcement and emergency medical personnel and psychiatric rating scales. Physical examination is usually performed to establish or exclude other illnesses, such as thyroid dysfunction or brain tumors, or identify any signs of self-harm; this examination may be done by someone else other than the psychiatrist, especially if Blood tests and medical imaging are performed.

Commencing treatment with medication requires the patient to agree to this treatment, although in many countries the law provides overriding circumstances, and that they will follow the dosage prescribed. Like all medications, psychiatric medications can have toxic effects in patients and hence often involve ongoing therapeutic drug monitoring, for instance full blood counts or, for patients taking lithium salts, serum levels of lithium. Electroconvulsive therapy (ECT) is sometimes administered for serious and disabling conditions, especially those unresponsive to medication.

Outpatient care

Psychiatric patients may be either inpatients or outpatients. Psychiatric outpatients periodically visit their clinician for consultation in his or her office, usually for an appointment lasting thirty to sixty minutes. These consultations normally involve the psychiatric practitioner interviewing the patient to update their assessment of the patient’s condition, and to provide psychotherapy or review medication. The frequency with which a psychiatric practitioner sees patients varies widely, from days to months, depending on the type, severity and stability of each patient’s condition, and depending on what the clinician and patient decide would be best.

Inpatient care

Psychiatric inpatients are patients admitted to a hospital or clinic to receive psychiatric care, sometimes involuntarily. In North America, the criteria for involuntary admission vary with jurisdiction. It may be as broad as having a mental disorder and being capable of mental or physical deterioration or as narrow as a patient being considered to be an immediate danger to themselves or others. In the UK, involuntary admission is limited to this narrow criterion. Inpatient psychiatric wards may be secure (for those thought to have a particular risk of violence or self-harm) or unlocked/open. Some wards are mixed-sex whilst same-sex wards are increasingly favoured as safer.

Once in the care of a hospital, patients are assessed, monitored, and often given medication and receive care from a multidisciplinary team, which may include physicians, psychiatric nurses, clinical psychologists, occupational therapists, psychotherapists, psychiatric social workers, and other mental health professionals. If patients are assessed as at particular risk of harming themselves or others, they may be put on constant or intermittent one-to-one supervision, and may be physically restrained or medicated. Inpatients may be allowed leave periods, either accompanied or on their own.

Theory and Focus

Mainstream psychiatry is considered a branch of medicine that is, or should aim to be, evidence-based in theory and practice. Psychiatric diagnosis is based on the concept of a distinct boundary between the mentally healthy and the mentally ill, and between different kinds of mental illness that can be medically differentiated, understood and treated. This is commonly done through standardized categories dubbed ‘neo-Kraepelian’ (Klerman, 1978), based on patterns of so-called ‘Feighner criteria’ (lists of symptoms with rules on the combinations required for different diagnoses).

Psychiatry is often described as being based within, or dominated by, a biomedical paradigm, although there are different theoretical approaches:

* Biopsychiatry (or Neuropsychiatry) – focused on genetics, neurochemistry and medication
* Social psychiatry or Community Psychiatry – focused on the interpersonal or public health context, including psychiatric rehabilitation
* Cross-cultural psychiatry – focused on the relevance of culture, including ethnicity and globalization.
* Psychoanalytic psychiatry (or Dynamic Psychiatry) – concerned with applying concepts and methods from psychoanalysis

Diagnostic systems of psychiatric disorders

ICD-10 (International Classification of Diseases)- the ICD 10 is published by the World Health Organisation and used world wide. In the United States, the standard system of psychiatric diagnoses is given in the Diagnostic and Statistical Manual of Mental Disorders (known as the DSM), overseen and revised by the American Psychiatric Association. It is currently in its fourth revised edition (IV-TR, published 2000) and is also used world-wide, perhaps more so than the ICD-10. The ICD-10 and the DSM are considered roughly on par with one another although the lack of a case example version of the ICD-10 is considered a problem by some. They are comparable in accuracy of diagnoses excepting certain categories which are more due to social differences in the countries themselves. For example disruptive disorders of childhood and multiple personality disorder are diagnosed to a greater extent in the U.S than the U.K.

The stated intention was to create a set of diagnoses that would be replicable and clinically useful whilst being atheoretical as regards etiology, although the categories are based on psychiatric theory, are broad, and many of the symptoms overlap. The two systems were designed to be compatible generally but there are inherent anomalies in both. While the system was originally intended only as a guide for experienced clinicians trained in its use, the nomenclature is now one of two standards widely used by clinicians, administrators and insurance companies in many countries. However, it has been critiqued for being vague, poorly defined, stigmatizing and lacking proper scientific foundation [1].

The DSM has five axes:

* Axis I: Psychiatric disorders
* Axis II: Personality disorders / mental retardation
* Axis III: General medical conditions
* Axis IV: Social functioning and impact of symptoms
* Axis V: Global Assessment of Functioning (described using a scale from 1 to 100)

Common axis I disorders between the two systems include substance dependence and abuse (e.g. alcohol dependence); mood disorders (e.g. depression, bipolar disorder); psychotic disorders (e.g. schizophrenia, schizoaffective disorder); and anxiety disorders (e.g. post-traumatic stress disorder, obsessive-compulsive disorder). Axis II disorders include borderline personality disorder, schizotypal personality disorder, avoidant personality disorder and antisocial personality disorder.

