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Bipolar disorder, also known as manic-depressive illness,
is a brain disorder that causes unusual shifts in a person's
mood, energy, and ability to function. Different from the
normal ups and downs that everyone goes through, the symptoms
of bipolar disorder are severe. They can result in damaged
relationships, poor job or school performance, and even
suicide. But there is good news: bipolar disorder can be
treated, and people with this illness can lead full and
More than 2 million American adults,
or about 1 percent of the population age 18 and older in any
have bipolar disorder. Bipolar disorder typically develops in
late adolescence or early adulthood. However, some people have
their first symptoms during childhood, and some develop them
late in life. It is often not recognized as an illness, and
people may suffer for years before it is properly diagnosed
and treated. Like diabetes or heart disease, bipolar disorder
is a long-term illness that must be carefully managed
throughout a person's life.
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Bipolar disorder causes dramatic mood swings—from overly
"high" and/or irritable to sad and hopeless, and then back
again, often with periods of normal mood in between. Severe
changes in energy and behavior go along with these changes in
mood. The periods of highs and lows are called episodes
of mania and depression.
- Increased energy, activity, and restlessness
- Excessively "high," overly good, euphoric mood
- Extreme irritability
- Racing thoughts and talking very fast, jumping from one
idea to another
- Distractibility, can't concentrate well
- Little sleep needed
- Unrealistic beliefs in one's abilities and powers
- Poor judgment
- Spending sprees
- A lasting period of behavior that is different from
- Increased sexual drive
- Abuse of drugs, particularly cocaine, alcohol, and
- Provocative, intrusive, or aggressive behavior
- Denial that anything is wrong
A manic episode is diagnosed if elevated mood occurs with
three or more of the other symptoms most of the day, nearly
every day, for 1 week or longer. If the mood is irritable,
four additional symptoms must be present.
- Lasting sad, anxious, or empty mood
- Feelings of hopelessness or pessimism
- Feelings of guilt, worthlessness, or helplessness
- Loss of interest or pleasure in activities once enjoyed,
- Decreased energy, a feeling of fatigue or of being
- Difficulty concentrating, remembering, making decisions
- Restlessness or irritability
- Sleeping too much, or can't sleep
- Change in appetite and/or unintended weight loss or gain
- Chronic pain or other persistent bodily symptoms that
are not caused by physical illness or injury
- Thoughts of death or suicide, or suicide attempts
A depressive episode is diagnosed if five or more of these
symptoms last most of the day, nearly every day, for a period
of 2 weeks or longer.
A mild to moderate level of mania is called
hypomania. Hypomania may feel good to the
person who experiences it and may even be associated with good
functioning and enhanced productivity. Thus even when family
and friends learn to recognize the mood swings as possible
bipolar disorder, the person may deny that anything is wrong.
Without proper treatment, however, hypomania can become severe
mania in some people or can switch into depression.
Sometimes, severe episodes of mania or depression include
symptoms of psychosis (or psychotic
symptoms). Common psychotic symptoms are hallucinations
(hearing, seeing, or otherwise sensing the presence of things
not actually there) and delusions (false, strongly held
beliefs not influenced by logical reasoning or explained by a
person's usual cultural concepts). Psychotic symptoms in
bipolar disorder tend to reflect the extreme mood state at the
time. For example, delusions of grandiosity, such as believing
one is the President or has special powers or wealth, may
occur during mania; delusions of guilt or worthlessness, such
as believing that one is ruined and penniless or has committed
some terrible crime, may appear during depression. People with
bipolar disorder who have these symptoms are sometimes
incorrectly diagnosed as having schizophrenia, another severe
It may be helpful to think of the various mood states in
bipolar disorder as a spectrum or continuous range. At one end
is severe depression, above which is moderate depression and
then mild low mood, which many people call "the blues" when it
is short-lived but is termed "dysthymia" when it is chronic.
