Many young adults can't wait to leave their parents' homes. But once they move out, they find that their independence involves many new responsibilities and stresses, as well as freedoms. And for some young people, this period of transition has a cruel twist as it may coincide with the emergence of a mental illness.
The first episodes of schizophrenia, bipolar disorder and major depressive disorder tend to appear in the late teens and early 20s. Researchers suspect that people are predisposed to develop these conditions from birth or childhood, but don't exhibit symptoms until they hit a particular phase of development and/or certain stressors.
Below, Dr. Karen Hochman, an assistant professor in the department of psychiatry and behavioral sciences at Emory University School of Medicine in Atlanta, Georgia, explains how young adults, and their parents, can recognize these mental illnesses early on, so that treatment can get underway.
What mental illnesses tend to develop in the late teens or 20s?
Schizophrenia, major depressive disorder and bipolar disorder can develop in early adulthood. The onset of schizophrenia is typically in the late teens, early 20s. Men will usually develop schizophrenia between the ages of 18 and 25. Women tend to develop it about five years later. Bipolar disorder usually begins in early adulthood, although there are some children and adolescents who develop it. And there is an increase in the incidence of major depressive disorder after the age when puberty is reached.
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Why do these illnesses tend to emerge at this time?
It's not well understood. "We think that certain people have a higher biological risk of developing these disorders," says Hochman. Risk factors may include a family history, prenatal illnesses, obstetrical incidents or head injuries in early childhood. It is not yet known how genes, the environment and brain development interact to trigger the disorder in young people. However, people tend not to develop symptoms until they reach the teen years.
"We think hormones might play a role," says Hochman. "For example, there are studies that are looking at whether or not there is an association between increasing levels of estrogen in girls, and increasing levels of testosterone in boys, with symptom progression in adolescents who are already experiencing adjustment problems".
Can stress trigger the first episode?
In many cases, there are stressors that precipitate the onset of mental illness in people who are predisposed to it. However, stressors are not thought to be the actual cause of the illnesses. For example, sometimes people will report to their doctor that the onset of their first episode followed a stressor, such as the death of a loved one or the loss of a job, or even positive events, like getting married or getting a promotion.
There are many stresses associated with young adulthood that might serve as a trigger, such as going to college, living away from home and taking responsibility for oneself.
Can drug and alcohol abuse trigger an episode?
Absolutely. Hallucinogenic drugs, such as marijuana and cocaine, frequently trigger or exacerbate psychotic symptoms associated with schizophrenia and bipolar disorder.
Some people with psychiatric illnesses try to cope with their symptoms by using substances like alcohol, marijuana and cocaine. However, they tend to have more problems. They are less likely to take medication properly and their symptoms are harder to control. Also they might need to be hospitalized more often and are at greater risk of becoming violent. The person might feel better when they are high or intoxicated, but it tends to cause many more problems in the long run.
How is schizophrenia recognized in young adults?
"What we look for is people losing their ability to function," Hochman says. If, for example, an adolescent was previously doing very well in school and socially, and then he or she regresses, that is concerning. So doctors look for a marked change in social or family functioning or their ability to get good grades or do well at work.
Early symptoms may include experiencing psychotic symptoms such as hallucinations, because certain pathways in their brains are being activated when they shouldn't be. Another worrisome quality is suspiciousness or paranoia. Also, young people might have difficulty expressing themselves verbally, when they didn't previously have trouble organizing their thoughts. Other early problems may include sleep difficulties and anxiety or depressed mood that is not severe enough to meet criteria for a major depressive episode.
There are a couple of ways that schizophrenia can develop. Schizophrenia is a lot easier to recognize when there is a very sudden onset. When, one day, they're doing fine, the next day, they're hallucinating and paranoid, then you know there's something wrong. But schizophrenia can also develop insidiously and slowly.
What are the early signs of bipolar disorder?