History

Physicians in Ancient Greece sought to explain and treat mental disturbance, notably melancholy and hysteria, but medieval thought focused on demonic possession. The first medical asylum, then known as Bedlam, started accepting some mentally disturbed patients in the 14th Century in England. In the 16th century, Johann Weyer argued that some cases of alleged witchcraft were actually mental illness. Mental disturbances were first systematically considered by physicians in the context of neurology, a term coined in the 17th century from the work of Thomas Willis. In 1758, William Battie gave impetus to the study and treatment of mental disturbance as a medical speciality. From the late 18th Century, the Moral Treatment movement developed the first humane methods and institutions for the mentally disturbed, developing partly from the work of physicians, notably Philippe Pinel.

Psychiatry developed as a clinical and academic profession in the early 19th Century, particularly in Germany. The field sought to systematically apply concepts and tools from general medicine and neurology to the study and treatment of abnormal mental distress and disorder. The term psychiatry was coined in 1808 by Johann Christian Reil, from the Greek “psyche” (soul) and “iatros” (doctor). Official teaching first began in Leipzig in 1811, with the first psychiatric department established in Berlin in 1865. Benjamin Rush pioneered the approach in the United States. The American Psychiatric Association was founded in 1844. Psychiatric nursing developed as a profession.

Early in the 20th Century, neurologist Sigmund Freud developed the field of psychoanalysis and Carl Jung popularized related ideas. Meanwhile Emil Kraepelin developed the foundations of the modern psychiatric classification and diagnosis of mental illnesses. Others who notably developed this approach included Karl Jaspers, Eugen Bleuler, Kurt Schneider and Karl Leonhard. Adolf Meyer was an influential figure in the first half of the twentieth century, combining biological and psychological approaches. Women were admitted as members of the profession[2]

Psychiatry was used by some totalitarian regimes as part of a system to enforce political control, for example in Nazi Germany [3], the Soviet Union under Psikhushka, and the apartheid system in South Africa [4]. For many years during the mid-20th century, Freudian and neo-Freudian thinking dominated psychiatric thinking. Social Psychiatry developed.

From the 1930s, a number of treatment practices came in to widespread use in psychiatry, including inducing seizures (by ECT, insulin or other drugs) or cutting connections between parts of the brain (leucotomy or lobotomy). In the 1950s and 1960s, lithium carbonate, chlorpromazine and other typical antipsychotics and early antidepressant and anxiolytic medications were discovered, and psychiatric medication came in to widespread use by psychiatrists and general physicians.

Coming to the fore in the 1960s, the field attracted an anti-psychiatry movement challenging its theoretical, clinical and legal legitimacy. Psychiatrists notably associated with critical challenges to mainstream psychiatry included R.D. Laing and Thomas Szasz.

Along with the development of fields such as genetics and tools such as neuroimaging, psychiatry moved away from psychoanalysis back to a focus on physical medicine and neurology[5] and to search for the causes of mental illnesses within the genome and the neurochemistry of the brain. Social psychiatry became marginalised relative to biopsychiatry. “Neo-Kraepelinian” categories were codified in diagnostic manuals, notably the ICD and DSM, which became widely adopted. Robert Spitzer was notable in this development. Psychiatry became more closely linked to pharmaceutical companies. New drugs came in to common use, notably SSRI antidepressants and atypical antipsychotics.

Psychiatry was involved in the development of psychotherapies. Neo-Freudian ideas continued, but there was a trend away from long-term psychoanalysis to more cost-effective or evidence-based approaches, particularly cognitive therapy from the work of Aaron Beck. Other mental health professions, particularly clinical psychology, were becoming more established and competing with or working with psychiatry.

During the last third the 20th century, the institutional confinement of people diagnosed with mental illness steadily declined, particularly in more developed countries. Among the reasons for this trend of deinstitutionalization were pressure for more humane care and greater social inclusion, advances in psychopharmacology, increases in public financial assistance for people with disabilities, and the Consumer/Survivor Movement. Developments in community services followed, for example psychiatric rehabilitation and Assertive Community Treatment.

Further considerations

Anti-psychiatry

Main article: Anti-psychiatry

There exist movements opposed to the practices of – and, in some cases, the existence of – psychiatry. These movements mostly originated in the 1960s and 1970s. Presently antipsychiatry encompasses a broad range of professional views, including a scholarly journal devoted exclusively to criticism of biopsychiatry, Ethical Human Psychology and Psychiatry[6], published by ICSPP. The movement is also driven by users and ex-users of psychiatric services and disability rights campaigners.

