Bipolar Disorder Meds: Your Complete Guide

Key Takeaways:

• Medication is key in managing bipolar.
• Consistency and doctor check-ins are crucial.
• Understand your meds to avoid side effects.
• Lithium requires regular monitoring.
• Medication alone may not be sufficient.

Bipolar disorder feels like a relentless rollercoaster, swinging between emotional highs and devastating lows. If you've been there, you know how exhausting it can be. And that's why medication can be a real game-changer. But let's face it: figuring out the right medication plan can be downright confusing and even intimidating. It's more than just popping a pill—it's about understanding how these meds work, why they're prescribed, and how to use them effectively. Let's explore how the right meds can help stabilize those unpredictable waves, giving you the control and peace of mind you deserve.

The role of medication in managing bipolar disorder

Medication plays a pivotal role in managing bipolar disorder, often acting as the anchor that keeps mood swings from spiraling out of control. If you've been struggling with the intense highs of mania or the deep lows of depression, the right bipolar meds can provide a lifeline. However, medications are not a one-size-fits-all solution. Everyone's journey with bipolar affective disorder is unique, and finding the right treatment plan requires patience, open communication, and sometimes a bit of trial and error.

It's common to feel apprehensive about starting bipolar drugs. You may worry about side effects or feel like taking pills means you're "giving in" to the illness. But here's the thing: bipolar disorder is a biochemical condition, and meds for bipolar disorder help restore balance to those chemical fluctuations in the brain. Renowned psychiatrist Kay Redfield Jamison, who herself has bipolar disorder, put it best in her book, An Unquiet Mind: "Mood disorders are biochemical, and treating them as if they are solely psychological can be dangerous."

Using medication for bipolar disorder, especially mood stabilizers like lithium or anticonvulsants, can dramatically reduce the frequency and severity of mood episodes. They won't erase the disorder entirely, but they can give you a much-needed buffer, helping you regain control over your life. If you're feeling uncertain, remember this: medication is not a crutch—it's a tool to help you live a fuller, more stable life.

Tips to maximize your medication for bipolar disorder

Starting on bipolar medication can be a significant step, but getting the most out of your treatment involves more than just picking up a prescription. Here are some strategies to ensure you stay on the right track:

1. Stick to your prescribed schedule: It's tempting to skip a dose, especially if you're feeling better or struggling with side effects. But bipolar meds are designed to keep your brain chemistry stable. Missing doses can throw you off balance, leading to potential relapse.

2. Keep a mood journal: Tracking your moods can help you and your doctor understand how well your medication is working. If you're noticing patterns—like feeling more irritable or lethargic after a dose change—it's worth discussing with your healthcare provider.

3. Don't adjust your dosage on your own: It's easy to think you can tweak your dose if you're feeling "too high" or "too low." But this can be risky. Always consult your doctor before making any changes to your meds for bipolar disorder.

4. Communicate openly with your doctor: If you're experiencing side effects like weight gain, fatigue, or even feelings of emotional numbness, don't suffer in silence. Many people stop taking their bipolar medication because of these effects, but your doctor can often adjust your treatment to alleviate these issues.

5. Embrace other supportive therapies: While medication can be the foundation, combining it with therapy, mindfulness practices, or even exercise can improve your overall well-being. Research shows that a multi-faceted approach works best for long-term stability.

Finding the right medication for bipolar disorder

Choosing the right medication for bipolar disorder can feel like searching for a needle in a haystack. With so many options—mood stabilizers, antipsychotics, antidepressants, and more—it's easy to feel overwhelmed. But don't lose hope. Finding the right treatment is possible with persistence and the right guidance.

One of the most important factors is understanding the specific type of bipolar disorder you have. Bipolar I and Bipolar II have different treatment needs. For instance, if your primary issue is severe manic episodes, your doctor may prioritize mood stabilizers like lithium. However, if depression dominates your symptoms, they may suggest a combination of mood stabilizers and antidepressants. This is why it's so critical to have honest conversations with your psychiatrist. They're not just throwing meds at you—they're using their expertise to tailor a plan that fits your needs.

It's also worth noting that it can take some time for bipolar medication to show its full effects. The process can feel frustrating, especially if you don't see immediate results. According to Dr. Ellen Frank, author of Treating Bipolar Disorder, “Sticking with a medication long enough to see if it works is often the most challenging step.” Patience and consistency are crucial here. Don't hesitate to lean on your support network during this adjustment period—having people who understand what you're going through can make a world of difference.