Bipolar disorder includes manic episodes and major depressive episodes. Mania is a mood state that is characterized by a dramatic change for at least a one-week period where they tend to be either euphoric or irritable or angry beyond what the situation would normally cause. Other symptoms include a decreased need for sleep, and an increased energy level. They also have an increase in risky behavior, such as excessive shopping or gambling, or being sexually promiscuous.
A depressive episode involves a change in one's mood to sadness or irritability that lasts for at least two weeks and includes changes in sleep and appetite, and low energy.
There can be psychotic symptoms along with a manic or depressive episode. If someone, for example, were to hear voices during the manic episodes, the voices would tell them that they are wonderful and fabulous. By contrast, with a depression, the psychotic features are very negative about the self, others and the world.
What are signs of major depression?
People with major depression will often lose interest in activities they once took pleasure in. Other symptoms are feelings of worthlessness or excessive and inappropriate guilt, difficulty concentrating, indecisiveness and recurrent thoughts of death or suicide. Major depression lasts for at least two weeks.
Are young people likely to have just a single episode?
About 50 percent of people with major depression will have just a single episode. But the more episodes you've had, the more likely this will be a recurring pattern.
With bipolar disorder, there can be a good prognosis with treatment. However, people are more likely to have many recurring episodes if they don't follow to their medication regimen.
Schizophrenia tends to be an illness that, by its definition, is accompanied by at least six months of symptoms and is also accompanied by a loss of functioning. If people are treated, however, they can go on to live very productive lives.
Are people usually hospitalized during their first episodes?
Usually, with a first episode of psychosis associated with schizophrenia or bipolar disorder, people need to be hospitalized for diagnostic and safety reasons.
In some cases, people with bipolar disorder or major depression need to be hospitalized because they might be having suicidal thoughts or are simply not able to function. People are often hospitalized for mania in order to receive treatment and, in some cases, to protect them from danger.
How can parents stay on top of their young-adult children's mental health?
It's important for parents to keep in touch with kids when they go away to college. Keep the dialogue going and let them know that you understand that it's a difficult time.
Parents should also be aware if there is a family history of depression or bipolar disorder or schizophrenia. "I think it's important for parents to talk with their kids and let them know when there's a family history," says Hochman. Parents should be knowledgeable about the fact that mental illness often begins in early adulthood and that the best thing to do is to recognize it. The earlier you recognize a disorder and get treatment, the less likely it is to get severe enough to require a hospitalization or withdrawal from college courses.
What should people do if they suspect a young adult might have a mental illness?
A parent or roommate who suspects that a young person may have signs of a mental illness should tell the person involved that they are concerned about them and explain why in a non-judgmental and empathic manner. It is important to convey concern and to seek the person's feedback. In addition, young people need to know that assistance is available and can be very effective. In non-urgent situations, the young person should be encouraged to seek an evaluation with their doctor. If the student has health insurance, they can contact their insurance company regarding which behavioral health providers are covered and how to get an appointment. If the student already sees a mental health clinician, they should be encouraged to speak about their recent concerns and then follow the recommendations of their provider.
However, when you suspect there is risk to the young adult or others, an urgent evaluation should be sought at the nearest emergency department.
Why is it hard for young adults to recognize these changes in themselves?
Psychotic disorders, which are disorders that affect your ability to recognize reality, are a hard thing to recognize in yourself. "It's something that none of us are prepared for," says Hochman. "And when it happens, it's hard to believe that you have a disorder, because the experiences, feelings or hallucinations that you have are very real experiences." It's just that they are not based on what is happening in the environment.
What is your advice to young adults concerned about their mental health?
It's important for young people to recognize what mental illness is and that it's treatable. It is also important that they do not delay treatment because of stigma or the belief that that having a mental illness means that there's something inherently bad or wrong about you.
If you think that you are becoming depressed, you are experiencing anxiety, you feel like you are hearing voices or you feel like your ability to function isn't what it used to be, seek help, support and encouragement.
If an adolescent or young adult has already been diagnosed with a mental illness, it's important for them to make sure that they are in regular contact with a mental health provider. Once one has a diagnosis, one should become an expert in the condition and the available treatments. Avoid substance abuse and ask lots of questions.