Neuroimaging and Mental Illness: A Window Into the Brain

Brain imaging scans, also called neuroimaging scans, are being used more and more to help detect and diagnose a number of medical disorders and illnesses. Currently, the main use of bran scans for mental disorders is in research studies to learn more about the disorders. Brain scans alone cannot be used to diagnose a mental disorder, such as autism, anxiety, depression, schizpohrenia, or bipolar disorder.

In some cases, a brain scan might be used to rule out other medical illnesses, such as a tumor, that could cause symptoms similar to a mental disorder, such as depression. Other types of tests are needed for a mental illness to be properly diagnosed. Scientists are studying differences in the brains of people with and without a mental illness to learn more about these disorders. However, at this time relying on brain scans alone cannot accurately diagnose a mental illness or tell you your risk of getting a mental illness in the future.

Some types of brain scans pose health risks due to the radiation they use to create a picture of the brain. Because of these risks, brain scans should not be used if you don't need them. In addition, these scans are very expensive, and unless your doctor prescribes such a test, they may not be fully covered by health insurance.

What Brain Scans Can Do

• Show damage to brain tissue, the skull, or blood vessels in the brain
• Be used with other medical tests to help doctors find the right diagnosis for mood and behavioral problems
• Help researchers study healthy brain development, effects of mental illnesses or effects of mental health treatments on the brain.

What Brain Scans Cannot Do

• Diagnose mental illness when used by themselves
• Predict risk of getting a mental illness.

Frequently Asked Questions about Brain Scans

Can a brain scan tell me what mental disorders I have or might get?

No scientific studies to date have shown that a brain scan by itself can be used for diagnosing a mental illness or to learn about a person's risk for disease. Researchers use brain scans to study brain development in healthy people and people with illnesses, disease progression, and the effects of medications or other treatments on the brain.

In practice, when used with other types of medical tests and done by an experienced doctor, brain scans can be used to confirm a diagnosis of a small number of disorders, such as brain tumors, where there is obvious damage in the brain. Brain scans are not usually the first test a doctor would do to diagnose changes in mood and behavior. Other medical tests a doctor may use include behavioral and cognitive tests or a medical interview.

Researcher analyzes FMRI brain images

Should I have a brain imaging scan?

 

When used with other medical tests, they can provide useful information about:

• Brain tumors, infections, and other brain diseases
• Bleeding, blood clots, or other signs of stroke
• Skull fractures or brain damage from head injuries
• Diseases or disorders affecting the skull or blood vessels in the brain.

What types of brain scans, or neuroimaging tests, are there?

 

There are two main types of neuroimaging tests: structural and functional.

• Structural imaging creates a "snapshot" of the brain's structure, including bone, tissue, blood vessels, tumors, infection, damage, or bleeding such as from a stroke.
• Functional imaging reveals the brain's ever-changing activity and chemistry by measuring the rate of blood flow, chemical activity, and electrical impulses in the brain during specific tasks.

 
Patient enters PET scan machine.

Are there risks associated with brain scans?

 

Brain scans are relatively safe and do not cause any pain. However, risks include exposure to magnetic fields and radiation. Safety measures are used to limit these risks such as using the lowest possible radiation or magnetic level to do the scan.

Children and teens may be more sensitive to these risks. If your child needs a brain scan, ask if there are special precautions you can take or whether a different type of brain scan can be used. Ask the doctor doing the scan if the machine's settings have been adjusted for a child.

Women who are pregnant or breastfeeding should also talk with their doctor about how to prepare for any type of brain scan. While most types of scans pose little risk to the developing fetus, the doctor may make different recommendations to accommodate pregnancy.

Another possible risk is claustrophobia, or a fear of small spaces. Many brain scanning machines look like large tubes or giant "donuts" that are open on both ends. The machines can be very loud while scanning takes place. Some people feel scared or nervous when inside the machines. Sometimes, an injury or other medical condition can make it uncomfortable or painful for a person to hold a certain position.