Main criticisms

* A lot of criticism and debate has focused on the efficacy, adverse effects and routine usage of psychiatric medications. The close relationship between psychiatry (and those prescribing psychiatric medication such as general physicians) and pharmaceutical companies has become increasingly controversial. Studies of pharmacogenetic polymorphism indicate that people of various ethnicities, for example one third of African American and Asian groups, have an increased risk of side effects and toxicity[4]. Critics also question whether psychiatric drugs are disorder- or problem-specific in the way that is claimed (Moncrieff and Cohen, 2005). ECT, termed electroshock by critics, is also much criticised, with concerns centred on evidence of long-term adverse effects and inefficacy, despite evidence of short-term benefits, and on how ECT is actually administered in routine practice.

* Critics highlight findings of problems with diagnostic reliability, including misdiagnosis (Williams et al, 1992; McGorry et al, 1995; Hirschfeld et al, 2003]), especially when comparing the criteria of the different psychiatric manuals (van Os et al, 1999). Some critics add that the criteria for many “mental illnesses” are openly culturally biased, or are extremely subjective and create essentially random diagnoses. See Schizophrenia. Rapid rises in the number diagnosed with particular disorders, sometimes relating to expanding of diagnostic criteria and increased prescribing of medication, for example with regard to childhood ADHD and ritalin, have also been criticised. Some critics claim that there are no established biological markers for many if not all the disorders the DSM purportedly identifies[7]. Although psychiatrists generally accept a medical model of mental disorders, some critics advocate alternative models that give more weight to environmental/social and psychological understandings and treatments.

* Another concern centers on the issue of involuntary commitment, which centers on issues of civil liberties and personal freedoms. In the U.S. someone may be involuntarily detained for psychiatric examination for a period of time (usually 24 to 72 hours depending on the state) if a government official declares the subject to be a danger to himself or others. With the attestation of an examining physician that a patient meets strict criteria of dangerousness to himself or others resulting from symptoms of mental illness, a judge may extend this commitment. Opposition to involuntary commitment is diverse and includes simple arguments that involuntary commitment is now or is inherently unconstitutional. The laws regarding the involuntary treatment of children vary widely from state to state[8].

Causes
Delayed ejaculation can be caused by physical and psychological reasons. Psychological causes are more common than physical.

Psychological causes of delayed ejaculation

Psychological causes of delayed ejaculation might include numerous factors that prevent a man from achieving orgasm during sexual intercourse.

The most common psychological cause of delayed ejaculation is being normalized to orgasm through masturbation. Commonly during masturbation, men exert much stronger pressure with their hands than is usually provided through sexual intercourse. Thus they train themselves to have a sexual response only to very strong pressure which they cannot get through friction inside the female vagina.

Delayed ejaculation might be caused by a strict religious background, which makes a person consider sex and enjoyment associated with it to be sinful. Therefore, a feeling of guilt does not allow the man to freely enjoy sexual intercourse and prevents him from reaching climax. Also, the inability to ejaculate can be caused by lack of attraction for a certain partner. A man can be prevented from ejaculating by some fears, such as the fear to cause pregnancy or considering the vagina to be a dirty place. Another factor causing delayed ejaculation is being so focused on the partner’s pleasure that prevents a man from getting enjoyment during sexual intercourse.

Delayed ejaculation can also be the result of some deep conflicts associated with the partner’s personality, for example sexual trauma caused by real or supposed partner’s unfaithfulness. Sometimes delayed ejaculation is caused by latent homosexuality or presence of a Paraphilia which prevent a man from having orgasm due to absence of some certain conditions, for example a man might be able to orgasm only during a BDSM session.

Physical causes

Physical causes of delayed ejaculation imply some diseases and conditions which affect a man’s ability to orgasm.. These include many neurological (for example stroke or damage to the back or spinal cord) and endocrine diseases (diabetes), prostate problems, some allergies and high blood pressure. As well difficulty in achieving orgasm can result from pelvic surgery that involved trauma to pelvic nerves which are responsible for orgasm.

Delayed ejaculation might be a side effect of some medications, usually of some antidepressants. Another reason for delayed ejaculation is excessive use of alcohol. In this case physical and psychological causes might co-exist. Alcohol addiction often implies psychological disorders which cause a man to become nervous and jealous without any reason. Thus two causes join and deepen the problem.

Complications

Delayed ejaculation causes a great deal of complications for a man who suffers from it as well as for his partner. To be precise in some cases delayed ejaculation can even contribute to sexual satisfaction of female partner who can orgasm for a few times during long lasting intercourse. However, after some time this is likely to become annoying for both a woman and a man who in spite of all efforts cannot achieve orgasm or achieves it after very long time. With the course of time the situation gets worse: both partners begin avoiding sex contacts which do not result in orgasm. Consequently, both partners suffer from sexual dissatisfaction and become likely to lose sexual desire. As the result relationships between partners worsen and often break. Divorces and breakups are especially widespread among those couples who plan to have children but cannot conceive due to the male partner’s inability to ejaculate inside the vagina.

Treatment

Treatment of delayed ejaculation depends on severity of the disorder and on its causes.

