Difference between revisions of "Clinical depression" - New World Encyclopedia

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[[Category:Politics and social sciences]]
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{{Infobox medical condition (new)
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[[Category:Psychology]]
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| name          = Clinical depression
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| image        = File:Vincent Willem van Gogh 002.jpg
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| alt          =
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| caption      = ''[[At Eternity's Gate|Sorrowing Old Man (At Eternity's Gate)]]''<br />by [[Vincent van Gogh]] (1890)
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| field        = [[Psychiatry]], [[clinical psychology]]
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| synonyms      = Major depressive disorder, major depression, unipolar depression, unipolar disorder, recurrent depression
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| symptoms      = [[depression (mood)|Low mood]], low [[self-esteem]], [[Anhedonia|loss of interest]] in normally enjoyable activities, low energy, [[pain]] without a clear cause<ref name=NIH2016>[https://www.nimh.nih.gov/health/topics/depression Depression] ''National Institute of Mental Health (NIMH)''. Retrieved October 10, 2022.</ref>
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| complications = [[Self-harm]], [[suicide]]<ref name=Rich2014>C. Steven Richards and Michael W. O'Hara (eds.), ''The Oxford Handbook of Depression and Comorbidity'' (Oxford University Press, 2014, ISBN 978-0199797004).</ref>
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| onset        = 20s<ref name=DSM-5>American Psychiatric Association, ''Diagnostic and Statistical Manual of Mental Disorders, 5th Edition: DSM-5'' (American Psychiatric Publishing, Inc., 2013, ISBN 978-0890425558).</ref>
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| duration      = > 2 weeks<ref name=NIH2016/>
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| causes        = Environmental ([[Psychological trauma|adverse life experiences]], stressful life events), [[Genetics|genetic]] and psychological factors<ref name=DSM-5/>
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| risks        = [[Family history (medicine)|Family history]], major life changes, certain [[medication]]s, [[chronic health problem]]s, [[substance use disorder]]<ref name=NIH2016/><ref name=DSM-5/>
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| diagnosis    =
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| differential  = [[Bipolar disorder]], [[ADHD]], [[sadness]]<ref name=DSM-5/>
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| prevention    =
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| treatment    = [[Psychotherapy]], [[antidepressant medication]], [[electroconvulsive therapy]], [[exercise]]<ref name=NIH2016/>
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| medication    = [[Antidepressant]]s
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| prognosis    =
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| frequency    =
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| deaths        =
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}}
  
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'''Clinical Depression''', also known as '''Major Depressive Disorder''' ('''MDD'''), is a [[mental disorder]] characterized by pervasive [[depression (mood)|low mood]], low [[self-esteem]], and [[anhedonia|loss of interest or pleasure]] in normally enjoyable activities over a protracted period of time.
  
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<references/>{{DiseaseDisorder infobox |
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The diagnosis of major depressive disorder is based on the person's reported experiences, behavior reported by relatives or friends, and a [[mental status examination]]. The course of the disorder varies widely, from one episode lasting months to a lifelong disorder with recurrent [[major depressive episode]]s. Major depressive disorder is believed to be caused by a combination of [[genetics|genetic]], environmental, and psychological factors. Risk factors include a [[Family history (medicine)|family history]] of the condition, major life changes, certain medications, [[chronic health problem]]s, and [[substance use disorder]]s. Those suffering from clinical depression are typically treated with [[psychotherapy]] and [[antidepressant medication]]. 
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  Name        = Depression |
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{{toc}}
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  ICD10      = {{ICD10|F|32||f|30}}, {{ICD10|F|33||f|30}}|
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Despite efforts to educate the public about [[mental disorder]]s, social stigma continues to make it difficult both for those suffering from serious depression to admit their problems and for health professionals to diagnose and treat them. The view held by some psychiatrists that such depression is merely a social construct or imagined illness that is inappropriately regarded as an actual disease compounds these difficulties. Compassion as well as support for effective treatment is needed to allow those suffering from depression to receive appropriate and effective treatment so that they may be successful members of society.
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  ICD9        = {{ICD9|296}} |
 
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  MedlinePlus = 003213|
 
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}}
 
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'''Clinical depression''' (also called '''major depressive disorder''', or sometimes '''unipolar''' when compared with [[bipolar disorder]]) is a state of intense [[sadness]], [[melancholia]] or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living. Although a low [[mood]] or state of dejection that does not affect functioning is often colloquially referred to as [[depression (mood)|depression]], clinical depression is a clinical diagnosis and may be different from the everyday meaning of "being depressed." Many people identify the feeling of being depressed as "being blue," "feeling sad for no reason", or "having no motivation to do anything." One suffering from depression may feel tired, sad, irritable, lazy, unmotivated, and apathetic. Clinical depression is generally acknowledged to be more serious than normal depressed feelings. It often leads to constant negative thinking and sometimes [[substance abuse]].
 