It is important to stay still in order to get a clear picture. Tell your doctor if you are afraid of being inside the brain scanning machine or think you cannot stay still for any other reason. The doctor can give you a sedative to help you lie still, or may suggest a different type of test entirely.

Talk with your doctor to make sure you understand the possible risks and benefits before deciding to get a brain scan. In general, a person should not need more than one of the same type of brain scan. If a doctor recommends a brain scan that you've already done in the past, ask if you really need to get the test repeated.

 
Patient in MEG scanner

What can research using brain imaging technologies tell us about disease risk?

 

As they continue to learn more about how the healthy brain develops and which processes may contribute to specific diseases, scientists are building a more complete picture of how to detect which people are at risk of common diseases.

This research also is helping to reveal biological pathways that guide thoughts and emotions, and how experiences, medications, or environmental substances affect the brain. Scientists can use this information to design better screening and prevention for specific disorders, and improve on the delivery and effectiveness of mental health treatments.

Technician checks MRI machine.

Risk from magnetic fields:*

Magnetic resonance imaging (MRI) Functional magnetic resonance imaging (FMRI) Magnetic resonance spectroscopy (MRS)

These scans use strong magnets to develop pictures of the brain. This means that a person must remove all jewelry, piercings, and clothing with metal before entering the scanning machine. Medication patches, such as nicotine patches or ones that release hormones, sometimes contain metal in the sticky backing, which can burn the skin if worn during an MRI. If you use such patches, talk to your doctor about if and when you should remove them. It's important to tell your doctor if you have any metal in your body, such as metal braces or metal fillings in your teeth, embedded bullets, shrapnel, or implanted medical devices - pacemakers, aneurysm clips, medication pumps, metal plates, screws, or pins. If located close to the head, they may distort the scanned image. Sometimes, the strong magnetic field causes these objects to move, which can cause an injury. If you're not sure about your risk, check with the doctor before getting this type of brain scan.

* Magnetoencephalography (MEG) scanning does not carry these risks because it does not use magnets.

Risk from radiation: Computed tomography (CT) or computed axial tomography (CAT) Positron emission tomography (PET) Single positron emission computed tomography (SPECT) These scans expose people to low levels of radiation. For example, the amount of radiation from one CT scan of the head is about the same as the amount that the average person receives from natural sources of radiation over eight months.1 Natural sources of radiation include naturally occurring radioactive materials and cosmic rays such as emitted by the sun. Also, some people may be allergic to the chemicals, called contrast dyes or tracers, used to make sure brain structures show up in these types of scans. In some cases, these chemicals are radioactive but lose their potency fairly quickly. If you have ever had a bad reaction to a contrast dye or tracer, tell the doctor before you get the scan. In general, children should not have PET or SPECT scans. This article is in the public domain of NIMH publications and may be reproduced or copied without the permission from the National Institute of Mental Health. For complete guidelines regarding the reproduction of this article, you may call their Information Resource Center at 1-866-615-6464 or send an email to nimhinfo@nih.gov.

Introduction to M

I met with my new therapist today and I like her. Like I've often said, each new person brings a fresh perspective and a new strategy to the old battleground. We just have to open ourselves up to trust them and to face the fear of them abandoning us, which is very difficult!

 I told M today "You're my sixth therapist in seven years."

She smiled. "You have a lot to compare me to."

"No, I'm just afraid you will leave like the rest of them do."

And of course she couldn't answer to that, because no one knows what the future holds. Starting over, and starting over again, and again, and again...it seems to be an inevitable trend when it comes to mental health care. Sometimes the turnover works for our benefit; sometimes it doesn't. Always, it's a nuisance, and it produces a realm of grief to share so much of yourself with someone and then never see them again. I had canceled what was to be my first appointment last week, and had intended to do so today as well. But my gut told me to go, so a lot of pep talk, anxiety and a Klonopin later I made that apprehensive journey to the unknown. And I survived it. That within itself is therapy.