Additionally, don't be discouraged if you need to try more than one medication before finding the right fit. Your body's response to bipolar meds can differ from others, so what works for one person might not work for you. The goal is to find a medication or a combination of medications that stabilizes your mood with the least disruptive side effects.

Understand your prescribed bipolar medication

Knowing what you're putting into your body is crucial. When it comes to managing bipolar disorder, understanding your prescribed bipolar meds can make a significant difference in how well they work for you. Dive into the details—what the medication does, its potential side effects, and how it interacts with other substances you might be taking. The more informed you are, the better equipped you'll be to spot any red flags early on.

For instance, mood stabilizers like lithium work by balancing neurotransmitters in the brain, but they come with their own set of side effects, like increased thirst and hand tremors. On the other hand, anticonvulsants like valproic acid can help with manic episodes but might cause drowsiness or weight gain. Educate yourself on what to expect so you're not caught off guard. When in doubt, bring your questions to your doctor—there's no such thing as asking too much when it comes to your health.

How often should you consult with your doctor?

Establishing a regular check-in schedule with your doctor is vital, especially in the early stages of starting or adjusting bipolar medications. These appointments are your opportunity to discuss how you're feeling, report any side effects, and adjust dosages if necessary. It's not uncommon to need frequent visits initially, sometimes every few weeks, until your meds are fine-tuned to meet your needs. After stabilization, quarterly or biannual check-ins might suffice.

Consider these meetings a partnership. Your doctor needs your feedback to understand how the medication affects you. If something feels off—even if it seems minor—bring it up. It's better to err on the side of caution than to let symptoms worsen. For example, if you notice sudden fatigue or mental fog, these could be signs that your dosage needs tweaking. Consistent communication is the key to a successful treatment journey.

Choosing between generic and brand-name medications

The debate between generic and brand-name drugs can be confusing, especially when you're already navigating the complexities of bipolar disorder. The good news is that, in most cases, generic medications are just as effective as their brand-name counterparts. They contain the same active ingredients, but they may have different fillers or binders, which can occasionally affect absorption rates.

That said, some people notice slight differences in how they feel when switching from brand-name to generic meds for bipolar disorder. If you're one of them, it's worth discussing with your doctor. They can help you decide whether the cost savings of generic options outweigh any slight changes in effectiveness. Ultimately, the best choice is the one that works best for you while fitting within your budget.

Taking bipolar medication responsibly

There's no denying that medication can be a powerful tool in managing bipolar disorder, but it's not a magic bullet. It requires responsibility and consistency on your part. One of the most important things to remember is that taking your meds as prescribed is non-negotiable. Skipping doses or stopping abruptly can lead to serious consequences, like triggering a manic or depressive episode.

Think of your medication routine like a lifeline. Whether you're on mood stabilizers, antipsychotics, or a combination, these drugs are carefully calibrated to keep you balanced. Disrupting that balance, even briefly, can set you back significantly. If you're ever tempted to stop because you're feeling better or you're struggling with side effects, reach out for support first. A quick conversation with your healthcare provider can help you weigh the pros and cons of any changes.

And let's be honest—taking meds can sometimes feel like a burden. But reframing your mindset can help. Instead of seeing it as a chore, view it as an act of self-care. You're doing something proactive to stabilize your life and protect your mental health. The peace and stability that come from consistently taking your medication are worth it, even on the tough days.

Practical tips for managing bipolar medications

Managing bipolar medication can feel like juggling several balls at once. But with a few practical strategies, it can become second nature. First, consider using a pill organizer or a medication tracking app. This helps ensure you don't accidentally miss a dose—because, let's face it, we all forget things sometimes. A missed dose might seem harmless, but it can throw off the delicate balance you've worked hard to achieve.

Another tip? Set reminders on your phone to take your meds at the same time each day. Consistency is key with bipolar drugs since they work best when they maintain stable levels in your system. Pairing your meds with a daily habit—like brushing your teeth—can also serve as a natural prompt. And don't forget to keep an eye out for expiration dates on your medications. Taking expired meds can reduce their effectiveness or even be harmful.