  
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Without careful assessment, [[delirium]] can easily be confused with [[depression]] and a number of other [[psychiatric disorders]] because many of the signs and [[symptoms]] are conditions present in [[depression]], as well as  other mental illnesses including [[dementia]] and [[psychosis]].<ref>[http://www.aafp.org/afp/20030301/1027.html American Family Physician, March 1, 2003 Delirium]</ref>
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==Terminology==
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[[File:Abraham Lincoln O-60 by Brady, 1862.jpg|thumb|300px|The 16th [[President of the United States|American president]], [[Abraham Lincoln]], had "[[Depression (mood)|melancholy]]", a condition that now may be referred to as "clinical depression."<ref>Joshua Wolf Shenk, [https://www.theatlantic.com/magazine/archive/2005/10/lincolns-great-depression/304247/ Lincoln's Great Depression] ''The Atlantic'', October 2005. Retrieved October 14, 2022.</ref>]]
  
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[[Image:Vincent_Willem_van_Gogh_002.jpg|thumb|250px|[[Vincent van Gogh]], who himself suffered from depression and committed suicide, painted this picture in 1890 of a man that can symbolize the desperation and hopelessness felt in depression.]]
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'''Clinical depression''', also known as '''Major depressive disorder''' ('''MDD'''), is classified as a [[mental disorder]]. However, the term "depression" is used in a number of different ways. It is often used to mean the syndrome but may refer to other [[mood disorder]]s or simply to a low mood. People's conceptualizations of depression vary widely: "Because of the lack of scientific certainty," one commentator has observed, "the debate over depression turns on questions of language. What we call it—'disease,' 'disorder,' 'state of mind'—affects how we view, diagnose, and treat it."<ref> Field Maloney, [https://slate.com/culture/2005/11/the-depression-wars.html The Depression Wars: Would Honest Abe Have Written the Gettysburg Address on Prozac?] ''Slate'', November 3, 2005. Retrieved October 14, 2022.</ref>
  
 
==History==
 
==History==
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[[File:Hippocrates pushkin02.jpg|thumb|right|300px|Diagnoses of depression go back at least as far as [[Hippocrates]].]]
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The Ancient Greek physician [[Hippocrates]] described a syndrome of [[melancholia]] ({{lang|grc|μελαγχολία}}, {{transl|grc|melankholía}}) as a distinct disease with particular mental and physical symptoms; he characterized all "fears and despondencies, if they last a long time" as being symptomatic of the ailment.<ref>Hippocrates, ''Aphorisms'', Section 6.23.</ref> It was a similar but far broader concept than today's depression; prominence was given to a clustering of the symptoms of sadness, dejection, and despondency, and often fear, anger, delusions, and obsessions were included.<ref name= Radden2003>Jennifer Radden, [https://psycnet.apa.org/record/2003-07847-007 Is This Dame Melancholy? Equating Today's Depression and Past Melancholia] ''Philosophy, Psychiatry, & Psychology'' 10(1) (2003): 37–52. Retrieved October 14, 2022.</ref>
  
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The modern idea of depression appears similar to the much older concept of melancholia. The name ''melancholia'' derives from "black bile," one of the "[[four humours]]" postulated by [[Galen]].
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The term "depression" was derived from the Latin verb {{lang|la|deprimere}}, meaning "to press down."<ref>[https://www.dictionary.com/browse/depress Depress] Dictionary.com''. Retrieved October 14, 2022. </ref> From the fourteenth century, "to depress" meant to subjugate or to bring down in spirits. It was used in 1665 in English author [[Richard Baker (chronicler)|Richard Baker's]] ''Chronicle'' to refer to someone having "a great depression of spirit," and by English author [[Samuel Johnson's health|Samuel Johnson]] in a similar sense in 1753.<ref name=Wolpert>Lewis Wolpert, ''Malignant Sadness: The Anatomy of Depression'' (Free Press, 2000, ISBN 978-0684870588).</ref> An early usage referring to a psychiatric symptom was by French psychiatrist [[Louis Delasiauve]] in 1856, and by the 1860s it was appearing in medical dictionaries to refer to a physiological and metaphorical lowering of emotional function.<ref>G.E. Berrios, [https://www.cambridge.org/core/journals/the-british-journal-of-psychiatry/article/abs/melancholia-and-depression-during-the-19th-century-a-conceptual-history/5257E8A5BA6C993A023F32462378CC92 Melancholia and depression during the 19th century: a conceptual history] ''The British Journal of Psychiatry'' 153(3) (September 1988): 298–304. Retrieved October 14, 2022. </ref> Since [[Aristotle]], melancholia had been associated with men of learning and intellectual brilliance, a hazard of contemplation and creativity. The newer concept abandoned these associations and through the nineteenth century, and became more associated with women.<ref name=Radden2003/>
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Clinical depression was originally considered to be a [[chemical imbalance theory|chemical imbalance]] in transmitters in the brain, a theory based on observations made in the 1950s of the effects of [[reserpine]] and [[isoniazid]] in altering monoamine neurotransmitter levels and affecting depressive symptoms.<ref>{{cite journal | last = Schildkraut | first = J.J. |date= 1965 | title =  The catecholamine hypothesis of affective disorders: a review of supporting evidence | journal = Am J Psychiatry | volume = 122 | issue = 5 | pages = 509-22}}</ref>  Since these suggestions, many other causes for clinical depression have been proposed{{Fact|date=February 2007}}.
 