Facts About Sleep

A Healthier Year, A Happier You

It's no big secret to anyone who knows me that I love to eat. I love food! I especially love carbs. I could live off of bread and pasta for the rest of my life and never miss the meat (well, except for the seafood). I enjoyed a good twenty years of being able to eat whatever I wanted and never gained a single pound. In fact, I was clinically underweight for a good portion of my youth. But then came the baby. And another. And another. Three kids later, at the age of 33, I am tired, overweight, and still loving on those carbs. I eat for fun. I eat for distraction from depression and stress. I eat because I'm breastfeeding and I'm really hungry all the time! To top it off, I don't get enough exercise. You would think running after a one year old would be enough aerobics for one gal, but it really isn't. I am miserably out of shape, and I need to do something about it, fast! I have begun to have major issues with high blood pressure, and that is scary. It doesn't help my mental health to eat poorly and skip on exercise, either. It's time to get control of this issue, before it takes several years off my life. I want to be around for my grandchildren and actually be able to pick them up and love on them. As much of a skeptic as I am about New Year's resolutions, this is one time when I will follow in the footsteps of so many others who plan to make 2013 a healthier year. Only, I don't intend on backsliding after a couple of months. I want to make it for the entire year. Who's with me?

The food choices we make affect us not only today, but for all our years to come. And it starts from the very beginning! A girl who drinks sodas and other sugar-laden beverages instead of milk throughout childhood will not only have a a greater chance of cavities, but will likely develop osteoporosis as an adult. A poor diet during pregnancy may produce a low birth weight infant and may cause other complications in the development of a fetus. What a woman eats-as a baby, a child, and an adult-can affect how long and how well she lives.

"You are what you eat." More specifically, you feel what you eat. Food's purpose is to enrich the body with nutrition for energy and optimal function. Good eating habits will make you feel strong and vibrant. Junk food will make you feel like junk.

Eating a large variety of food is best for providing a well balanced array of vitamins and minerals for your body and mind. Supplements may be advised for people who do not receive all the nutrition they need from food, but supplements should not take the place of healthy eating habits. Supplements can sometimes be harmful, so discuss with your doctor what your best options are. It is possible to overdose even on essential vitamins and minerals, and some supplements may cause dangerous interactions or lessen the effectiveness of other medications you are on.

Women have different needs at different times in their lives. Younger women often have a greater need for iron due to the loss of it during menstruation. Sometimes an iron supplement is recommended by doctors. It is also very important to intake enough calcium throughout your life, since after menopause your bones will tell on you by becoming brittle and easy to break. Plenty of calcium when you are younger decreases the chance of osteoporosis. The suggested amount of calcium for each age group is:

• 9-18 years old: 1,300 mg
• 19-50 years old :1,000 mg
• over 50: 1,200-1,500 mg

Ask your doctor if he or she recommends more or less for your particular health needs. A major leach to calcium is, sadly, caffeine and phosphorus, both often found in our favorite sodas. It is best to limit these types of beverages for healthier bones. To increase your absorption of calcium your body requires Vitamin D. That is why it is essential to get enough sunlight and drink low fat milk fortified with this vitamin.I don't know about you, but if I drank in as much sunlight as I drink of Dr. Pepper, I would be substantially covered on the Vitamin D thing.

A significant need for pregnant women is folic acid. This reduces the chance of birth defects of the brain and spinal cord. It is recommended that pregnant women intake 400-800 mcg. of folic acid, and breastfeeding mothers need 500 mcg. Doctors often urge women to begin taking a prenatal vitamin that includes a good source of folic acid before conception and to continue throughout pregnancy and lactation to ensure a healthy baby. Even if you are not pregnant and not planning on conceiving any time soon, folic acid is a necessary component of a healthy diet. Research suggests that it may lower your risk for a stroke, and a deficiency in folic acid has been linked to depression.