Then there is normal or balanced mood, above which comes
hypomania (mild to moderate mania), and then severe
In some people, however, symptoms of mania and depression
may occur together in what is called a mixed
bipolar state. Symptoms of a mixed state often include
agitation, trouble sleeping, significant change in appetite,
psychosis, and suicidal thinking. A person may have a very
sad, hopeless mood while at the same time feeling extremely
Bipolar disorder may appear to be a problem other than
mental illness—for instance, alcohol or drug abuse, poor
school or work performance, or strained interpersonal
relationships. Such problems in fact may be signs of an
underlying mood disorder.
Like other mental illnesses, bipolar disorder cannot yet be
identified physiologically—for example, through a blood test
or a brain scan. Therefore, a diagnosis of bipolar disorder is
made on the basis of symptoms, course of illness, and, when
available, family history. The diagnostic criteria for bipolar
disorder are described in the Diagnostic and Statistical
Manual for Mental Disorders, fourth edition
Depression: I doubt completely my
ability to do anything well. It seems as though my mind has
slowed down and burned out to the point of being virtually
useless…. [I am] haunt[ed]… with the total, the desperate
hopelessness of it all…. Others say, "It's only temporary, it
will pass, you will get over it," but of course they haven't
any idea of how I feel, although they are certain they do. If
I can't feel, move, think or care, then what on earth is the
Hypomania: At first when I'm high,
it's tremendous… ideas are fast… like shooting stars you
follow until brighter ones appear…. All shyness disappears,
the right words and gestures are suddenly there… uninteresting
people, things become intensely interesting. Sensuality is
pervasive, the desire to seduce and be seduced is
irresistible. Your marrow is infused with unbelievable
feelings of ease, power, well-being, omnipotence, euphoria…
you can do anything… but, somewhere this changes.
Mania: The fast ideas become too fast
and there are far too many… overwhelming confusion replaces
clarity… you stop keeping up with it—memory goes. Infectious
humor ceases to amuse. Your friends become frightened….
everything is now against the grain… you are irritable, angry,
frightened, uncontrollable, and trapped.
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Some people with bipolar disorder become suicidal.
Anyone who is thinking about committing suicide needs
immediate attention, preferably from a mental health
professional or a physician. Anyone who talks about suicide
should be taken seriously. Risk for suicide appears
to be higher earlier in the course of the illness. Therefore,
recognizing bipolar disorder early and learning how best to
manage it may decrease the risk of death by suicide.
Signs and symptoms that may accompany suicidal feelings
- talking about feeling suicidal or wanting to die
- feeling hopeless, that nothing will ever change or get
- feeling helpless, that nothing one does makes any
- feeling like a burden to family and friends
- abusing alcohol or drugs
- putting affairs in order (e.g., organizing finances or
giving away possessions to prepare for one's death)
- writing a suicide note
- putting oneself in harm's way, or in situations where
there is a danger of being killed
If you are feeling suicidal or know someone who is:
- call a doctor, emergency room, or 911 right away to get
- make sure you, or the suicidal person, are not left
- make sure that access is prevented to large amounts of
medication, weapons, or other items that could be used for
While some suicide attempts are carefully planned over
time, others are impulsive acts that have not been well
thought out; thus, the final point in the box above may be a
valuable long-term strategy for people with bipolar
disorder. Either way, it is important to understand that
suicidal feelings and actions are symptoms of an illness that
can be treated. With proper treatment, suicidal feelings can
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Episodes of mania and depression typically recur across the
life span. Between episodes, most people with bipolar disorder
are free of symptoms, but as many as one-third of people have
some residual symptoms. A small percentage of people
experience chronic unremitting symptoms despite
The classic form of the illness, which involves recurrent
episodes of mania and depression, is called bipolar I
disorder. Some people, however, never develop severe
mania but instead experience milder episodes of hypomania that
alternate with depression; this form of the illness is called
bipolar II disorder. When four or more
episodes of illness occur within a 12-month period, a person
is said to have rapid-cycling bipolar
disorder. Some people experience multiple episodes within a
single week, or even within a single day. Rapid cycling tends
to develop later in the course of illness and is more common
among women than among men.
People with bipolar disorder can lead healthy and
productive lives when the illness is effectively treated .
Without treatment, however, the natural course of bipolar
disorder tends to worsen. Over
time a person may suffer more frequent (more rapid-cycling)
and more severe manic and depressive episodes than those
experienced when the illness first appeared.