Lastly, don't hesitate to ask for support. Whether it's a loved one reminding you to take your meds or attending a support group where others share their own tips, you're not alone in this journey. Remember, consistency with your bipolar medication can be the difference between a stable mood and an episode waiting to happen.

Lithium: The original mood stabilizer

Lithium has earned its reputation as the gold standard in treating bipolar disorder. This simple salt compound has been around for decades and remains one of the most effective mood stabilizers for managing both mania and depression. If you're prescribed lithium, it means your doctor believes it's the best option to help keep your mood swings under control.

But here's the thing: while lithium can be a game-changer, it's not without its quirks. The medication needs to be managed carefully to avoid potential side effects and complications. It's like driving a high-performance car—you can't just fill the tank and drive off; you need regular maintenance to keep it running smoothly. And that's where things like blood tests and lifestyle adjustments come into play.

Common lithium side effects

Let's talk about the elephant in the room—side effects. While lithium is effective, it doesn't come without some potential downsides. Some people experience increased thirst, frequent urination, and hand tremors. You might also notice weight gain or feelings of lethargy. These side effects can be bothersome, but many people find that they diminish over time as your body adjusts to the medication.

However, if the side effects feel unmanageable, don't just stop taking your medication abruptly. Speak to your doctor first. Sometimes, a slight adjustment to the dosage can make a world of difference. Remember, it's all about finding that sweet spot where the benefits outweigh any downsides. Dr. Kay Jamison notes in An Unquiet Mind that for many, “The side effects of lithium are a small price to pay for stability.”

The need for regular blood monitoring

If you're on lithium, regular blood tests are a must. These tests check your lithium levels to ensure they're in the therapeutic range—not too high, not too low. Think of it like tuning a guitar. If the levels are off, your mood stability can be affected, and too much lithium can even lead to toxicity. This is why your doctor will often schedule bloodwork every few months, especially in the early stages of treatment.

Some patients find the blood tests inconvenient, but they're a necessary part of keeping you safe. Lithium has a narrow therapeutic window, meaning that the difference between a helpful dose and a harmful one can be quite small. By keeping up with these tests, you're actively protecting your mental and physical health.

Factors that can influence lithium levels

Did you know that your lithium levels can fluctuate based on things you might not even think about? For example, dehydration can cause your lithium levels to spike, increasing the risk of toxicity. That's why staying hydrated is essential if you're on lithium. Likewise, changes in your diet—like cutting back on salt—can also affect your lithium levels since lithium and sodium interact in the body.

Even something as simple as switching medications can impact how your body processes lithium. Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen can increase lithium levels, potentially leading to dangerous side effects. Always inform your doctor about any new meds you're taking, even over-the-counter ones.

By staying mindful of these factors and communicating with your healthcare provider, you can minimize risks and make the most of your bipolar medication plan. It's about playing an active role in your treatment, keeping you stable, and living the life you deserve.

Avoiding toxic levels of lithium

Maintaining the right balance of lithium in your system is critical. Too much of it, and you could face lithium toxicity—a condition that can cause confusion, muscle weakness, tremors, and even kidney damage. But don't let that scare you off. With a few precautions, you can stay on top of your levels and avoid any nasty surprises.

The first rule? Stay hydrated. Lithium levels can shoot up quickly if you're dehydrated, so make sure you're drinking enough water, especially if you're exercising or it's hot outside. Also, pay attention to your sodium intake. If you drastically reduce salt in your diet, your lithium levels could spike, so any major dietary changes should be discussed with your doctor.

Finally, be mindful of medications that could interact with lithium. Nonsteroidal anti-inflammatory drugs (NSAIDs), like ibuprofen, can raise lithium levels. Always check with your healthcare provider before starting any new medication, even if it's something you can buy over the counter. By keeping an eye on these factors, you can avoid the dangerous pitfalls of lithium toxicity.

Anticonvulsants as mood stabilizers

If lithium isn't the right fit for you, anticonvulsant medications might be another option. Originally developed to treat seizures, these drugs have been found to stabilize mood swings, particularly in those with bipolar disorder. They're often used when lithium alone doesn't provide enough stability or if you can't tolerate its side effects. The most well-known of these anticonvulsants is valproic acid, commonly known as Depakote.