There are many changes to our way of eating that will improve our overall health:

• Eat a variety of fruits, vegetables, and whole grain foods. (See food pyramid below for recommended servings.)
• Limit fat, especially saturated fat and cholesterol.
• Maintain a healthy body weight.
• Choose and prepare foods with less sodium.
• Limit alcohol, sodas, and sweets.
• Avoid packaged foods with lots of preservatives and other "what is that?" ingredients. The closer to fresh and homegrown, the better.
• Drink 8-10 glasses of water per day.
• Remember that calcium! 

If you are like me and could stand to lose a few pounds (okay, several), then there are ways you can improve your health and manage a sensible plan for weight loss.

• Avoid fad diets. I will save you the time, trouble and money, and tell you that they don't work. Sure, you may lose a significant amount of weight initially, but only permanent lifestyle changes will keep that weight off, and fad diets do not provide the healthy ongoing nutrition that you need, plus they are nearly impossible not to cheat on! 
• To lose weight and keep it off takes a long-term effort. Aim to lose 1/2 to 1 pound a week. 
• To keep the pounds off, form good basic eating habits, limit portions, and boost your level of physical activity. The key to weight loss is to burn more calories than you take in.
• Notice any social, emotional, or stressful situations that trigger overeating and find better ways to cope. 
• Avoid diet pills! They have unhealthy side effects and do not work for long-term weight loss. 
• Plan meals and snacks for the day so that you are more apt to stick to the menu and not binge on something else. Snacking on fruits and veggies can satisfy hunger in a healthy way, so reach for those instead of junk food. 

The graph below displays what is considered a healthy weight for your height:

While many women struggle with being overweight, it is also dangerous to weigh too little. Some women may have a metabolic disorder or other illness that contributes to their low weight, but many women are becoming malnourished by eating disorders. The two most serious eating disorders mainly affect teenage girls and young women. Anorexia nervosa is starving oneself. Bulimia nervosa is binge eating and then removing the food and fluid by forced vomiting and/or overuse of laxatives and enemas. Death rates are as high as 10 to 20 percent from these very dangerous practices. There tends to be a strong mental and emotional link to eating disorders, so both medical and psychological help is needed for proper treatment . National Eating Disorders Association provides a hotline number for anyone who is struggling with an eating disorder. Click on the link I have provided and it will take you to a page with their number and a search tool to find treatment near you.

Beyond good eating habits, physical activity is a must for a healthy lifestyle. A few of the many benefits of exercise are:

• Helps prevent osteoporosis by strengthening bones (weight-bearing exercise increases this benefit)
• Strengthens muscles, which improves balance and slows age-related muscle loss
• Reduces back pain and strain
• Improves self-image and increases energy
• Helps relieve stress and control anxiety
• Promotes weight loss and lowers body fat
• Reduces the risk of developing diabetes
• Reduces risk of heart disease
• Boosts mood and fights off depression by releasing endorphins, the body's natural feel-good chemicals

 If you're just beginning an exercise routine, take things slowly! Some of those muscles have probably not been worked in a long time, and your heart isn't used to the increase in activity either. Talk to your doctor about your overall health and what exercises you should start out with. Choose an activity you can do 5-10 minutes without getting tired, and gradually increase the length of time as your fitness improves. When I first began exercising again, I used a fitness ball for ten minutes and then fell asleep on the floor! In two weeks' time, however, I had built up to thirty minutes of activity, and my workouts slowly increased to an hour. Unfortunately, I have fallen off the exercise wagon, as is so easy for us busy women to do, but my new goal is to rebuild my exercise routine and not quit this time around! I will provide updates on my progress and would love to hear about yours as well.

Exercise should get your heart rate into a target heart rate zone, which you can determine with a Target Heart Rate Calculator. It is a common misconception that in order for exercise to be effective it has to be grueling and loathsome. Although drastic changes in appearance do require workouts to be challenging and thorough, nothing says it has to be a bore! Choose activities that you can have fun with. This could be brisk walking, swimming, biking, a favorite sport, or aerobic dancing. If your goal is simply to feel better and reduce your risk for health problems, then something as easy as walking 1-3 hours a week will do just fine. If your goal is to shape and tone your body, then your workouts will have to be more intense and geared toward specific areas to achieve the results you want.