But in most cases, proper treatment can help reduce the
frequency and severity of episodes and can help people with
bipolar disorder maintain good quality of life.
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Both children and adolescents can develop bipolar disorder.
It is more likely to affect the children of parents who have
Unlike many adults with bipolar disorder, whose episodes tend to be more
clearly defined, children and young adolescents with the illness often experience
very fast mood swings between depression and mania many times within a day.
Children with mania are more likely to be irritable and prone to destructive
tantrums than to be overly happy and elated. Mixed symptoms also are common
in youths with bipolar disorder. Older adolescents who develop the illness
may have more classic, adult-type episodes and symptoms.
Bipolar disorder in children and adolescents can be hard to
tell apart from other problems that may occur in these age
groups. For example, while irritability and aggressiveness can
indicate bipolar disorder, they also can be symptoms of
attention deficit hyperactivity disorder, conduct disorder,
oppositional defiant disorder, or other types of mental
disorders more common among adults such as major depression or
schizophrenia. Drug abuse also may lead to such symptoms.
For any illness, however, effective treatment depends on
appropriate diagnosis. Children or adolescents with emotional
and behavioral symptoms should be carefully evaluated by a
mental health professional. Any child or adolescent
who has suicidal feelings, talks about suicide, or attempts
suicide should be taken seriously and should receive immediate
help from a mental health specialist.
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Scientists are learning about the possible causes of
bipolar disorder through several kinds of studies. Most
scientists now agree that there is no single cause for bipolar
disorder—rather, many factors act together to produce the
Because bipolar disorder tends to run in families,
researchers have been searching for specific genes—the
microscopic "building blocks" of DNA inside all cells that
influence how the body and mind work and grow—passed down
through generations that may increase a person's chance of
developing the illness. But genes are not the whole story.
Studies of identical twins, who share all the same genes,
indicate that both genes and other factors play a role in
bipolar disorder. If bipolar disorder were caused entirely by
genes, then the identical twin of someone with the illness
would always develop the illness, and research has
shown that this is not the case. But if one twin has bipolar
disorder, the other twin is more likely to develop the illness
than is another sibling.
In addition, findings from gene research suggest that
bipolar disorder, like other mental illnesses, does not occur
because of a single gene.
It appears likely that many different genes act together, and
in combination with other factors of the person or the
person's environment, to cause bipolar disorder. Finding these
genes, each of which contributes only a small amount toward
the vulnerability to bipolar disorder, has been extremely
difficult. But scientists expect that the advanced research
tools now being used will lead to these discoveries and to new
and better treatments for bipolar disorder.
Brain-imaging studies are helping scientists learn what
goes wrong in the brain to produce bipolar disorder and
New brain-imaging techniques allow researchers to take
pictures of the living brain at work, to examine its structure
and activity, without the need for surgery or other invasive
procedures. These techniques include magnetic resonance
imaging (MRI), positron emission tomography (PET), and
functional magnetic resonance imaging (fMRI). There is
evidence from imaging studies that the brains of people with
bipolar disorder may differ from the brains of healthy
individuals. As the differences are more clearly identified
and defined through research, scientists will gain a better
understanding of the underlying causes of the illness, and
eventually may be able to predict which types of treatment
will work most effectively.
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Most people with bipolar disorder—even those with the most
severe forms—can achieve substantial stabilization of their
mood swings and related symptoms with proper treatment.
Because bipolar disorder is a recurrent illness, long-term
preventive treatment is strongly recommended and almost always
indicated. A strategy that combines medication and
psychosocial treatment is optimal for managing the disorder
In most cases, bipolar disorder is much better controlled
if treatment is continuous than if it is on and off. But even
when there are no breaks in treatment, mood changes can occur
and should be reported immediately to your doctor. The doctor
may be able to prevent a full-blown episode by making
adjustments to the treatment plan. Working closely with the
doctor and communicating openly about treatment concerns and
options can make a difference in treatment effectiveness.
In addition, keeping a chart of daily mood symptoms,
treatments, sleep patterns, and life events may help people
with bipolar disorder and their families to better understand
the illness. This chart also can help the doctor track and
treat the illness most effectively.