What makes anticonvulsants like valproic acid effective? They work by calming the overactive electrical signals in your brain. This can be particularly helpful for managing manic episodes, which often feel like your brain is firing on all cylinders without any brakes. But just like any medication, anticonvulsants come with their own set of pros and cons.

Valproic acid (Depakote)

Valproic acid, or Depakote, has been a go-to medication for treating bipolar disorder, especially when mania takes center stage. It's often prescribed for people who don't respond well to lithium or who experience rapid cycling between manic and depressive states. Depakote works by increasing the availability of a neurotransmitter called GABA, which helps calm the brain.

However, Depakote isn't without its side effects. Some people experience weight gain, hair thinning, or digestive issues like nausea. One thing to keep in mind: Depakote requires regular liver function tests since it can be hard on your liver. This makes regular check-ups a must. But when it works, it can be a powerful ally in stabilizing those unpredictable mood swings.

Other anticonvulsants for managing bipolar

While Depakote gets most of the spotlight, there are other anticonvulsants that can help manage bipolar symptoms. Lamotrigine (Lamictal) is one of the most popular, especially for preventing the depressive episodes of bipolar II disorder. Unlike Depakote, lamotrigine is generally better tolerated, with fewer side effects related to weight gain or drowsiness. However, it does carry a rare but serious risk of developing a skin rash known as Stevens-Johnson syndrome, so any unusual skin changes should be reported to your doctor immediately.

Carbamazepine (Tegretol) is another option, particularly for those who experience mixed episodes or rapid cycling. However, it requires regular blood tests to monitor for potential side effects, like low white blood cell counts. With these medications, the key is finding the right balance—one that stabilizes your mood without making you feel like a zombie. Your doctor will help guide you through this process, adjusting doses and medications as needed.

Using antidepressants for bipolar disorder

Antidepressants might seem like a logical choice if you're struggling with the lows of bipolar disorder. After all, who wouldn't want relief from the crushing weight of depression? But here's the catch: antidepressants can sometimes trigger manic episodes or rapid cycling, especially if they're not paired with a mood stabilizer. This is why they're usually prescribed with caution and often in conjunction with a medication like lithium or an anticonvulsant.

The goal is to lift you out of depression without pushing you into mania. Doctors might prescribe an antidepressant if you've tried mood stabilizers alone and still find yourself sinking into those dark places. However, if you notice a sudden burst of energy, racing thoughts, or decreased need for sleep after starting an antidepressant, it's crucial to reach out to your doctor. These could be signs of mania on the horizon.

So, are antidepressants worth the risk? It depends on your unique situation. For some, they can be a lifeline. For others, the risks outweigh the benefits. That's why it's essential to work closely with your psychiatrist, monitoring how your mind and body respond. Remember, it's not just about managing the symptoms—it's about finding a treatment plan that lets you live your life to the fullest.

Caution: Antidepressants and bipolar disorder

Antidepressants can be a tricky addition to a bipolar treatment plan. While they're commonly used to treat major depressive disorder, their effects on someone with bipolar disorder can be unpredictable. The problem? Antidepressants can sometimes trigger mania or hypomania, especially if they're not paired with a mood stabilizer. This phenomenon, known as antidepressant-induced mania, is more common than you might think.

Many people assume that taking an antidepressant will simply lift them out of their depressive state, but bipolar disorder is more complex than that. Because of the risk of triggering a manic episode, doctors usually approach these meds with caution, especially in those who've had a history of rapid cycling. If your doctor prescribes one, they'll likely keep a close eye on you in the initial weeks to catch any signs of mood elevation before it spirals out of control.

Treating bipolar depression with mood stabilizers

So, if antidepressants come with so many risks, what's the alternative? For many, the answer lies in mood stabilizers. Medications like lithium, lamotrigine, or certain antipsychotics can effectively manage depressive symptoms without the risk of triggering mania. These drugs work by evening out the highs and lows, allowing you to feel more balanced over the long term.

It's important to recognize that treating bipolar depression isn't just about lifting your mood; it's about keeping your mood stable. Mood stabilizers may not provide the immediate relief that antidepressants do, but they're less likely to throw you into a manic episode. For those who've tried antidepressants in the past with mixed results, this approach can be a game-changer.

That being said, mood stabilizers can take a bit longer to show their full effects. Patience is key here. The goal is steady, long-term improvement rather than a quick but risky boost in mood. If you're willing to wait it out, you may find that mood stabilizers offer more sustainable relief without the emotional whiplash.