If you already have a fitness program in progress, then I commend you. Keep up the great work! If you're like me and have allowed unhealthy eating habits and a sedentary lifestyle to rob you of your vitality, then I urge you to join me in making some very crucial changes. Oftentimes, the best defense against falling into old bad habits is to include a friend in your health journey. Two or more people banded together with the same goals can be a powerful motivator! Ask around among your friends, family members, and colleagues to see if anyone is interested in joining the challenge with you for a healthier year in 2013. There are also countless support groups online that you can find through your search engine. Two successful groups that may be located in your area are TOPS and Weight Watchers.

Our mental health is so greatly impacted by our physical health that it would be ignorant to assume that not taking care of our bodies will ever allow for optimum psychological stability. Changing your lifestyle-and not falling back on old habits-is no easy task! But we can do it. We really can! We deserve to take care of ourselves. Stop making excuses not to.

The Weightless Days

Among the highs and lows of bipolar disorder, there are the weightless days, where you float on the fact that you don't know how you feel. There is no certain feeling, no crushing weight, no pumping high. And yet there is a lifelessness to these days. For all the passion of the ups and downs, these days are clouded with cotton, heavy and empty all at once, and not so unlike depression. You don't know whether you are coming up for air or sinking to the bottom. So you wait. For an emotion. For the wind of change. For hope or for doubt. You wait for the uncertainty to pass so you know what the next door opens to; whether there is a lion on the other side or a lamb.

Keep On Keeping On

It has been a long day. I got a lot of cleaning done, but it only made me see more things that need to be cleaned, and then the anxiety took over. That, of course, was my OCD kicking into overdrive, and I have such a tendency to get so easily overwhelmed. Oh well. A lot got done today, and I have to choose to view that as an accomplishment, rather than a platform to negativity and perceived failure. We all have to check our perspective about twenty times a day to make sure it's in the right gear for pleasant success and not harmful self-criticism. It's okay to not "get it all right" in one day, or a month, or even a lifetime. Just keep trying and doing the best you can. My goal today was a trivial one; housekeeping is important, but not the most essential task on the planet. Perhaps you are struggling through a similar goal or something much bigger, and I want you to know that YOU CAN DO IT! I can't promise you it will be easy, or fun, or even the best idea ever, but if you have a will for it, then by all means, give it your all. Many blessings and self-appreciation to you!

The Different Forms of Depression

Everyone occasionally feels blue or sad, but these feelings are usually fleeting and pass within a couple of days. When a person has a depressive disorder, it interferes with daily life, normal functioning, and causes pain for both the person with the disorder and those who care about him or her. Depression is a common but serious illness, and most who experience it need treatment to get better. Depression is not a choice or a weakness in character. It goes beyond circumstances or rational emotions.

Many people with a depressive illness never seek treatment. But the vast majority, even those with the most severe depression, can get better with treatment. Intensive research into the illness has resulted in the development of medications, psychotherapies, and other methods to treat people with this disabling disorder.

WHAT ARE THE DIFFERENT FORMS OF DEPRESSION?

There are several forms of depressive disorders. The most common are major depressive disorder and dysthymic disorder.

Major Depressive Disorder, also called major depression, is characterized by a combination of symptoms that interfere with a person's ability to work, sleep, study, eat, and enjoy once pleasurable activities. Major depression is disabling and prevents a person from functioning normally. An episode of major depression may occur only once in a person's lifetime, but more often, it recurs throughout a person's life.

Dysthymic Disorder, also called dysthymia, is characterized by long-term (two years or longer) but less severe symptoms that may not disable a person but can prevent one from functioning normally or feeling well. People with dysthymia may also experience one or more episodes of major depression during their lifetimes.

Bipolar Disorder, also called manic-depressive illness, is not as common as major depression or dysthymia. Bipolar disorder is characterized by cycling mood changes-from extreme highs to extreme lows. 