Medications for bipolar disorder are prescribed by
psychiatrists—medical doctors (M.D.) with expertise in the
diagnosis and treatment of mental disorders. While primary
care physicians who do not specialize in psychiatry also may
prescribe these medications, it is recommended that people
with bipolar disorder see a psychiatrist for treatment.
Medications known as "mood stabilizers" usually are
prescribed to help control bipolar disorder.
Several different types of mood stabilizers are available. In
general, people with bipolar disorder continue treatment with
mood stabilizers for extended periods of time (years). Other
medications are added when necessary, typically for shorter
periods, to treat episodes of mania or depression that break
through despite the mood stabilizer.
- Lithium, the first mood-stabilizing medication approved by the U.S. Food
and Drug Administration (FDA) for treatment of mania, is often very effective
in controlling mania and preventing the recurrence of both manic and depressive
- Anticonvulsant medications, such as valproate (Depakote®) or
carbamazepine (Tegretol®), also can have mood-stabilizing effects
and may be especially useful for difficult-to-treat bipolar episodes. Valproate
was FDA-approved in 1995 for treatment of mania.
- Newer anticonvulsant medications, including lamotrigine (Lamictal®),
gabapentin (Neurontin®), and topiramate (Topamax®),
are being studied to determine how well they work in stabilizing mood cycles.
- Anticonvulsant medications may be combined with lithium, or with each
other, for maximum effect.
- Children and adolescents with bipolar disorder generally are treated with
lithium, but valproate and carbamazepine also are used. Researchers are
evaluating the safety and efficacy of these and other psychotropic medications
in children and adolescents. There is some evidence that valproate may
lead to adverse hormone changes in teenage girls and polycystic ovary syndrome
in women who began taking the medication before age 20. Therefore,
young female patients taking valproate should be monitored carefully by
- Women with bipolar disorder who wish to conceive, or who become pregnant,
face special challenges due to the possible harmful effects of existing
mood stabilizing medications on the developing fetus and the nursing infant.
Therefore, the benefits and risks of all available treatment options should
be discussed with a clinician skilled in this area. New treatments with
reduced risks during pregnancy and lactation are under study.
Treatment of Bipolar Depression
Research has shown that people with bipolar disorder are at
risk of switching into mania or hypomania, or of developing
rapid cycling, during treatment with antidepressant
Therefore, "mood-stabilizing" medications generally are
required, alone or in combination with antidepressants, to
protect people with bipolar disorder from this switch.
Lithium and valproate are the most commonly used
mood-stabilizing drugs today. However, research studies
continue to evaluate the potential mood-stabilizing effects of
- Atypical antipsychotic medications, including clozapine (Clozaril®),
olanzapine (Zyprexa®), risperidone (Risperdal®), quetiapine
(Seroquel®), and ziprasidone (Geodon®), are being
studied as possible treatments for bipolar disorder. Evidence suggests clozapine
may be helpful as a mood stabilizer for people who do not respond to lithium
or anticonvulsants. Other research has supported the efficacy
of olanzapine for acute mania, an indication that has recently received
FDA approval. Olanzapine may also help relieve psychotic depression.
- If insomnia is a problem, a high-potency benzodiazepine medication such
as clonazepam (Klonopin®) or lorazepam (Ativan®) may
be helpful to promote better sleep. However, since these medications may
be habit-forming, they are best prescribed on a short-term basis. Other
types of sedative medications, such as zolpidem (Ambien®), are
sometimes used instead.
- Changes to the treatment plan may be needed at various times during the
course of bipolar disorder to manage the illness most effectively. A psychiatrist
should guide any changes in type or dose of medication.
- Be sure to tell the psychiatrist about all other prescription drugs, over-the-counter
medications, or natural supplements you may be taking. This is important
because certain medications and supplements taken together may cause adverse
- To reduce the chance of relapse or of developing a new episode, it is
important to stick to the treatment plan. Talk to your doctor if you have
any concerns about the medications.
People with bipolar disorder often have abnormal thyroid
Because too much or too little thyroid hormone alone can lead
to mood and energy changes, it is important that thyroid
levels are carefully monitored by a physician.