If a man has never had ejaculation through any kind of sexual stimulation (such as vaginal or anal intercourse, oral sex, masturbation, wet dreams) than he should consult a urologist in order to find out whether there is a physical abnormality and then get necessary treatment which depends on the abnormality revealed.

If the disorder is not so severe and a man can ejaculate through some form of stimulation, he should apply to a sex therapist specializing in this area. This is very important in cases when a man can ejaculate through any form of stimulation but intercourse. Usually treatment for this disorder includes both partners.

Therapy usually involves homework assignments and exercises intended to help a man get used to orgasm through vaginal intercourse i.e through the way he is not accustomed to. Commonly the couple is adviced to go through three stages. At the first stage a man masturbates in the presence of his partner. Sometimes this is not an easy matter as a man might be used to orgasm alone. After a man learns to ejaculate in the presence of his partner, the couple gets to another stage where the man’s hand is replaced with the hand of his partner. Step by step a man learns to ejaculate closer and closer to the vagina. In the final stage a woman inserts her partner’s penis into her vagina as soon as she realizes he is about to ejaculate. Thus a man gradually learns to ejaculate inside the vagina. Clearly this is written from the point of view of heterosexual relationships. Different approaches would apply for homosexual and repressed homosexual males.

If relationships in a couple are found problematic, therapy intended to enhance emotional itimacy might be required as prelimenary step.

In some cases hypnosis is of good help, esecially if a partner does not want to participate in therapy.

Naturally, if delayed ejaculation is caused by a disease, the disease is first of all treated. In those cases when delayed ejaculation is a side effect of a medication the man’s physician is to review other medication options.

In case of alcohol addiction a man should get necessary treatment intended to help treat his addiction.

Prognosis

A typical treatment for delayed ejaculation requires from 12 to 18 sessions which on average is successful in 70-80 per cent of cases.

The following factors are signs of better outcome: having sexual desire, being in love with the sexual partner, being eager to get rid of the problem, absence of deep psychological problems, short duration of the disorder and having satisfying sexual experiences before.

Success of treatment for delayed ejaculation caused by medication recovery totally depends on whether the physician can discontinue the medication.

Prevention

First of all a man should have healthy attitude towards sexuality and his sexual response. He should be fully aware of the fact that anxiety and fears cannot contribute to normal and satisfying sexual experience.

A man who wants to avoid ejaculation problems should concentrate on the pleasure he gets rather than to worry about when and whether his ejaculation is going to occur. As well the partner should be tactful enough and should not put pressure on the man by asking him whether he has ejaculated or not. Instead a partner should create relaxed atmosphere in which a man is going to feel free and enjoy sexual pleasure without worrying about ejaculation. And of course, open discussing of anxieties and fears contribute to better sexual relationships and normal sexual satisfaction.

The causes of erectile dysfunction may be physiological or psychological. Psychological impotence can often be helped by almost anything that the patient believes in; there is a very strong placebo effect.

Due to its embarrassing nature and the shame felt by sufferers, the subject was taboo for a long time, and is the subject of many urban legends. Folk remedies have long been advocated, with some being advertised widely since the 1930s. The introduction of perhaps the first pharmacologically effective remedy for impotence, sildenafil (trade name Viagra), in the 1990s caused a wave of public attention, propelled in part by the news-worthiness of stories about it and heavy advertising.

The Latin term impotentia coeundi describes simple inability to insert the penis into the vagina. It is now mostly replaced by more precise terms.

Medical symptoms
Erectile dysfunction is characterized by the inability to maintain an erection. Normal erections during sleep and in the early morning suggest a psychogenic cause, while loss of these erections may signify underlying disease, often cardiovascular in origin. Other factors leading to erectile dysfunction are diabetes mellitus (causing neuropathy) or hypogonadism (decreased testosterone levels due to disease affecting the testicles or the pituitary gland).

Medical diagnosis
There are no formal tests to diagnose erectile dysfunction. Some blood tests are generally done to exclude underlying disease, such as diabetes, hypogonadism and prolactinoma. Impotence is also related to generally poor physical health, poor dietary habits, obesity, and most specifically cardiovascular disease such as coronary artery disease and peripheral vascular disease.

A useful and simple way to distinguish between physiological and psychological impotence is to determine whether the patient ever has an erection. If never, the problem is likely to be physiological; if sometimes (however rarely), it is more likely to be psychological. The current diagnostic and statistical manual of mental diseases (DSM-IV) has included a listing for impotence.

Clinical tests used to diagnose ED

Duplex ultrasound
Duplex ultrasound is used to evaluate blood flow, venous leak, signs of atherosclerosis, and scarring or calcification of erectile tissue. Injecting prostaglandin, a hormone-like stimulator produced in the body, induces erection. Ultrasound is then used to see vascular dilation and measure penile blood pressure. Measurements are compared to those taken when the penis is flaccid.

Penile nerves function
Tests such as the bulbocavernosus reflex test are used to determine if there is sufficient nerve sensation in the penis. The physician squeezes the glans (head) of the penis, which immediately causes the anus to contract if nerve function is normal. A physician measures the latency between squeeze and contraction by observing the anal sphincter or by feeling it with a gloved finger inserted past the anus. Specific nerve tests are used in patients with suspected nerve damage as a result of diabetes or nerve disease.

