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According to the American Congress of Obstetricians and Gynecologists, about one out of every five or six women will experience symptoms of depression during pregnancy. We diagnose prenatal depression when a women experiences two weeks or more of persistent sadness, loss of interest in enjoyable activities, significant changes in sleep or appetite, feelings of guilt or worthlessness, or repeated thoughts of death or self-harm. Women with a personal or family history of depression are at higher risk. Other risk factors include relationship problems, stressful life events, and pregnancy-related issues, such as earlier age of pregnancy, greater number of children, infertility treatments, medical complications, and previous pregnancy loss.

Untreated depression during pregnancy is unhealthy for mother and baby. A woman who is depressed may not take adequate care of herself, leading to poor nutrition, drinking, smoking, and suicidal behavior. Risks for the baby include premature birth, low birth weight, and developmental problems. Women who experience depression in pregnancy are also at risk for depression after delivery, or postpartum depression, and that may interfere with bonding behavior between mother and baby.

Effective treatment for depression is important to mother and baby. Good self care (exercise, a healthy diet, regular sleep) is always important. For women with mild or moderate depression, support groups and individual or group psychotherapy, especially cognitive behavioral therapy, may be enough. Women who experience more severe depression sometimes take antidepressant medication. A decision to take medication must balance the possible benefits and risks. All antidepressants cross the placenta and get into the baby’s blood stream. There is not enough information to say that any antidepressants are completely safe, and some antidepressants may be linked to physical malformations, heart problems, pulmonary hypertension, and low birth weight. Talk with your prenatal care and mental health providers about risks and benefits of specific antidepressants, and remember that new information about safety of antidepressants in pregnancy is always becoming available.

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Lithium dietary supplements usually contain lithium orotate, a different lithium "salt" from the lithium carbonate or lithium citrate in most prescription lithium. Lithium doses in dietary supplements are much lower than in prescription lithium—usually 10mg per pill instead of 300mg or 450mg. There are some claims that lithium orotate is better absorbed or more active, so lower doses are still effective. But there is no clear evidence (no randomized, placebo-controlled, blinded trials) showing that low doses of lithium orotate are effective for treatment or long-term prevention of mood symptoms.

Still, it is possible that very low doses of lithium are helpful for some people. Lithium is a naturally occurring mineral, and trace amounts are present in the water many of us drink. And areas with more lithium in the water supply tend to have lower suicide rates! So, very tiny amounts of lithium—less than 1% of the lithium even in low-dose dietary supplements—might sometimes be helpful.

But if you are taking prescription lithium, you definitely do not want to switch to a low-dose nutritional supplement without talking with your doctor. For some people, suddenly stopping lithium or suddenly decreasing the dose can cause severe mood swings or symptoms of mania.

And you wouldn't want to add a lithium nutritional supplement to prescription lithium. That might increase your blood level of lithium enough to cause side effects or increase your risk of long-term problems from lithium.

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Finding the right counseling or therapy is complicated—but you already know that! You have to think about the specific person you are seeing (do they listen to you and care about you) and the kind of therapy they provide (does this approach seem to help you). Start by telling yourself that you are hiring a therapist to help you. That means you get to decide what the most important problem is, and your therapist's job is to work with you to solve it. Explain how you think that your experience of abuse or trauma affects you now. Ask your therapist how they would try to help you with that. Your therapist should be able to describe some specific things that the two of you can try together. There are different brands of psychotherapy, including cognitive therapy, behavioral therapy, interpersonal therapy, and EMDR. Each is based on a specific idea about what helps people. Your therapist should be able to tell you what idea or ideas they think will be most helpful for you. And you should be able to see how those specific ideas apply to the things you discuss in each visit. If your therapist suggests a plan that doesn't sound right to you, it's a good idea to listen and consider it. Your therapist probably does have some useful training and experience. But you are the best judge of what works for you. Here are some of the most important questions you can ask: How will this kind of therapy help with the problems I think are most important? When and how will we decide if this approach is helping me?

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Congratulations! And thank you for sharing the news that recovery is possible.