People with rapid cycling tend to have co-occurring thyroid
problems and may need to take thyroid pills in addition to
their medications for bipolar disorder. Also, lithium
treatment may cause low thyroid levels in some people,
resulting in the need for thyroid supplementation.
Medication Side Effects
Before starting a new medication for bipolar disorder,
always talk with your psychiatrist and/or pharmacist about
possible side effects. Depending on the medication, side
effects may include weight gain, nausea, tremor, reduced
sexual drive or performance, anxiety, hair loss, movement
problems, or dry mouth. Be sure to tell the doctor about all
side effects you notice during treatment. He or she may be
able to change the dose or offer a different medication to
relieve them. Your medication should not be changed or stopped
without the psychiatrist's guidance.
As an addition to medication, psychosocial
treatments—including certain forms of psychotherapy (or "talk"
therapy)—are helpful in providing support, education, and
guidance to people with bipolar disorder and their families.
Studies have shown that psychosocial interventions can lead to
increased mood stability, fewer hospitalizations, and improved
functioning in several areas.
A licensed psychologist, social worker, or counselor typically
provides these therapies and often works together with the
psychiatrist to monitor a patient's progress. The number,
frequency, and type of sessions should be based on the
treatment needs of each person.
Psychosocial interventions commonly used for bipolar
disorder are cognitive behavioral therapy, psychoeducation,
family therapy, and a newer technique, interpersonal and
social rhythm therapy. NIMH researchers are studying how these
interventions compare to one another when added to medication
treatment for bipolar disorder.
- Cognitive behavioral therapy helps people with bipolar disorder learn
to change inappropriate or negative thought patterns and behaviors associated
with the illness.
- Psychoeducation involves teaching people with bipolar disorder about the
illness and its treatment, and how to recognize signs of relapse so that
early intervention can be sought before a full-blown illness episode occurs.
Psychoeducation also may be helpful for family members.
- Family therapy uses strategies to reduce the level of distress within
the family that may either contribute to or result from the ill person's
- Interpersonal and social rhythm therapy helps people with bipolar disorder
both to improve interpersonal relationships and to regularize their daily
routines. Regular daily routines and sleep schedules may help protect against
- As with medication, it is important to follow the treatment plan for any
psychosocial intervention to achieve the greatest benefit.
- In situations where medication, psychosocial treatment, and the combination
of these interventions prove ineffective, or work too slowly to relieve
severe symptoms such as psychosis or suicidality, electroconvulsive therapy
(ECT) may be considered. ECT may also be considered to treat acute episodes
when medical conditions, including pregnancy, make the use of medications
too risky. ECT is a highly effective treatment for severe depressive, manic,
and/or mixed episodes. The possibility of long-lasting memory problems,
although a concern in the past, has been significantly reduced with modern
ECT techniques. However, the potential benefits and risks of ECT, and of
available alternative interventions, should be carefully reviewed and discussed
with individuals considering this treatment and, where appropriate, with
family or friends
- Herbal or natural supplements, such as St. John's wort (Hypericum perforatum),
have not been well studied, and little is known about their effects on bipolar
disorder. Because the FDA does not regulate their production, different
brands of these supplements can contain different amounts of active ingredient.
Before trying herbal or natural supplements, it is important to discuss
them with your doctor. There is evidence that St. John's wort can reduce
the effectiveness of certain medications. In addition, like prescription
antidepressants, St. John's wort may cause a switch into mania in some individuals
with bipolar disorder, especially if no mood stabilizer is being taken.
- Omega-3 fatty acids found in fish oil are being studied to determine their
usefulness, alone and when added to conventional medications, for long-term
treatment of bipolar disorder.
A Long-Term Illness That Can Be Effectively Treated
Even though episodes of mania and depression naturally come
and go, it is important to understand that bipolar disorder is
a long-term illness that currently has no cure. Staying on
treatment, even during well times, can help keep the disease
under control and reduce the chance of having recurrent,
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Alcohol and drug abuse are very common among people with
bipolar disorder. Research findings suggest that many factors
may contribute to these substance abuse problems, including
self-medication of symptoms, mood symptoms either brought on
or perpetuated by substance abuse, and risk factors that may
influence the occurrence of both bipolar disorder and
substance use disorders.