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==Prevalence==
 
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'''Clinical depression''' affects about 16%<ref>{{cite journal | url = http://www.cpa-apc.org/Publications/Archives/PDF/1997/May/BLAND.pdf | last = Bland | first = R.C. |date= 1997 | title = Epidemiology of Affective Disorders: A Review | journal = Can J Psychiatry | volume = 42 | pages = 367?377 }}</ref> of the population on at least one occasion in their lives. In some countries, such as Australia, one in four women and one in eight men will suffer from depression. The [[mean]] age of onset, from a number of studies, is in the late 20s. About twice as many females as males report or receive treatment for clinical depression, though this imbalance is shrinking over the course of recent history; this difference seems to completely disappear after the age of 50 - 55. Clinical depression is currently the leading cause of  [[disability]] in North America as well as other countries, and is expected to become the second leading cause of disability worldwide (after [[heart disease]]) by the year 2020, according to the [[World Health Organization]].<ref>{{cite journal | last = Murray | first = C.J.L. | coauthors = Lopez, A.D. |date= 1997 | title = Alternative projections of mortality and disability by cause 1990-2020: Global Burden of Disease Study | journal = Lancet | volume = 349 | pages = 1498?1504 }}</ref>
 
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===Symptoms===
 
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According to the [http://www.behavenet.com/capsules/disorders/mjrdepd.htm DSM-IV-TR criteria for diagnosing a major depressive disorder] ([[DSM cautionary statement|cautionary statement]]) one of the following two elements must be present for a period of at least two weeks:
 
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* [[Depression (mood)|Depressed mood]], or
 
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* [[Anhedonia]]
 
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It is sufficient to have either of these symptoms in conjunction with five of a list of other symptoms over a two-week period. These include:
 
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* Feelings of overwhelming [[sadness]] and/or [[fear]], or the seeming inability to feel [[emotion]] ([[emptiness]]). 
 
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* A decrease in the amount of interest or pleasure in all, or almost all, daily activities.
 
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* Changing [[appetite]] and marked weight gain or loss.
 
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* Disturbed sleep patterns, such as [[insomnia]], loss of REM sleep, or excessive sleep ([[Hypersomnia]]).
 
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* [[Psychomotor agitation]] or [[Psychomotor retardation|retardation]] nearly every day.
 
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* [[Fatigue (physical)|Fatigue]], mental or physical, also loss of energy.
 
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* Intense feelings of [[guilt]], helplessness, hopelessness, worthlessness, isolation/loneliness and/or [[anxiety]].
 
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* Trouble concentrating, keeping focus or making decisions or a generalized slowing and obtunding of cognition, including memory.
 
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* Recurrent thoughts of death (not just fear of dying), desire to just "lie down and die" or "stop breathing", recurrent [[suicidal ideation]] without a specific plan, or a [[Parasuicide|suicide attempt]] or a specific plan for committing [[suicide]].
 
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* Feeling and/or fear of being abandoned by those close to one.
 
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Other symptoms often reported but not usually taken into account in diagnosis include:
 
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* [[Self-loathing]].
 
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* A decrease in [[self-esteem]].
 
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* Inattention to personal hygiene.
 
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* Sensitivity to noise.
 
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* Physical aches and pains, and the belief these may be signs of serious illness.
 
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* Fear of 'going mad'.
 
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* Change in perception of time.
 
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* Periods of sobbing.
 
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* Possible behavioral changes, such as [[aggression]] and/or irritability.
 