Mood disorders (including depression and bipolar disorder) usually have many causes or contributing factors: the genes you were born with, positive and negative things that happen to you, your physical health, and substances you put into your body. Symptoms of depression or bipolar disorder are not a yes/no thing (like being pregnant, where either you are or you are not). Instead, symptoms of mood disorder are like high blood pressure. Some lucky people are born with a very low tendency to high blood pressure. But some people are born with a higher risk. Whether or not that risk comes out as high blood pressure depends on lots of other factors in your life (diet, exercise, stress, etc). And even if you develop high blood pressure, you can bring it down over time by working on those other factors. In the same way, you can certainly reduce symptoms of depression or bipolar disorder by making positive changes in your life: working to avoid or better manage negative events or stress, avoiding alcohol or drugs, increasing your physical activity. So positive life changes can certainly change the chemistry of your brain and reduce symptoms of mood disorder.

Some people refer to bipolar disorder as a chemical imbalance, and that term has both positives and negatives. On the plus side, that term reminds us that bipolar disorder is a serious illness and not just a moral weakness or character flaw. But on the negative side, that term can sometimes give the impression that there is nothing you can do to change the way the illness affects you. Recovery is hard work, but it is possible.

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Addressing any symptom begins with trying to diagnosis the cause. You may be wondering whether your symptoms are due to your mood disorder or could be caused by a general medical disorder.

Since your condition seems to be life-long, it's not likely that you are suffering from a medication side effect, infection, or have an acute life threatening condition. Simple blood tests and an EKG are usually sufficient to rule out the most relevant medical problems. Most people are not well served by endlessly pursuing expensive evaluations for rare conditions.

This brings us to the realm of psychiatry. There are three main possibilities to sort out: 1. Your treatment could be ineffective, 2. Your treatment could be partially effective, or 3. Your symptoms could be due to side effects of your treatment. In some cases the answer may seem obvious, but for most cases there is substantial uncertainty and management proceeds based on a working hypothesis.

Under hypotheses 1 and 2, you haven't responded adequately to current Plan A and will be looking for a more effective Plan B. Before you move on to Plan B, however, it's sensible to be sure you have given Plan A adequate time at a therapeutic dose before moving on to a higher dose of A or to new treatment B. Importantly, patients may find antidepressant medications work best when used in conjunction with lifestyle changes (e.g., regular exercise, a healthy sleep/wake cycle, and a healthy diet) and/or formal psychosocial treatments (e.g., Cognitive Behavior Therapy, Interpersonal Social Rhythm Therapy, or Family Focused Therapy).

Under hypothesis 3, you will be weighing the risks and benefits of management by subtraction, reducing the dose or eliminating the offending treatment. Management by subtraction (of ineffective medications) is a very attractive option, because it can often produce quick improvement, but reducing partially effective medication can lead to worsening depression. This risk may be managed by reducing the dose gradually in search of a level where the adverse effects resolve and the treatment remains effective.

Whichever management option you choose, routine measurement of your progress can be a helpful way to guide your care. This can be as simple as keeping a daily mood chart or using a rating scale once a month.

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Anyone can have problems with anger or irritability, but those problems are more common for people who live with depression or bipolar disorder. Irritability or anger outbursts are common symptoms of mania, and some people have problems with irritability when they are more depressed. Do your problems with anger tend to go along with other symptoms of mania (like feeling speeded up or racy, not needing to sleep) or symptoms of depression (like low mood, negative thinking, or losing interest in things)?

If you are taking medication for depression or bipolar disorder, be sure to tell your doctor about problems with anger or losing control and about how those problems relate to other mood symptoms. If anger problems seem to be symptoms of depression or mania, then your doctor may recommend some adjustment in medication.

Whether or not anger problems are related to depression or mania, there are specific steps you can take to better manage irritability or control anger outbursts. These include:

• Learning to recognize the external situations (people, places, events) that tend to make you more irritable or angry.
• Planning ahead for managing those high-risk situations by either avoiding them or preparing for them.
• Learning to recognize the internal warning signs (thoughts, emotions, physical feelings) that indicate you are more irritable or angry.
• Identifying specific things you can do when you notice those internal warning signs. Those might include things you can say to yourself, physical relaxation (like deep breathing), or actions you can take to interrupt the anger (like going outside and walking).

If you are seeing a counselor or therapist, you should talk with them about difficulties with irritability or anger outbursts. Your therapist can work with you to find the skills or strategies that help you the most.