Treatment for co-occurring substance abuse, when present, is
an important part of the overall treatment plan.
Anxiety disorders, such as post-traumatic stress disorder
and obsessive-compulsive disorder, also may be common in
people with bipolar disorder.
Co-occurring anxiety disorders may respond to the treatments
used for bipolar disorder, or they may require separate
treatment. For more information on anxiety disorders, contact
NIMH (see below).
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Anyone with bipolar disorder should be under the care of a
psychiatrist skilled in the diagnosis and treatment of this
disease. Other mental health professionals, such as
psychologists, psychiatric social workers, and psychiatric
nurses, can assist in providing the person and family with
additional approaches to treatment.
Help can be found at:
- University—or medical school—affiliated programs
- Hospital departments of psychiatry
- Private psychiatric offices and clinics
- Health maintenance organizations (HMOs)
- Offices of family physicians, internists, and
- Public community mental health centers
People with bipolar disorder may need help to get help.
- Often people with bipolar disorder do not realize how impaired they are,
or they blame their problems on some cause other than mental illness.
- A person with bipolar disorder may need strong encouragement from family
and friends to seek treatment. Family physicians can play an important role
in providing referral to a mental health professional.
- Sometimes a family member or friend may need to take the person with bipolar
disorder for proper mental health evaluation and treatment.
- A person who is in the midst of a severe episode may need to be hospitalized
for his or her own protection and for much-needed treatment. There may be
times when the person must be hospitalized against his or her wishes.
- Ongoing encouragement and support are needed after a person obtains treatment,
because it may take a while to find the best treatment plan for each individual.
- In some cases, individuals with bipolar disorder may agree, when the disorder
is under good control, to a preferred course of action in the event of a
future manic or depressive relapse.
- Like other serious illnesses, bipolar disorder is also hard on spouses,
family members, friends, and employers.
- Family members of someone with bipolar disorder often have to cope with
the person's serious behavioral problems, such as wild spending sprees during
mania or extreme withdrawal from others during depression, and the lasting
consequences of these behaviors.
- Many people with bipolar disorder benefit from joining support groups
such as those sponsored by the National Depressive and Manic Depressive
Association (NDMDA), the National Alliance for the Mentally Ill (NAMI),
and the National Mental Health Association (NMHA). Families and friends
can also benefit from support groups offered by these organizations.
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Some people with bipolar disorder receive medication and/or
psychosocial therapy by volunteering to participate in
clinical studies (clinical trials). Clinical studies involve
the scientific investigation of illness and treatment of
illness in humans. Clinical studies in mental health can yield
information about the efficacy of a medication or a
combination of treatments, the usefulness of a behavioral
intervention or type of psychotherapy, the reliability of a
diagnostic procedure, or the success of a prevention method.
Clinical studies also guide scientists in learning how illness
develops, progresses, lessens, and affects both mind and body.
Millions of Americans diagnosed with mental illness lead
healthy, productive lives because of information discovered
through clinical studies. These studies are not always right
for everyone, however. It is important for each individual to
consider carefully the possible risks and benefits of a
clinical study before making a decision to participate.
In recent years, NIMH has introduced a new generation of
"real-world" clinical studies. They are called "real-world"
studies for several reasons. Unlike traditional clinical
trials, they offer multiple different treatments and treatment
combinations. In addition, they aim to include large numbers
of people with mental disorders living in communities
throughout the U.S. and receiving treatment across a wide
variety of settings. Individuals with more than one mental
disorder, as well as those with co-occurring physical
illnesses, are encouraged to consider participating in these
new studies. The main goal of the real-world studies is to
improve treatment strategies and outcomes for all people with
these disorders. In addition to measuring improvement in
illness symptoms, the studies will evaluate how treatments
influence other important, real-world issues such as quality
of life, ability to work, and social functioning. They also
will assess the cost-effectiveness of different treatments and
factors that affect how well people stay on their treatment
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Center for Mental Health Services
National Institute of Mental Health
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