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Depression in children is not as obvious as it is in adults. Here are some symptoms that children might display:
 
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* Loss of appetite.
 
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* Irritability.
 
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* Sleep problems, such as recurrent [[nightmare]]s.
 
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* Learning or memory problems where none existed before.
 
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* Significant behavioral changes; such as withdrawal, social isolation, and [[aggression]].
 
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An additional indicator could be the excessive use of drugs or [[Alcoholic beverage|alcohol]].  Depressed adolescents are at particular risk of further destructive behaviours, such as [[eating disorder]]s and [[self-harm]].
 
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One of the most widely used instruments for measuring depression severity is the [[Beck Depression Inventory]], a 21-question multiple choice survey.
 
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It is hard for people who have not experienced clinical depression, either personally or by regular exposure to people suffering it, to understand its emotional impact and severity, interpreting it instead as being similar to "having the blues" or "feeling down."  As the list of symptoms above indicates, clinical depression is a serious, potentially lethal systemic disorder characterized by the psychiatric profession as interlocking physical, affective, and cognitive symptoms that have consequences for function and survival well beyond sad or painful feelings.
 
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===Mnemonics===
 
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[[Mnemonics]] commonly used to remember the DSM-IV criteria are '''SIGECAPS'''<ref>Carlat DJ. The Psychiatric Review of Symptoms: A Screening Tool for Family Physicians. American Family Physician. Vol. 58/No. 7 ([[November 1]] [[1998]]). Available at: [http://www.aafp.org/afp/981101ap/carlat.html http://www.aafp.org/afp/981101ap/carlat.html]. Accessed on: [[April 30]] [[2006]].</ref> ('''s'''leep, '''i'''nterest (anhedonia), '''g'''uilt, '''e'''nergy, '''c'''oncentration, '''a'''ppetite, '''p'''sychomotor, '''s'''uicidality) and '''DEAD SWAMP'''<ref>Depression: major depression criteria. MedicalMnemonics.com. URL: [http://www.medicalmnemonics.com/cgi-bin/return_browse.cfm?discipline=Psychiatry&browse=1 http://www.medicalmnemonics.com/cgi-bin/return_browse.cfm?discipline=Psychiatry&browse=1]. Accessed on: [[April 30]] [[2006]].</ref> ('''d'''epressed mood, '''e'''nergy, '''a'''nhedonia, '''d'''eath (thoughts of), '''s'''leep, '''w'''orthlessness/guilt, '''a'''ppetite, '''m'''entation, '''p'''sychomotor).
 
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==Types of depression==
 
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The diagnostic category ''major depressive disorder'' appears in the [[Diagnostic and Statistical Manual of Mental Disorders]] of the [[American Psychiatric Association]].  The term is generally not used in countries which instead use the ICD-10 system, but the diagnosis of ''depressive episode'' is very similar to an episode of major depression.  ''Clinical depression'' also usually refers to acute or chronic depression severe enough to need treatment. ''Minor depression'' is a less-used term for a subclinical depression that does not meet criteria for major depression but where there are at least two symptoms present for two weeks.
 
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===Major clinical depression===
 
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''Major Depression,'' or, more properly, ''Major Depressive Disorder (MDD),'' is characterized by a severely depressed mood that persists for at least two weeks. Major Depressive Disorder is specified as either "a single episode" or "recurrent"; periods of depression may occur as discrete events or as recurrent over the lifespan.  Episodes of major or clinical depression may be further divided into mild, major or severe.  Where the patient has already had an episode of [[mania]] or [[hypomania|markedly elevated mood]], a diagnosis of ''[[bipolar disorder]]'' (also called ''bipolar affective disorder'') is usually made instead of MDD; depression without periods of elation or mania is therefore sometimes referred to as ''unipolar depression'' because their mood remains on one pole.  The diagnosis also usually excludes cases where the symptoms are a normal result of [[bereavement]].
 
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Diagnosticians recognize several possible subtypes of Major Depressive Disorder.  ICD-10 does not specify a melancholic subtype, but does distinguish on presence or absence of [[psychosis]]. 
 
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* ''[[Melancholic depression|Depression with Melancholic Features]]'' - Melancholia is characterized by a loss of pleasure (anhedonia) in most or all activities, a failure of reactivity to pleasurable stimuli, a quality of depressed mood more pronounced than that of grief or loss, a worsening of symptoms in the morning hours, early morning waking, psychomotor retardation, anorexia (excessive weight loss, not to be confused with [[Anorexia Nervosa]]), or excessive guilt.
 