Finally, alcohol and some drugs (especially stimulant drugs like cocaine and methamphetamine) can increase the chances that anger will get out of control. If you use alcohol or street drugs and you are having problems with anger outbursts, then you will probably want to look at how alcohol or drugs are affecting you.

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Brain scans come in a variety of types. Some investigate brain structures, for example, "CT" or "CAT" scans ("computerized axial tomography") or "MRI" scans (magnetic resonance imaging). Other types of scans investigate how the brain functions, such as "functional MRI" or "MRS" (magnetic resonance spectroscopy) scans. There are two reasons that individuals or their clinicians may be interested in brain scans. One reason is clinical, and the other reason is to contribute to research.

With regard to the clinical reason for brain scans, they are often used to be sure that there is no brain injury or abnormality that could be responsible for bipolar symptoms—for instance, a tumor or a stroke or multiple sclerosis. These causes are rare, and brain scans are often done with the clinician thinking, "I'm don't think so but just in case…" The cases where there actually is a structural brain problem that the scans could detect are so rare that clinical practice guidelines usually don't recommend them for routine use.

In the research setting, brain scans are being used to attempt to identify structures or chemical processes that underlie the symptoms of bipolar disorder. In these cases, the clinician informs the individual that a particular scan he or she is suggesting a brain scan specifically for research purposes, and that typically no information specific to their individual diagnosis or treatment should be expected—the individual is agreeing to a brain scan to further the cause of identifying mechanisms and treatments for bipolar symptoms. In these situations a formal informed consent form is signed after the clinician describes not only the benefits but also the risks of the procedure.

However, individuals should be aware that there are no scans that can "diagnose" bipolar disorder directly. We hope that in the future there will be. Currently, a bipolar disorder diagnosis is made based on history and clinical interview. Beware the clinician who wants to order a brain scan "to see if you have bipolar disorder."

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Losing weight is often a struggle, especially when a person is also living with a mood disorder. The causes are multiple. Increased appetite and carbohydrate craving, along with reduced activity level, are common symptoms of depression. And yes, certain antidepressants and other medications may increase appetite. However, most medications do not alter metabolism, per se. Thus, weight loss can still occur when attention is given to other factors, including the composition and timing of dietary intake.

Eating more frequently and smaller amounts, increasing the relative amount of protein eaten (people generally feel more "full" when eating high protein content foods), reducing breads and starches, eating a healthful breakfast, and avoiding large meals or snacks late in the evening can provide a more balanced diet throughout the entire day.

If one believes their current efforts to lose weight should be more productive, a consultation with a nutritionist may be helpful. If that isn't possible, keeping a written log of one's consumption may provide clues to problem areas and reinforce better dietary habits. In particular, check out the nutritional content of commonly eaten foods and foods believed to be "healthy".

Several readily available websites and phone apps list nutritional information for prepared and restaurant food items, and provide logs for recording consumption. We are often unaware of the hidden calories in many foods we eat. Even so-called "low fat" or "no fat" foods may be loaded with empty carbohydrates. Soft drinks, sport drinks, energy bars, restaurant salads and salad dressings may contain excessive amounts of sugar. Alcoholic beverages such as wine and beer are also loaded with carbohydrates and are a source of excessive calorie intake for some individuals.

Another critical ingredient for weight loss is exercise. Increasing both aerobic exercise and strength training, ideally four times a week for a minimum of 30 to 45 minutes, can increase muscle tone and metabolism and reduce fat stores. Regular exercise has also been shown to reduce risk for depression relapse when combined with a stable medication regimen. If one is already exercising regularly, changing up your routine and challenging your body in novel ways with repeated bursts of exertion can make your work-outs more efficient.

Chronic, low-grade sleep deprivation is another contributor to obesity. Skipping sleep leads to persistently elevated levels of the body's stress hormone, which can cause elevated blood sugar levels and increased fat stores. Staying up late may also make one more prone to late night snacking.

Lastly, a person carefully tending to all the above yet still gaining weight should consult their physician. Certain medical conditions such as thyroid abnormalities can cause weight gain as well as complicate depression.