Some forms of depressive disorder exhibit slightly different characteristics than those described above, or they may develop under unique circumstances. However, not all scientists agree on how to characterize and define these forms of depression. They include:

Psychotic Depression, which occurs when a severe depressive illness is accompanied by some form of psychosis, such as a break with reality, hallucinations, and delusions. 

Postpartum Depression, which is diagnosed if a new mother develops a major depressive episode within one month after delivery. It is estimated that 10 to 15 percent of women experience postpartum depression after giving birth.

Seasonal Affective Disorder (SAD), which is characterized by the onset of a depressive illness during the winter months, when there is less natural sunlight. The depression generally lifts during spring and summer. SAD may be effectively treated with light therapy, but nearly half of those with SAD do not respond to light therapy alone. Antidepressants and psychotherapy can reduce SAD symptoms, either alone or in combination with light therapy.

WHAT ARE THE SYMPTOMS OF DEPRESSION?

People with depressive illnesses do not all experience the same symptoms. The severity, frequency and duration of symptoms will vary depending on the individual and his or her particular illness. Here are a few of the most common symptoms associated with depression:

• Persistent sad, anxious, or "empty" feelings
• Feelings of hopelessness and/or pessimism
• Feelings of guilt, worthlessness and/or helplessness
• Irritability, restlessness
• Loss of interest in activities or hobbies once pleasurable, including sex
• Fatigue and decreased energy
• Difficulty concentrating, remembering details and making decisions
• Insomnia, early-morning wakefulness, or excessive sleeping
• Overeating, or appetite loss
• Thoughts and/or attempts of suicide
• Persistent aches or pains, headaches, cramps, or digestive problems that do not ease even with treatment

WHAT ILLNESSES OFTEN CO-EXIST WITH DEPRESSION?

Depression often co-exists with other illnesses. Such illnesses may precede the depression, cause it, and/or be a consequence of it. It is likely that the mechanics behind the intersection of depression and other illnesses differ for every person and situation. Regardless, these other co-occurring illnesses need to be diagnosed and treated.

Anxiety Disorders, such as Post-Traumatic Stress Disorder (PTSD), Obsessive-Compulsive Disorder, Panic Disorder, Social Phobia, and Generalized Anxiety Disorder, often accompany depression. People experiencing PTSD are especially prone to having co-occurring depression. PTSD is a debilitating condition that can result after a person experiences a terrifying event or ordeal, such as a violent assault, natural disaster, an accident, terrorism or military combat.

People with PTSD often re-live the traumatic event in flashbacks, memories or nightmares. Other symptoms include irritability, angry outbursts, intense guilt, and avoidance of thinking or talking about the traumatic ordeal. In a National Institute of Mental Health (NIMH) funded study, researchers found that more than 40 percent of people with PTSD also had depression at one-month and four-month intervals after the traumatic event.

Alcohol and other Substance Abuse or Dependence may also co-occur with depression. In fact, research has indicated that the co-existence of mood disorders and substance abuse is pervasive among the U.S. population.

Depression also co-exists with other serious medical illnesses such as Heart Disease, Stroke, Cancer, HIV/AIDS, Diabetes, and Parkinson's Disease. Studies have shown that people who have depression in addition to another serious medical illness tend to have more severe symptoms of both depression and the medical illness, more difficulty adapting to their medical condition, and more medical costs than those who do not have co-occurring depression. Research has yielded increasing evidence that treating the depression can also help improve the outcome of treating the co-occurring illness.

If you are suffering with the symptoms of depression, it is imperative that you seek treatment. Talk to your doctor and ask about what treatment options are right for you. There is no single known cause of depression. Rather, it likely results from a combination of genetic, biochemical, environmental, and psychological factors.