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* ''[[Atypical depression|Depression with Atypical Features]]'' - Atypical Depression is characterized by mood reactivity (paradoxical anhedonia) and positivity, significant weight gain or increased appetite, excessive sleep or somnolence (hypersomnia), leaden paralysis, or significant social impairment as a consequence of hypersensitivity to perceived interpersonal rejection. Contrary to its name, atypical depression is the most common form of depression.<ref>[http://depression.about.com/cs/diagnosis/a/atypicaldepress.htm Atypical Depression Actually Very Typical]</ref>
 
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* ''[[Psychotic depression|Depression with Psychotic Features]]'' - Some people with Major Depressive or Manic episode may experience psychotic features. They may be presented with [[hallucination]]s or [[delusion]]s that are either mood-congruent (content coincident with depressive themes) or non-mood-congruent (content not coincident with depressive themes).  It is clinically more common to encounter a delusional system as an adjunct to depression than to encounter hallucinations, whether visual or auditory.
 
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===Other categories of depression===
 
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[[Dysthymia]] is a long-term, mild depression that lasts for a minimum of two years. There must be persistent depressed mood continuously for at least two years. By definition the symptoms are not as severe as with Major Depression, although those with Dysthymia are vulnerable to co-occurring episodes of Major Depression. This disorder often begins in [[adolescence]] and crosses the lifespan. People who are diagnosed with major depressive episodes and dysthymic disorder are diagnosed with double depression. Dysthymic disorder develops first and then one or more major depressive episodes happen later.
 
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[[Bipolar I Disorder]] is an episodic illness in which moods may cycle between mania and depression.  In the United States, Bipolar Disorder was previously called Manic Depression.  This term is no longer favored by the medical community, however, even though depression plays a much stronger (in terms of disability and potential for suicide) role in the disorder. "Manic Depression" is still often used in the non-medical community.
 
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[[Bipolar II Disorder]] is an episodic illness that is defined primarily by depression but evidences episodes of hypomania.
 
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[[Postpartum Depression]] or ''Post-Natal Depression'' is clinical depression that occurs within two years of childbirth. Owing to physical, mental and emotional exhaustion combined with sleep-deprivation, motherhood can "set women up", so to speak, for clinical depression.<ref name="Kathy Fray">Fray, Kathy: "Oh Baby...Birth, Babies & Motherhood Uncensored", pages 367-381. Random House NZ, 2005, ISBN 1-86941-713-5</ref>
 
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Premenstrual dysphoriais is a pattern of recurrent depressive symptoms tied to the menstrual cycle.  The premenstrual decline in brain serotonin function is strongly correlated with the concomitant worsening of self-rated cardinal mood symptoms.<ref> http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=Abstract&list_uids=16515859&query_hl=2&itool=pubmed_docsum</ref> Of considerable clinical importance, the recent understanding of premenstrual dysphoria as depression points directly to effective treatment with [[Selective serotonin reuptake inhibitor]] (SSRI) antidepressants.  Previously, disrupting ovarian cyclicity had been the only recognized treatment.  A recent review of studies of a number of SSRIs has revealed that they can effectively ameliorate symptoms of premenstrual dysphoria and may actually work best when taken only during the part of the menstrual cycle when dysphoric symptoms are evident.<ref> http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=Abstract&list_uids=10471170&query_hl=1&itool=pubmed_docsum
 
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</ref>
 
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==The role of anxiety in depression==
 
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===Anxiety===
 
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The different types of Depression and Anxiety are classified separately by the DSM-IV-TR, with the exception of hypomania, which is included in the bipolar disorder category. Despite the different categories, depression and anxiety can indeed be co-occurring (occurring together, independently, and without [[mood congruence]]), or [[comorbid]] (occurring together, with overlapping symptoms, and with mood congruence). In an effort to bridge the gap between the [[DSM-IV-TR]] categories and what clinicians actually encounter, experts such as Herman Van Praag of [[Maastricht University]] have proposed ideas such as anxiety/aggression-driven depression<ref>{{cite journal | last = van Praag | first = HM | title = Can Stress Cause Depression? | journal = World J Biol Psychiatry | volume = 6 Suppl | pages = 5-22 |date= 2005 | url = http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16166019&query_hl=1&itool=pubmed_docsum}}</ref>.  This idea refers to an anxiety/depression spectrum for these two disorders, which differs from the mainstream perspective of discrete diagnostic categories.
 
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Although there is no specific diagnostic category for the comorbidity of depression and anxiety in the DSM or ICD, the National Comorbidity Survey (US) reports that 58 percent of those with major depression also suffer from lifetime anxiety.  Supporting this finding, two widely accepted clinical colloquialisms include
 
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:*''agitated depression'' - a state of depression that presents as anxiety and includes [[akathisia]], suicide, insomnia (not early morning wakefulness), nonclinical (meaning "doesn't meet the standard for formal diagnosis") and nonspecific panic, and a general sense of dread.
 