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The short answer to this very good question is that this treatment is still considered experimental. Ketamine is not approved by the FDA to treat depression, it is not available outside of research studies. At this point, it is more useful to help us understand the biology of depression and to point the way to future treatments.

However, let's spend some time describing what ketamine is and what it is supposed to do.

Ketamine is an experimental drug currently under study at the National Institute of Mental Health and other research infrastructures around the world. Under the leadership of Carlos Zarate, MD, this compound has been shown to possess rapid and marked short-term efficacy in the treatment of major depressive episodes in both Major Depressive Disorder (unipolar disorder) and bipolar disorder. Not only do the symptoms of depression go away quite quickly, but thoughts of suicide do so as well. The results of Dr. Zarate's studies are quite remarkable because it normally takes several weeks to make a major depressive episode go away. Unfortunately, Ketamine can have severe side effects, and it is subject to abuse.

Ketamine is a drug which has been used in human and veterinary medicine. When used in human medicine, it is used prior to surgery by anesthesiologists to induce and maintain general anesthesia. Although Ketamine has been used safely and effectively by anesthesiologists, it has gained some notoriety for its use on the streets as a way to induce hallucinations, known as "Special K".

Let's finish by talking about how ketamine is important in the regulation of mood. Ketamine is believed to have its effect by changing how nerve endings talk to one another. When one nerve talks to another nerve within the brain, it does so by putting out neurotransmitters. There are three categories of neurotransmitters amines (norepinephrine, serotonin, dopamine, etc.), peptides (enkephalins, neuropeptide Y, substance P, etc), and amino acids (glutamate, glycine). Ketamine is now known to affect the excitatory amino acid, glutamate. Glutamate is one of 20 amino acids (the building blocks of the human body), and one of only two primary excitatory amino acids the other is aspartate.

Stay tuned for more developments on ketamine as it is likely to lead to major breakthroughs in at least the short-term treatment of major depressive episodes.

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Both depression and borderline personality disorder (BPD) can cause difficulties with interpersonal relationships. Feeling low or empty can lead people to withdraw from social situations. If, because of illness, you have spent long periods of time unable to work, sustain relationships, or even get out of the house, you may fail to develop reliable social skills or lose the social skills you used to have. A good analogy would: be after breaking a leg, walking is difficult even when the cast comes off because the leg muscles are weak from disuse. Similarly, it may be hard to know how to interact with others, even when you are feeling better, if you have suffered from depression and BPD for a long time. Relationships are more complicated when a person has suffered from emotional or sexual abuse, both of which are common in people with depression or BPD. So it's not surprising—and not your fault—that you sometimes feel uncomfortable around others if you suffer from depression and BPD.

Continuing the broken leg analogy, after the cast comes off, you might need physical therapy to build strength before you walk again. Similarly, specific kinds of psychotherapy can re-build social skills. Types of psychotherapy that have been shown to help individuals with depression and BPD include cognitive behavior therapy (CBT), interpersonal psychotherapy (IPT), and dialectical behavior therapy (DBT). Examples of strategies used in these therapies include: 1) Exposure (CBT): the more you avoid situations you're afraid of, the more difficult it will be ultimately to face them. If social situations make you anxious, you can develop skills to help you manage your anxiety more effectively such as controlling or counter-acting fearful thoughts. You can then push youself to try situations that provoke mild anxiety and practice your new skills. In CBT, your therapist might ask you to put yourself initially in lower-stress social interactions such as joining an on-line chat group or engaging in "pleasantries" with store clerks. Mastering these experiences will prepare you for more complicated situations such as (eventually) asking someone on a date or participating in a job interview. 2) Social skills (IPT): IPT focuses on the two-way relationship between mood and interpersonal relationships. In IPT, the therapist will help you with role-playing and/or coaching to help you find better ways to manage difficult interpersonal situations. You can learn to improve eye contact, better understand non-verbal cues, practice empathic listening, and develop strategies for asking effectively for things. You'll practice these skills in "easy" situations before trying them in more difficult ones. 3) Emotion Regulation (DBT): With both depression and BPD, unstable mood can interfere with social functioning. DBT helps develop skills like mindfulness to current emotions, labeling and identifying emotions, and tolerating negative emotions without acting impulsively. Improved mood stability can help you to manage more stressful or challenging interpersonal situations.