What if you're already on antidepressants?

If you're already taking antidepressants for bipolar disorder and doing well, you might wonder if you should continue. The short answer? It depends. If you haven't experienced any manic symptoms and your mood feels stable, your doctor may decide it's safe to keep you on them. However, if you've noticed any signs of mood elevation—like racing thoughts or a sudden burst of energy—it's essential to bring it up with your healthcare provider.

Sometimes, doctors will try to gradually reduce your antidepressant dose while introducing a mood stabilizer. This approach helps ease the transition without pulling the rug out from under you. The process can feel nerve-wracking, especially if the antidepressant has been your lifeline. But with the right support and a well-monitored plan, you can find a balance that doesn't sacrifice your stability.

Antipsychotic medications for bipolar symptoms

Antipsychotics might sound intimidating, but they've become a cornerstone in managing bipolar disorder, especially for those who experience severe mania or psychotic features like hallucinations or delusions. These medications can quickly bring down the intensity of a manic episode, making them incredibly useful in acute situations. But that's not all—they're also effective in treating depressive episodes and can be used as long-term mood stabilizers.

Some commonly prescribed antipsychotics include olanzapine (Zyprexa), quetiapine (Seroquel), and aripiprazole (Abilify). These meds help by regulating dopamine, a neurotransmitter that's often out of whack during mood episodes. By dampening the overactive signals in the brain, they can help bring you back to a more balanced state.

However, antipsychotics aren't just for crisis management. Many people use them as part of their regular medication regimen to keep mood swings in check, especially if they're dealing with mixed episodes or rapid cycling. The key is finding the right dose that manages your symptoms without leaving you feeling overly sedated.

Common antipsychotic side effects

While antipsychotics can be life-changing for managing bipolar symptoms, they do come with a list of potential side effects. One of the most common is drowsiness, which can make it hard to stay alert during the day. Some people also experience weight gain, which can be significant with medications like olanzapine. If you're concerned about these side effects, don't hesitate to bring it up with your doctor—they can often adjust your dosage or switch you to a different medication.

Another side effect worth mentioning is the potential for movement-related issues, like tremors or muscle stiffness. These symptoms are more common with older antipsychotics but can still occur with newer ones. Regular check-ups with your doctor can help catch these side effects early, allowing you to adjust your treatment before they become too bothersome.

Dealing with side effects can be frustrating, but it's often a matter of weighing the benefits against the drawbacks. For many, the stability these medications provide far outweighs the temporary discomfort. Still, your quality of life matters, so don't be afraid to advocate for yourself if something doesn't feel right.

Managing antipsychotic-induced erectile dysfunction

One of the more challenging side effects of antipsychotic medications—something that's not always openly discussed—is erectile dysfunction (ED). For many men, this can feel embarrassing or frustrating, especially if your mood has stabilized, but your intimate life has taken a hit. Antipsychotics can affect dopamine levels, which play a crucial role in sexual function. This isn't just about physical performance; it can also impact your confidence and emotional well-being.

If you're dealing with ED as a side effect of your bipolar meds, don't suffer in silence. Talk to your doctor; they may adjust your dose or suggest switching to another medication with fewer sexual side effects. Additionally, medications like sildenafil (Viagra) can be prescribed to help counteract this issue. Lifestyle changes—such as regular exercise, reducing alcohol intake, and managing stress—can also support sexual health. Remember, addressing this problem is part of your overall treatment, not a separate issue to ignore.

Exploring other medications for bipolar

While mood stabilizers, antipsychotics, and antidepressants form the backbone of treating bipolar disorder, they aren't the only options out there. Sometimes, a combination of less conventional medications can provide the right mix to stabilize mood without overwhelming you with side effects. Let's dive into some alternatives that may be used to complement your treatment plan.

Benzodiazepines

Benzodiazepines like lorazepam (Ativan) and clonazepam (Klonopin) are often used to control acute symptoms, particularly during manic episodes when anxiety, agitation, or insomnia takes over. These medications work quickly, providing a calming effect that can bring you back from the edge. However, benzodiazepines are typically used for short-term relief rather than long-term maintenance due to their risk of dependence and tolerance.