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:*''akathitic depression'' - a state of depression that presents as anxiety or suicidality and includes akathisia but does not include symptoms of panic.
 
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It is also clear that even mild anxiety symptoms can have a major impact on the course of a depressive illness, and the commingling of any anxiety symptoms with the primary depression is important to consider. A pilot study by Ellen Frank et al., at the [[University of Pittsburgh]], found that depressed or bipolar patients with lifetime panic symptoms experienced significant delays in their remission. {{Fact|date=February 2007}}  These patients also had higher levels of residual impairment, or the ability to get back into the swing of things.  On a similar note, [[Robert Sapolsky]] of [[Stanford University]] and others also argue that the relationship between stress, anxiety, and depression could be measured and demonstrated biologically.<ref>{{cite book | first = Robert M., Ph.D. | last = Sapolsky | year = 2004 | title = Why Zebras Don't Get Ulcers | chapter =  | editor =  | pages = 291-298 | publisher = Henry Holt and Company, LLC|id = ISBN 0-8050-7369-8 }}</ref> To that point, a [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10918705&query_hl=13&itool=pubmed_docsum study] by [[Heim]] and Nemeroff et al., of [[Emory University]], found that depressed and anxious women with a history of childhood abuse recorded higher heart rates and the stress hormone [[ACTH]] when subjected to stressful situations.
 
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===Hypomania===
 
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[[Hypomania]], as the name suggests, is a state of mind or behavior that is "below" (''hypo'') mania.  In other words, a person in a hypomanic state often displays behavior that has all the hallmarks of a full-blown mania (e.g., marked elevation of mood that is characterized by euphoria, over activity, disinhibition, impulsivity, a decreased need for sleep, hypersexuality), but these symptoms, though disruptive and seemingly out of character, are not so pronounced as to be considered a diagnosably manic episode.  In a psychiatric context, it is important to identify the possible presence and characteristics of manic and hypomanic episodes, since these may lead to a diagnosis of [[bipolar disorder]], which is medically treated differently from depression.
 
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Another important point is that hypomania is a diagnostic category that includes both anxiety and depression.  It often presents as a state of anxiety that occurs in the context of a clinical depression.  Patients in a hypomanic state often describe a sense of extreme generalized or specific anxiety, recurring panic attacks, night terrors, guilt, and [[agency]] (as it pertains to [[codependence]] and counterdependence). All of this happens while they are in a state of retarded or somnolent depression. This is the type of depression in which a person is lethargic and unable to move through life.  The terms ''retarded'' and ''somnolent'' are shorthand for states of depression that include lethargy, hypersomnia, a lack of motivation, a collapse of ADLs (activities of daily living), and social withdrawal.  This is similar to the shorthand used to describe an "agitated" or "[[akathisia|akathitic]]" depression.
 
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In considering the hypomania-depression connection, a distinction should be made between anxiety, [[panic]], and [[Stress (medicine)|stress]]. Anxiety is a physiological state that is caused by the [[sympathetic nervous system]]. Anxiety does not need an outside influence to occur. Panic is related to the [[fight or flight|"fight or flight"]] mechanism.  It  is a reaction, induced by an outside stimulus, and is a product of the [[sympathetic nervous system]] and the [[cerebral cortex]].  More plainly, panic is an anxiety state that we are thinking about. Finally, stress is a [[psychosocial]] reaction, influenced by how a person filters nonthreatening external events.  This filtering is based on one's own ideas, assumptions, and expectations. Taken together, these ideas, assumptions, and expectations are called social [[constructionism]].
 
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On a final note, researchers at the [[University of California]], [[San Diego]], under the guidance of Hagop Akiskal MD, have found convincing evidence for the co-occurrence of hypomanic symptoms associated with a diagnosis of depression where the diagnosis does not meet criteria for Bipolar Disorder.{{Fact|date=February 2007}}  Symptoms under consideration, such as irritability, misdirected anger, and compulsivity, also may not present sufficiently to be considered a hypomanic episode, as described by a [[Bipolar|Bipolar II]] Disorder. As noted in the Frank study {{Fact|date=February 2007}} mentioned above, this particular course of the disease, with the breakthrough of anxiety, may have a significant impact on the overall course of the depression.
 