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You are right to be concerned about how marijuana affects people who live with depression and bipolar disorder—especially younger people.

Using marijuana can certainly contribute to or worsen depression. Low motivation, fatigue, and withdrawal from positive activities are central features of depression and marijuana can worsen each of those problems. Some people do say that marijuana dulls anxiety or negative feelings. But it also dulls energy and motivation. And we know that activation and engagement are key parts of recovery from depression.

Marijuana can be even more troublesome for people—especially younger people—who live with bipolar disorder. In addition to worsening depression, marijuana can increase the likelihood of experiencing symptoms of psychosis—like hallucinations or paranoid ideas. In younger people who are at higher risk for bipolar disorder or schizophrenia, using marijuana increases the chances of developing a severe or disabling mental illness.

You'll want to express your concerns to your husband in a way that feels caring rather than confrontational. If you talk to him about negative effects of marijuana use, the old advice about "I statements" definitely applies. You can say things like: "I notice that you seem less active and more withdrawn when you use marijuana" or "I'm concerned that using marijuana keeps you from doing positive things that would help you to feel better."

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The first task is to try to determine what's driving the meltdown. Is it part of a bipolar episode (or a signal of one that's approaching)? Is it difficulty with changing tasks, typical of both bipolar disorder and ADHD? Does it stem from OCD-related frustration? You may not always be able to tell, but you'll have an easier time if you are monitoring your kid's symptoms on a daily basis with a mood chart (for example, look at http://www.child-behavior-guide.com/feelings-chart.html). If the child's mood has been getting steadily more irritable over the past few days, and his or her sleep is getting irregular, you may be seeing the beginnings of a manic or hypomanic episode. Look for accompanying signs of excessive energy, unrealistic thoughts. On the other side, for depression, look for fatigue, pessimism, excessive sleeping, or suicidal ideation.

Let's start with the possibility that this is a manic or hypomanic episode. If this fits, then your options can include:

Use collaborative problem-solving early in the escalation. Start by validating your child's needs ("I know you really want to play video games now, I'm sure that would be fun"), but also set limits and point him/her toward problem-solving ("it's time to do homework. What are we going to do about this? What options do you think we have?").

It's harder to use this approach as the kid gets angrier (see a great discussion of these issues in Ross Greene's book, The Explosive Child). If he keeps escalating, make clear your point of view, but keep in mind the three-volley rule: after you and your son/daughter have gone back and forth three times, your side of the argument ends, even if s/he keeps it going. Walk away, and give yourself a time out. Use ignoring as much as possible: close your door and let him yell and scream as long as he doesn't hurt himself or anyone else.

Sometimes, it can be helpful to change the scene. Take him for a drive, or ask your spouse or an older sibling to take him somewhere. Call a relative to "spell you" for a time. Make sure you take care of yourself so that you don't let anger get the better of you. If your child is older, you should call the police if you feel in any way threatened or if you fear for others in the household.

If it is OCD that's driving the meltdown, an important consideration is whether the child is receiving (or has received) treatment for OCD, particularly exposure-based cognitive-behavioral therapy. If not, he or she may have limited skills for managing the frustration. If your child is in treatment for OCD, perhaps the best response would be, "Do you think that's your OCD talking?" If your child says yes, prompt him/her with, "Is there a skill you can use to fight back/resist?" If she continues to be upset, disengage (walk away) and let your child simmer down on her own. The back and forth when kids are activated typically just gets everyone more upset. Say something like, "I know this is hard, but I know you can do it. I'm going to give you a chance to work on this on your own."

In either case, it's good to debrief later on when everyone is feeling calm and to think about prevention. Ask your child what you think set him off, and what skills he could have used (deep breathing? Distraction? Self-talk?). Ask him what others could have done (other than give in to his demands) that would have made things easier. Make sure your child's therapist is aware of her problems with regulating emotions and is working with her on self-care skills.

Some children with ADHD do much better when they know the exact order of their evening routines dinner, homework, games, bath, bedtime. Writing down the expected routine in a place where everyone can find it may help prevent these disagreements.

As always, consider whether your child is getting the right medication regimen. If meltdowns are occurring frequently, his or her psychiatrist may add an atypical antipsychotic medication or increase the dosage, or, if ADHD is present but untreated, a stimulant medication like Ritalin.