It's crucial to use these medications responsibly. While they can be a godsend during moments of crisis, long-term use can lead to addiction or withdrawal symptoms. If your doctor prescribes benzodiazepines, be sure to follow their guidelines closely, and don't hesitate to ask about alternative strategies if you're concerned about dependency.

Calcium channel blockers

Calcium channel blockers might not be the first thing that comes to mind for treating bipolar disorder, but they're sometimes used as an off-label option, especially when traditional mood stabilizers cause too many side effects. Medications like verapamil can help by regulating neurotransmitter release and reducing mood fluctuations. While these drugs are primarily used for high blood pressure and heart conditions, they have shown promise in stabilizing mood in some patients.

Because they aren't commonly prescribed for bipolar disorder, there's less research on their effectiveness compared to lithium or anticonvulsants. That said, for those who are sensitive to standard bipolar meds, calcium channel blockers can offer a different route to achieving balance without the side effects that might come with more traditional treatments.

Thyroid medications

One of the lesser-known treatment strategies for bipolar disorder involves thyroid medications. Yes, you heard that right—sometimes an underactive thyroid can contribute to mood instability, especially depression. In these cases, supplementing with thyroid hormones like levothyroxine can help stabilize mood swings. This is particularly relevant for those who haven't found success with other medications or who have existing thyroid issues.

However, thyroid medications aren't for everyone. They're usually considered when other treatments haven't fully resolved your symptoms. If your doctor suggests this option, they'll likely monitor your thyroid levels closely to ensure they remain in a healthy range. While it might seem odd to take a medication meant for a completely different condition, the body is a complex system, and sometimes an imbalance in one area can have ripple effects on your mental health.

Exploring these alternative options requires an open mind and a willingness to try new strategies under the guidance of a trusted healthcare provider. Whether it's adding a benzodiazepine for short-term relief or considering thyroid supplementation, these less conventional medications can sometimes be the missing piece in your treatment puzzle.

Why medication alone isn't enough

Taking bipolar medication is undeniably a crucial part of managing the disorder, but it's not the whole picture. Imagine trying to build a house with just one tool—it might get the job started, but it won't be enough to finish the job properly. That's how it is with meds for bipolar disorder. Yes, they stabilize your mood, reduce symptoms, and help prevent relapses, but they can't address every facet of your life.

The reality is that bipolar disorder affects more than just your brain chemistry. It impacts your relationships, your job, your self-esteem, and even your day-to-day routine. This is where a comprehensive treatment plan comes in. Therapy, lifestyle changes, and a strong support network can fill in the gaps that medication alone can't cover. Cognitive Behavioral Therapy (CBT), for example, helps you identify negative thought patterns that might trigger mood swings. By addressing these underlying issues, therapy works hand-in-hand with medication to offer a more balanced, sustainable approach to managing your condition.

Another vital component is lifestyle. Things like regular exercise, sleep hygiene, and a balanced diet play an enormous role in keeping your mood stable. Consistent physical activity, for instance, boosts serotonin levels, acting as a natural mood stabilizer. Sleep, on the other hand, is like the unsung hero of mental health. When you're sleep-deprived, your emotions can spiral, no matter how good your medication is. That's why it's crucial to create a sleep schedule and stick to it.

Don't forget the power of a solid support system. Isolation can be a breeding ground for depressive episodes, so staying connected with friends, family, or even a support group can make all the difference. Sharing your struggles with people who genuinely understand what you're going through can be incredibly empowering. It's not just about unloading your burdens—it's about feeling seen, heard, and validated.

And let's not overlook self-care practices. Mindfulness meditation, journaling, or simply spending time in nature can help you stay grounded when everything feels overwhelming. Medication provides the chemical balance, but these practices give you the emotional tools to navigate life's challenges. So, while bipolar meds are an essential part of the treatment puzzle, they're most effective when combined with other strategies that support your overall well-being.

Recommended Resources

• An Unquiet Mind by Dr. Kay Redfield Jamison – A deeply personal and insightful memoir from a psychiatrist who herself battles with bipolar disorder.
• Treating Bipolar Disorder by Dr. Ellen Frank – A comprehensive guide on combining medication with therapy for effective treatment.
• The Bipolar Disorder Survival Guide by Dr. David J. Miklowitz – Practical advice for managing the disorder, including lifestyle changes and coping strategies.