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This idea of co-occurring anxiety and depression is supported in a study by Giovanni Cassano MD of the [[University of Pisa]] and his collaborators on the Spectrum Project, who found a correlation between lifetime hypomanic and manic symptoms and the severity of the depression.{{Fact|date=February 2007}}
 
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{{quotation|The presence of a significant number of manic/hypomanic items in patients with recurrent unipolar depression seems to challenge the traditional unipolar-bipolar dichotomy.}}
 
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These authors, along with many other researchers{{Fact|date=February 2007}}, argue in support of a revision of the approach to psychiatric diagnosis into what is being called the mood spectrum, so as to "[make] more accurate diagnostic evaluation[s]." This approach, although controversial, has begun to be given consideration by many behavioral health professionals.
 
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==Causes of depression==
 
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No specific cause for depression has been identified, but a number of factors are believed to be involved.
 
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* '''[[Heredity]]''' &ndash; The tendency to develop depression may be inherited; there is some evidence that this disorder may run in families. "Running in families" may indicate an environmental cause, however. A 2004 [[press release]] from the [[National Institute of Mental Health]] declares "major depression is thought to be 40–70 percent heritable, but likely involves an interaction of several genes with environmental events". [http://depression.about.com/od/causes/a/mutantgene.htm]
 
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[[Image:synapse.png|thumbnail|200px|right|Brain chemicals called neurotransmitters allow electrical signals to move from the axon of one nerve cell to the neuron of another. A shortage of neurotransmitters impairs brain communication.]]
 
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* '''[[Physiology]]''' &ndash; There may be changes or imbalances in chemicals that transmit information in the brain, called [[neurotransmitters]].  Many modern [[antidepressant]] [[Psychoactive drug|drug]]s increase levels of certain neurotransmitters, such as [[serotonin]] and [[norepinephrine]] (noradrenaline).  Although the causal relationship is unclear, it is known that antidepressant medications can relieve certain symptoms of depression, although critics point out that the relationship between [[serotonin]], [[Selective serotonin reuptake inhibitor|SSRIs]], and depression usually is typically greatly oversimplified when presented to the public (see [http://medicine.plosjournals.org/archive/1549-1676/2/12/pdf/10.1371_journal.pmed.0020392-L.pdf here]). Recent research has suggested that there may be a link between depression and [[neurogenesis]] of the [[hippocampus]].{{Fact|date=February 2007}}  This horseshoe-shaped structure is a center for both mood and memory.  Loss of neurons in the hippocampus is found in depression and correlates with impaired memory and dysthemic mood.  The hippocampus regains mass when exposed to treatments that increase brain serotonin, and when regrown, mood and memory tend to be restored. 
 
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*[[Seasonal affective disorder]] (SAD) is a type of depressive disorder that occurs in the winter when daylight hours are short.  It is believed that the body's production of [[melatonin]], which is produced at higher levels in the dark, plays a major part in the onset of SAD and that many sufferers respond well to bright light therapy, also known as [[phototherapy]].
 
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* '''[[Psychology|Psychological]] factors''' &ndash; Low [[self-esteem]] and self-defeating or distorted thinking are connected with depression. Although it is not clear which is the cause and which is the effect, it is known that depressed persons who are able to make corrections in their thinking patterns can show improved mood and [[self-esteem]].{{Fact|date=February 2007}}  Psychological factors related to depression include the complex development of one's [[personality]] and how one has learned to cope with external environmental factors such as [[Stress (medicine)|stress]].{{Fact|date=February 2007}}
 
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* '''Early experiences''' &ndash; Events such as the death of a parent, [[abandonment]] or rejection, [[neglect]], chronic illness, and physical, psychological, or sexual [[abuse]] can also increase the likelihood of depression later in life. [[Post-traumatic stress disorder]] (PTSD) includes depression as one of its major symptoms.
 
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* '''Life experiences''' &ndash; Job loss, [[poverty]], financial difficulties, [[gambling addiction]], long periods of [[unemployment]], the [[Grief|loss]] of a spouse or other family member, divorce or the end of a committed relationship, [[involuntary celibacy]], or other [[Psychological trauma|trauma]]tic events may trigger depression.  Long-term [[Stress (medicine)|stress]] at home, work, or school can also be involved. Bullying in late adolescence is also thought to be a contributing factor. 
 
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* '''Medical conditions''' &ndash; Certain illnesses, including cardiovascular disease,<ref>{{cite journal | url = http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15581413&query_hl=7 | title = 5-Lipoxygenase as a putative link between cardiovascular and psychiatric disorders | last = Manev | first = R | coauthors = Manev H | journal = Critical Reviews in Neurobiology |date= 2004 | volume = 16 | issue = 1?2 | pages = 181?6 }}</ref> [[hepatitis]], [[mononucleosis]], [[hypothyroidism]], and organic brain damage caused by degenerative conditions such as Parkinson disease, Multiple Sclerosis or by traumatic blunt force injury may contribute to depression, as may certain prescription drugs such as [[hormonal contraception]] methods and [[steroid]]s. Gender dysphoria can also cause depression.
 