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It's clear that ECT affects short-term memory. If you think of your brain as a computer, ECT can erase anything that you haven't yet saved to your hard disk. Some people can't remember events from the day of each treatment. Some people lose memory for the previous few days. For people receiving ECT treatments two or three times a week, that can mean remembering very little of the whole treatment.

It's less clear if ECT causes ongoing memory problems. To continue the computer anaology, the question is whether ECT damages your hard disk so you can't save information in the future. Most research says that ECT doesn't cause long-term memory problems. But some people do describe long-term problems with memory after ECT.

Concerns about risks of ECT (memory problems or other risks of anesthesia) were a major motivation to develop alternative treatments. These alternatives - transcranial magnetic stimulation (TMS) and vagus nerve stimulation (VNS) - were hoped to have the effectiveness of ECT without the risks or side effects. Both TMS and VNS have both been approved for treatment of major depression that does not improve with standard antidepressant medications. But it is not clear that either VNS or TMS is as effective as ECT for severe depression that has not responded to treatment with several medications. For the most severe and treatment-resistant depression, ECT still has the strongest evidence for effectiveness.

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Bariatric surgery programs often ask for a pre-operative mental health evaluation. The main purpose is to identify any barriers to success after surgery, especially barriers that can be effectively addressed or overcome. We do know that people with some specific mental health conditions such as an active eating disorder, active drug or alcohol problems, severe mood symptoms, or psychotic symptoms - can be barriers to recovery from surgery and losing weight. In these situations, delaying surgery and getting effective treatment can increase the chances of success. Another purpose of a pre-operative mental health evaluation is to understand the psychological factors that may interfere with success, such as using food as a coping mechanism. Counseling focused on these issues can increase the chance of successful weight loss after surgery. It is important to emphasize that having a diagnosis of depression or bipolar disorder does not mean that bariatric surgery is not safe or effective. Research shows that people with depression are just as successful losing weight after surgery. And losing weight often leads to improvement in depression.

While bariatric surgery is more and more common, we lack good research about how surgery affects the dosing, effectiveness, or side effects of mental health medications. Bariatric surgery can certainly change or reduce absorption of medications - so they are less effective. This may be a bigger problem with sustained- or slow-release medications. With some medications, your doctor may want to measure blood levels before surgery and again after to see if doses need to be adjusted. Monitoring of lithium is particularly important, because large changes in weight can affect how your kidneys clear lithium from your body. If you are planning weight loss surgery, you'll want to discuss these issues with your health care providers well in advance. And you'll want to make sure that your different health care providers (psychiatrist, therapist, surgeon) communicate clearly with each other. They will usually need your written permission to do that.

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The evidence for the benefits of fish oil (or omega-3 fatty acids) in the treatment of depression is mixed. Some studies show moderate benefit, and some show no more benefit than a placebo. But no studies show harm from fish oil supplements, and (unlike antidepressant medications) fish oil supplements do not seem to increase risk of mania or greater mood instability. We would like to have more evidence, but the evidence we have now indicates that fish oil is safe and may be helpful to some people in reducing symptoms of depression.

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Losing interest in things you used to enjoy is a central part of depression. Withdrawing from positive activities can keep you feeling depressed. As you feel better, you should start to feel more interested in things. And pushing yourself to do things you used to enjoy will help you to feel better faster. Phobia or phobic anxiety adds another layer. The core of phobia is avoiding things because doing them (or even thinking about doing them) makes you feel anxious. Phobias tend to be self-reinforcing. When you avoid situations because of anxiety, the avoidance helps the anxiety to grow stronger. The surest cure for phobic anxiety is pushing yourself to gradually overcome the anxiety. That's easier said than done, but it helps to follow a specific plan. Pick an activity that is important to you - something you would enjoy or something that you need to do to move forward in life. Chose a small and specific first step, then practice that step over and over until it doesn't make you anxious. Once you master the first step, choose a second step that's a little more of a stretch. And practice that one until you master it. For example, if you're feeling anxious about social situations, your first step could be as simple as going to the grocery store every day and saying something positive to the checker every time. They certainly won't mind. If you have trouble making a plan or sticking with it, a therapist who knows about anxiety problems can be very helpful.