Nocturnal penile tumescence (NPT)
It is normal for a man to have five to six erections during sleep, especially during rapid eye movement (REM). Their absence may indicate a problem with nerve function or blood supply in the penis. There are two methods for measuring changes in penile rigidity and circumference during nocturnal erection: snap gauge and strain gauge.

Penile biothesiometry
This test uses electromagnetic vibration to evaluate sensitivity and nerve function in the glans and shaft of the penis. A decreased perception of vibration may indicate nerve damage in the pelvic area, which can lead to impotence.

Penile Angiogram
Invasive test – allows visualization of the circulation in the penis and is used during the repair of a priapism.

Dynamic Infusion Cavernosometry
(Abbreviated DICC) technique in which fluid is pumped into the penis at a known rate and pressure. It gives a measurement of the vascular pressure in the corpus cavernosum during an erection. To do this test, a vasodilator like prostaglandin E-1 is injected to measure the rate of infusion required to get a rigid erection and to help find how severe the venous leak is.

Corpus Cavernosometry
Cavernosography is an adjunct to Dynamic Infusion Cavernosometry, where a contrast material is injected and then it is x-rayed to visualize any leakage.

Digital Subtration Angiography
In DSA, the images are acquired digitally. The computer crates a mask from lower-contrast x-rays of the same area and digitally isolates the blood vessels (this is done manually through darkroom masking with traditional angiography).

Magnetic resonance angiography (MRA)
This is similar to magnetic resonance imaging. Magnetic resonance angiography uses magnetic fields and radio waves to provide detailed images of the blood vessels. Doctors may inject a “contrast agent” into the patient’s bloodstream that causes vascular tissues to stand out against other tissues. The contrast agent provides for enhanced information regarding blood supply and vascular anomalies. Aside from the IV used to introduce the contrast material into the bloodstream, magnetic resonance angiography is noninvasive and painless.

Pathophysiology
Penile erection is managed by two different mechanisms. The first one is the reflex erection, which is achieved by directly touching the penile shaft. The second is the psychogenic erection, which is achieved by erotic stimuli. The former uses the peripheral nerves and the lower parts of the spinal cord, whereas the latter uses the limbic system of the brain. In both conditions an intact neural system is required for a successful and complete erection. Stimulation of penile shaft by the nervous system leads to the secretion of nitric oxide (NO), which causes the relaxation of smooth muscles of corpora cavernosa (the main erectile tissue of penis), and subsequently penile erection. Additionally, adequate levels of testosterone (produced by the testes) and an intact pituitary gland are required for the development of a healthy male erectile system. As can be understood from the mechanisms of a normal erection, impotence may develop due to hormonal deficiency, disorders of the neural system, lack of adequate penile blood supply or psychological problems. Restriction of blood flow can arise from impaired endothelial function due to the usual causes associated with coronary artery disease, but can also include causation by prolonged exposure to bright light or chronic exposure to high noise levels.

A few causes of impotence may be iatrogenic (medically caused). Various antihypertensives (medications intended to control high blood pressure) and some drugs that modify central nervous system response may inhibit erection by denying blood supply or by altering nerve activity. Psychiatric medications, especially SSRIs have been shown to cause erectile dysfunction in patients, both males and females. Although usually reversible, these sexual side effects can, in rare cases, last for months or years or permanently after the drug has been completely withdrawn. This disorder is known as Post SSRI Sexual Dysfunction.

Surgical intervention for a number of different conditions may remove anatomical structures necessary to erection, damage nerves, or impair blood supply. Some studies have shown that male circumcision may result in an increased risk of impotence, while others have found no such effect, and another found the opposite.

Excessive alcohol use has long been recognised as one cause of impotence, leading to the euphemism “brewer’s droop,” or “whiskey dick;” Shakespeare made light of this phenomenon in Macbeth.

A study in 2002 found that ED can also be associated with bicycling. The number of hours on a bike and/or the pressure on the penis from the saddle of an upright bicycle is directly related to erectile dysfunction.

Treatment
Treatment depends on the cause. Testosterone supplements may be used for cases due to hormonal deficiency. However, the cause is more usually lack of adequate penile blood supply as a result of damage to inner walls of blood vessels. This damage is more frequent in older men, and often associated with disease, in particular diabetes.

Treatments (with the exception of testosterone supplementation, where effective) work on a temporary basis: they enable an erection to be attained and maintained long enough for intercourse, but do not permanently improve the underlying condition.

ED can in many cases be treated by drugs taken orally, injected, or as penile suppositories. These drugs increase the efficacy of NO, which dilates the blood vessels of corpora cavernosa. When oral drugs or suppositories fail, injections (e.g. of apomorphine) into the erectile tissue of the penile shaft may work.

When pharmacological methods fail, a purpose-designed external vacuum pump can be used to attain erection, with a separate compression ring fitted to the penis to maintain it. These pumps should be distinguished from other “penis pumps” (supplied without compression rings) which, rather than being used for temporary treatment of impotence, are claimed to increase penis length if used frequently, or vibrate as an aid to masturbation.