Research indicates that depressive illnesses are disorders of the brain. Brain-imaging technologies, such as magnetic resonance imaging (MRI), have shown that the brains of people who have depression look different than those of people without depression. The parts of the brain responsible for regulating mood, thinking, sleep, appetite, and behavior appear to function abnormally. In addition, important neurotransmitters-chemicals that brain cells use to communicate-appear to be out of balance. But unfortunately, these images do not revel why the depression has occurred. 

Some types of depression tend to run in families, suggesting a genetic link. However, depression can occur in individuals without family history of depression as well. Genetics research indicates that risk for depression results from the influence of multiple genes acting together with environmental or other factors.

In addition, trauma, loss of a loved one, a difficult relationship, or any stressful situation may trigger a depressive episode. Subsequent depressive episodes may occur with or without an obvious trigger.

Recovering From a Suicide Attempt

Today may feel like the hardest day of your life. You have seriously thought about or perhaps attempted to end your life. You may be exhausted. A common experience after surviving a suicide attempt is extreme fatigue. You may be angry. You may feel embarrassed or ashamed. The attempt itself, the reactions of other people, transportation to and treatment in an emergency room or other health care facility-all these can be overwhelming to you right now. But, recovery is likely, and all the feelings you are experiencing right now will eventually subside.

After you have been treated for a suicide attempt in the emergency room and the doctors believe you are medically stabilized, you will either be discharged or hospitalized. If you are discharged after your suicide attempt, the staff in the emergency room should provide you with a plan for followup care.

The exact steps for followup care will vary with each person, but your plan should include:

• A scheduled appointment in the near future with a mental health provider (such as a psychiatrist and/or licensed therapist). Make sure that the name and contact information for the provider is given to you before you leave the hospital and that your appointment is scheduled as soon as possilbe. 
• Information on any treatments that you received in the emergency room, such as medications, and what, if anything, you will need to do about those treatments after you leave.
• Referrals to local and national resources and crisis hotlines for information and support.

Once you have a plan for followup care that you understand and are comfortable with, you and, if appropriate, a family member should work closely with a therapist to ensure that your safety plan is meaningful and effective.  

If the emergency room staff feel that you need more immediate care or longer-term care than the emergency room can provide, you will be referred to inpatient hospitalization. If hospitalization is necessary, you and your family can begin to work with the hospital to develop a plan for the next steps of your care. Hospital staff (usually a social worker) should help you with this process.

People generally have the right to consent to or refuse treatment. However, if the emergency physician believes you are still a danger to yourself or someone else, he or she must consider having you hospitalized involuntarily for a limited period of time (a 72 hour suicide watch is common). Laws about commitment vary by state. If you have questions about your rights as a patient, you should contact your local Protection and Advocacy organization. These are legal centers that are funded to protect the rights of persons with mental health needs. You can either go to their national website at www.ndrn.org or call the office at 202-408-9514 to inquire about the nearest center in your state.

Next Steps: Moving Ahead and Coping With Future Thoughts of Suicide

Recovery from the negative thoughts and feelings that made you want to end your life is possible. You may get to a place where you never have thoughts of suicide again and you can lead a happy, satisfying life. You also may learn to live with these thoughts in a way that keeps you safe.

After you leave the hospital there are several things you can do to help in your recovery. It may feel difficult and overwhelming right now, but over the next few days, following these tips can help turn things around.