More drastically, inflatable or rigid penile implants may be fitted surgically. Implants are irreversible and costly.

All these mechanical methods are based on simple principles of hydraulics and mechanics and are quite reliable, but have their disadvantages.

In a few cases there is a vascular problem which can be treated surgically.

Uncontroversial treatments
PDE5 Inhibitors
The prescription PDE5 inhibitors sildenafil (Viagra®), vardenafil (Levitra®) and tadalafil (Cialis®) are prescription drugs which are taken orally. They work by blocking the action of PDE5, which causes cGMP to degrade. cGMP causes the smooth muscle of the arteries in the penis to relax, allowing the corpus cavernosum to fill with blood.

Vacuum pump
An external vacuum pump will produce an engorged penis with success approaching 90%; a penis ring will maintain this state, although it should be removed after not more than 30 minutes. The erection is not as rigid or hard as a natural erection; drugs or injections, when they work, may be preferable. Various studies show the degree of satisfaction of users and their partners to be vary variable, even when drugs and injections do not work; in one study, about 20% of men who tried a (high-priced) pump decided to proceed to purchase one. Other studies show higher percentages of satisfied users.
In some cases frequent use of a vacuum pump can eventually improve the degree of erection attainable without use of the pump. Claims of cheap “penis pumps” to permanently increase maximum penis size should be viewed with caution, however.
Some vacuum pumps, such as Osbon ErecAid, are sold at a higher price with 100% refund within 90 days to dissatisfied users, with a somewhat lower price with 50% refund guarantee.This pump is supported by medical insurance schemes, including the UK’s NHS and US Medicare and private insurers. The better-known pumps sell for prices of around 200 GBP/400 USD (2006). There is at least one vacuum pump with rings which sells for around one-fifth of this price.

(Specific devices are mentioned for information only; mention should not be taken as endorsement).

Dopamine Receptor Agonist
Apomorphine acts mainly on D2-like receptors and is administered sublingually in the presence of sexual stimulation. Studies have been inconclusive with efficacy rates ranging from 48-55% to 9-38%.[10] Currently, the use of apomorphine is limited to pateints with mild ED.

Inflatable implant

Rigid implant

Surgical treatment of certain cases

Controversial and unapproved treatments

Bremelanotide
The experimental drug Bremelanotide (formerly PT-141) does not act on the vascular system like the former compounds but allegedly increases sexual desire and drive in males as well as females. It is applied as a nasal spray. Bremelanotide allegedly works by activating melanocortin receptors in the brain. It is currently in Phase IIb trials.

hMaxi-K
hMaxi-K is a form of gene therapy using a plasmid vector that expresses the hSlo gene, that encodes the alpha-subunit of the Maxi-K channel. It has undergone phase I safety trials

GinsengA double-blind study appears to show evidence that ginseng is better than placebo: see the ginseng article for more details.

Enzyte
Enzyte is a product that has been advertised by saturation coverage on television channels such as CourtTV. However, the Center for Science in the Public Interest (CSPI) has filed a complaint with the Federal Trade Commission (FTC) about Enzyte for deceptive advertising. It is manufactured by Berkeley Nutritionals, which is alleged to be the subject of an investigation by the Attorney General of Ohio and the defendant in class-action lawsuits.

Enzyte is a supplement that claims to increase the male libido or frequency of erections of the penis. Commercials for Enzyte are shown regularly on television. These commercials feature a man named Bob who never stops smiling, apparently because he had taken Enzyte and improved the size of his sex organs. The commercials are riddled with symbolic phallic imagery, e.g. golf clubs, remarkably tall glasses of iced tea, and a hose spraying barely a trickle of water (carried by someone who doesn’t use Enzyte).

The effectiveness of Enzyte is in dispute. Some medical professionals in fact advise against taking Enzyte, saying that it can lead to damage. The Center for Science in the Public Interest have urged the Federal Trade Commission to disallow further television advertising for Enzyte due to a lack of proper studies supporting claims. Enzyte maker Berkeley Premium Nutraceuticals, Inc., is currently under a class action lawsuit for false advertising.

Enzyte is said to contain: Tribulus terrestris; Yohimbe Extract; Niacin; Epimedium; Avena sativa; Zinc Oxide; Maca; Muira Pauma; Ginkgo biloba; L-Arginine; Saw Palmetto. Other ingredients: gelatin, rice bran, oat fiber, magnesium stearate, silicon dioxide.

Herbal and other alternative treatments
These are generally ineffective when tested blind, but may be useful for their psychological (placebo) effect: if a good result is expected, any highly-praised, and often expensive, treatment can be effective. Reputable drugs can also benefit from the same effect.