• Create a safety plan. You and your doctor or therapist should work together to develop a safety plan to help reduce the risk of a future suicide attempt. When creating such a plan, be honest with yourself and your doctor to ensure that the plan meets your needs and that you feel comfortable with it. Although everyone's safety plan is different, some common things that may be included in yours are:signs that may indicate a return of suicidal thoughts and what to do about them; when to seek additional treatment; and contact information for your doctor, therapist, crisis hotline number, and a trusted friend or family member. Keep a written copy of your safety plan nearby so you can refer to it as needed. 
• Build a support system. A support system is a key part of recovering from a suicide attempt and preventing future attempts. It is important that you have at least one person in your life who can be your "ally". This must be a person you trust and can be honest with-especially if you start to have thoughts of ending your life again. Family members or a close friend can serve this important purpose. A member of the clergy, mentor, or colleague also could be helpful to you at this time. Having more than one ally can be a tremendous asset. Even when you are feeling alone, always remember that there are people in your life who care about you a great deal and are willing to help.
• Learn to live again. When you are recovering, the world can look like a pretty bleak place. It may take a little while before your life starts to feel worthwhile again. One thing you can do to help is to get back into a routine. Eat three healthy meals a day, exercise 30 minutes a day, and go to bed and wake at the same times each day. Try to join in your usual activities a little at a time, and add in more when you feel comfortable. 
• Listen closely and carefully consider the support and advice you receive from others.  It is important to be honest with yourself, your doctor, and others about your feelings so that you receive the best possible care. Sometimes being under pressure and having thoughts of suicide can make it difficult for you to make the best decisions, and at those times, other people may have a more realistic view of your situation than you do. Your ally can help you work through these confusing and isolating thoughts and feelings and help keep you safe.
• Keep in mind that everyone's recovery is different. Some people have persistent thoughts of suicide. For others, such thoughts may accompany only certain moods and circumstances. Following the steps mentioned in this article can help you prevent negative and destructive thoughts taking control of you in the future. 
• Remove the means for hurting yourself from your environment.  Work with your ally to remove methods of self-harm. It is best not to have these items around while you are recovering. If you use medication, keep only a few days' supply on hand and ask someone else to hold onto the rest. For other means of self-harm, such as weapons, give them to someone else for safe-keeping until you are no longer a potential danger to yourself.
• Identify what triggers suicidal thoughts or behavior for you. It may be the anniversary of a painful event, or seeing a knife in the kitchen. Plan to minimize the effect of these triggers on your life. Sometimes you can avoid them or train yourself to respond differently, or you can involve your allies ahead of time to help you face a difficult situation. Remember that life events do not cause a suicide, but they can certainly increase the risk of an attempt. 
• Learn all you can about mental illness. Whether you have been diagnosed with a mental disorder or not, it is quite common for suicidal tendencies to be linked to a chemical imbalance in the brain. Ask your doctor about screening you for illnesses such as bipolar disorder, schizophrenia, and major depression. The more you know the better you are at finding a successful treatment that is right for your particular needs.
• Keep a list of crisis hotlines in an easy to reach spot. Hotlines provide you with a trained person to talk to when you are having suicidal thoughts or other unbearable feelings. This person will listen to you and help you choose another path that does not involve harm to yourself or others. If you have a safety plan written out, make sure to have it on hand while you talk to the hotline worker, as he or she can help you through the actions you need to take to keep yourself safe. If you do not have a safety plan in place, the crisis staff will help you create one. This link will take you to a list of crisis hotline numbers that may be useful to you. The emergency room, your doctor or a mental health facility may have a list of local numbers to contact. Make sure to ask for a list of crisis hotline numbers, and keep them in an easily accessible place. 
• Join a support group. There are many types of support groups, and you may wish to participate in one in your area. Learning from others and sharing your experience can make a big difference in the way you think about your life. It also may help save the life of someone else. Ask your doctor or therapist about what groups are available in your area. It may feel a little scary joining a group of people, but I personally have had great success in recovery thanks to group therapy (and I happen to be an extremely shy person). Sometimes stepping outside of your comfort zone can be a very rewarding experience, and you are bound to meet people and hear stories that will change your life-and perspective-for the better.
• Get involved in life. Finding a hobby or enjoying a favorite pastime-such as listening to music, watching your favorite movie, writing in a journal, or painting-is a great way to help you cope when life is overwhelming. Hobbies or activities that involve interacting with others are an especially good idea. Whatever your interests may be, make sure you have access to the things you enjoy. That way, if your negative thoughts come back, you can turn to something that brings you comfort and enjoyment. 

Remember, there are reasons to live and things will get better.  You can survive, and even thrive, despite the way you feel at times. You hold the key to your recovery, and you are stronger than you think.