Prelox
Prelox is a Proprietary mix/combination of naturally occurring ingredients, L-arginine aspartate and Pycnogenol. In double blind tests carried out by Dr. Steven Lamm at New York University School of Medicine, 81.1% of men overall judged Prelox to be effective in improving their ability to engage in sexual activity.Prelox® for improvement of erectile function: A review European Bulletin of Drug Research, Volume 11, No. 3, 2003. Steven Lamm, Frank Schoenlau, Peter Rohdewald Whilst the supplements should be taken daily, the manufacturers claim that it brings the spontaneity back into ones’ love life; unlike other products which must be remembered to be taken a fixed time before sexual activity.

Diagnosis and causes
Most men experience premature ejaculation at least once in their lives. Often adolescents and young men experience premature ejaculation during their first sexual encounters, but eventually learn ejaculatory control. Because there is great variability in both how long it takes men to ejaculate and how long both partners want sex to last, researchers have begun to form a quantitative definition of premature ejaculation. Current evidence supports an average ejaculation latency time (IELT) of seven to ten minutes. If the disorder is defined as an IELT percentile below 2.5, then premature ejaculation could be suggested by an IELT of less than about one and a half minutes. Nevertheless, it is well accepted that men with IELTs below 1.5 minutes could be “happy” with their performance and do not report a lack of control and therefore do not suffer from PE. On the other hand, a man with 2 minutes IELT could present with perception of poor control over his ejaculation, distressed about his condition, has interpersonal difficulties and therfore be diagnosed with PE.

Scientists have long suspected a genetic link to premature ejaculation. In one study, ninety-one percent of men who suffered from lifelong premature ejaculation also had a first-relative with lifelong premature ejaculation. Other researchers have noted that men who suffer from premature ejaculation have a faster neurological response in the pelvic muscles. Simple exercises commonly suggested by sex therapists can significantly improve ejaculatory control for men with premature ejaculation caused by neurological factors[citation needed]. Often, these men may benefit from anti-anxiety medication or selective serotonin reuptake inhibitors (SSRIs), such as sertraline or paroxetine. Some men prefer using anaesthetic creams; however, these creams may also deaden sensations in the man’s partner, and are not generally recommended by sex therapists.

Psychological factors also commonly contribute to premature ejaculation. While men sometimes underestimate the relationship between sexual performance and emotional well-being, premature ejaculation can be caused by temporary depression, stress over financial matters, unrealistic expectations about performance, a history of sexual repression, or an overall lack of confidence. Interpersonal dynamics strongly contribute to sexual function, and premature ejaculation can be caused by a lack of communication between partners, hurt feelings, or unresolved conflicts that interfere with the ability to achieve emotional intimacy. Neurological premature ejaculation can also lead to other forms of sexual dysfunction, or intensify the existing problem, by creating performance anxiety. In a less pathological context, premature ejaculation could also be simply caused by extreme arousal.

Some physical illnesses, such as a prostate infection, are also known to induce premature ejaculation. In other instances, premature ejaculation is caused by a physical injury that affects the nervous system. Certain medications, such as cold medications containing pseudoephedrine, also cause premature ejaculation. Sexual dysfunction is a common symptom of psychiatric afflictions ranging from bipolar disorder to post-traumatic stress disorder. In these cases, it is best to discuss the issues openly with a physician.

Today it is believed that the neurotransmitor serotonin (5HT) has a central role in modulating ejaculation. Several animal studies have demostrated its inhibitory effect on ejaculation modulated through the PGI system in the brain. Therfore, it is perceived that low level of serotonin in the synaptic cleft in these specific areas in the brain could cause premature ejaculation. This theory is further supported by the proven effectiveness of SSRIs, which increase serotonin level in the synapse, in treating PE.

Studies show that one in three men could have fixed their PE problem just by simply drinking less coffee every day, since caffeine has been proven to cause the male to ejaculate much sooner from the added energy[citation needed].

Definitions
Many definitions for premature ejaculation have been proposed by individual researches like Masters and Johnson and more recently Waldinger. In addition, several professional organizations like the American Psychiatric Association- DSM-IV-TR, American Urological Association, European Association of Urology World Health Organization- have proposed their own definition. These definitions include common concepts like short ejaculatory latency time with a proposed cutoff time of 1-2 minutes, lack of control over ejaculation or the inability to delay ejaculation, personal distress, interpersonal or relationship difficulties and dissatisfaction with sexual intercourse. The most commonly used definition is the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria for PE include the following: 1) persistent or recurrent ejaculation with minimal sexual stimulation before, on, or shortly after penetration and before the person wishes; 2) causes marked distress or interpersonal difficulty; and 3) is not exclusively due to the direct effects of a substance.

Treatment
Depending on severity, premature ejaculation symptoms can be significantly reduced. In mundane cases, treatments are focused on gradually training and improving mental habituation to sex and physical development of stimulation control. In clinical cases, various medications are being trialled to help slow down the speed of the arousal response.

SSRI antidepressants have been shown to delay ejaculation in men treated for different psychiatry disorders. SSRIs are considered the most effective treatment currently available for PE. These include paroxetine, fluoxetine, sertraline and more. The use of these drugs, that require chronic therapy is limited by the neuropsychiatric side effects. New SSRI drugs specifically targeted to treat premature ejaculation (e.g. dapoxetine) can be taken on an as needed basis and have been recently shown positive results in large phase III studies. Nevertheless dapoxetine is not yet approved by any regulatory authority around the world. There is speculation that some of the associated effects are caused by lowered libido and blood pressure as well as lowered anxiety levels. Other pharmaceutical products known to delay male orgasm are; opioids, cocaine, and diphenhydramine.

Local anesthetic creams (like lidocaine, prilocaine and combinations) have shown to be very effective in clinical trials and are being used of the treatment of PE. Their use is limited by its own anesthetic effect that reduce sensation on the penis and female vagina.

Most sex therapists prescribe a series of exercises to enable the man to gain ejaculatory control. While the exercises are intended for men who suffer from premature ejaculation, other men can use the exercises to enhance their sex lives. By far the most common exercise is the so-called start-stop technique. While the technique varies, the purpose is to get the male accustomed to maintaining an erection for an extended period of time while gradually increasing sexual tolerance. In doing this exercise, the male obtains an erection through self-stimulation, or masturbation. After achieving an erection, he stops stimulating himself until he begins to lose his erection; at that point, he begins to stimulate himself again. Gradually, over a period of several weeks, he is able to stimulate himself for longer periods of time, eventually gaining ejaculatory control. In order for this technique to be successful, the male should avoid feeling discouraged if he ejaculates rapidly; instead, he should use his sexual responses to learn how to vary the technique in a way that most benefits him. The male can choose to integrate his partner into these exercises.

The male’s partner is usually integrated into the exercises. They can stimulate the partner using the stop-start technique. When the male has achieved some level of ejaculatory control, he can insert his penis into his partner without thrusting. After his penis becomes accustomed to being inside his partner, thrusting can be gradually included, according to the male’s abilities, using the stop-start technique. In less severe cases, the male might overcome his premature ejaculation early on, making exercises with his partner superfluous.

The male’s partner plays an essential role in enabling him to overcome premature ejaculation. Without understanding and emotional support, the male is unlikely to obtain the level of relaxation required for sexual satisfaction. Both the male and his partner should communicate their feelings openly and with sensitivity. The male should learn to sexually satisfy his partner, orally or otherwise, while they work with him to overcome his premature ejaculation.

External latex rigid sheathes fastened to the body have been developed that cover all part of the penis during penetration so that the penis is protected from all the stimulation of the vagina. these help to gain control and to provide satisfaction to the partner.

Many alternative therapies are available for the treatment of PE. Caution should be exercised when researching alternative sources of advice however, most treatments have not actually been shown to be effective. Some web sites even advocate the dangerous and antiquated method of pulling the testes downwards when aroused. This is actually a good way to slightly strain the interior of the testes and is associated with reports of injury and weakened/deteriorated erection. For some reason this advice is still widespread on the Internet.

Hypnosis has also proven very effective in the treatment of premature ejaculation.[citation needed] It is believed that ejaculation is a subconscious habit and by giving the mind hypnotic suggestions to last longer, the problem can be greatly alleviated if not completely cured.[citation needed] Most men report dramatic improvement after only a few sessions of hypnosis.

The prostate gland plays a very important part in regulating arousal. Pressure in between the engorged prostate and the erection causes most of the pleasurable sensations and it may be emptied manually before sex by prostate massage. this causes the erection to be strong but less sensitive, and increases a patients awareness of his physiology.

There is a trend toward the use of nutritional supplements when treating men who suffer from PE. Effective supplements must contain 5HTP which is a precursor to serotonin. Famed physiologist, Dr. William Ganong, noted over 50 years ago that serum serotonin levels could be increased through dietary means. Increasing the serum level of serotonin helps inhibit the ejaculatory reflex. There are a number of nutritional remedies available primarily on the Internet.

Diagnosis
Diagnostic criteria for Premature Ejaculation DSM-IV-TR (American Psychiatric Association)

A. Persistent or recurrent ejaculation with minimal sexual stimulation before, on, or shortly after penetration and before the person wishes it. The clinician must take into account factors that affect duration of the excitement phase, such as age, novelty of the sexual partner or situation, and recent frequency of sexual activity.

B. The disturbance causes marked distress or interpersonal difficulty.

C. The premature ejaculation is not due exclusively to the direct effects of a substance (e.g., withdrawal from opioids).

Differential diagnosis
Premature ejaculation should be distinguished from erectile dysfunction related to the development of a general medical condition. Some individuals with erectile dysfunction may omit their usual strategies for delaying orgasm. Others require prolonged noncoital stimulation to develop a degree of erection sufficient for intromission. In such individuals, sexual arousal may be so high that ejaculation occurs immediately. Occasional problems with premature ejaculation that are not persistent or recurrent or are not accompanied by marked distress or interpersonal difficulty do not qualify for the diagnosis of premature ejaculation. The clinician should also take into account the individual’s age, overall sexual experience, recent sexual activity, and the novelty of the partner. When problems with premature ejaculation are due exclusively to substance use (e.g., opioid withdrawal), a substance-induced sexual dysfunction can be diagnosed.