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* '''Diet''' &ndash; The increase in depression in industrialised societies has been linked to [[diet (nutrition)|diet]], particularly to reduced levels of [[omega-3]] [[fatty acids]] in [[intensive farming|intensively farmed]] food and processed foods.<ref>{{cite book | first = Felicity | last = Lawrence | year = 2004 | title = Not on the Label | chapter = The Ready Meal | editor = Kate Barker | pages = 214 | publisher = Penguin | id = ISBN 0-14-101566-7 }}</ref>  This link has been at least partly validated by studies using [[dietary supplements]] in schools<ref>{{cite web | title = Using Fatty Acids for Enhancing Classroom Achievement | url = http://www.durhamtrial.org/ | accessmonthday = January|accessyear = 2004 }}</ref> and by a double-blind test in a prison. An excess of [[omega-6]] fatty acids in the diet was shown to cause depression in rats.<ref>{{cite web | title = Omega-6 Levels in Brain Linked to Depression | url = http://www.durhamtrial.org | accessmonthday=May| accessyear = 2006 }}</ref>
 
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* '''Alcohol and other drugs''' &ndash; Alcohol can have a negative effect on mood, and misuse of alcohol, [[benzodiazepine]]-based tranquilizers, and sleeping medications can all play a major role in the length and severity of depression.
 
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* '''[[Postpartum depression]]''' (also known as ''postnatal depression'') &ndash; Dr. Ruta M Nonacs writes that while many women experience some mood changes after giving birth, "10-15% of women experience a more disabling and persistent form of mood disturbance (e.g., postpartum depression, postpartum psychosis)".[http://www.emedicine.com/med/topic3408.htm] When it occurs, the onset typically is within three months after delivery, and it may last for several months.  About two new mothers out of a thousand experience the more serious depressive disorder Postnatal [[Psychosis]] which includes hallucinations and/or delusions.
 
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* '''Living with a depressed person''' &ndash; Those living with someone suffering from depression experience increased anxiety and life disruption, increasing the possibility of also becoming depressed.{{Fact|date=February 2007}}
 
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* '''Evolutionary biological hypotheses of depression''' &ndash; Evolutionary analyses usually consider possible functions for depressed mood as well as clinical depression.
 
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:* '''The psychic pain hypothesis''': psychic pain, such as depression, is analogous to physical pain. The function of physical pain is to inform the organism that it is suffering damage, to motivate it to withdraw from the source of damage, and to learn to avoid such damage-causing circumstances in the future. Analogously, depression informs the sufferer that current circumstances, such as the loss of a mate, are imposing a threat to biological fitness, it motivates the sufferer to cease activities that led to the costly situation, if possible, and it causes him or her to learn to avoid similar circumstances in the future. Proponents of this view tend to focus on low mood, and regard clinical depression as a dysfunctional extreme of low mood. See, e.g., [http://www-personal.umich.edu/~nesse/Articles/IsDepAdapt-ArchGenPsychiat-2000.pdf Nesse 2000] and [http://www-personal.umich.edu/~nesse/Articles/Keller-Nesse-MoodSubtypes-JAD-2005.pdf Keller and Nesse 2005]; see also [http://itb1.biologie.hu-berlin.de/~hagen/papers/perinatal.pdf Hagen and Barrett n.d.].
 
  
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:* '''[[Rank theory of depression|Rank theory]]''': If an individual is involved in a lengthy fight for dominance in a [[social]] group and is clearly losing, depression causes the individual to back down and accept the submissive role.  In doing so, the individual is protected from unnecessary harm.  In this way, depression helps maintain a social hierarchy. This theory is a special case of a more general theory derived from the psychic pain hypothesis: that the cognitive response that produces modern-day depression evolved as a mechanism that allows people to assess whether they are in pursuit of an unreachable goal, and if they are, to motivate them to desist. See, e.g., [http://www-personal.umich.edu/~nesse/Articles/IsDepAdapt-ArchGenPsychiat-2000.pdf Nesse 2000].
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Although "melancholia" remained the dominant diagnostic term, "depression" gained increasing currency in medical treatises and was a synonym by the end of the century; German psychiatrist [[Emil Kraepelin]] may have been the first to use it as the overarching term, referring to different kinds of melancholia as "depressive states."<ref name=Wolpert/> [[Freud]] likened the state of melancholia to mourning in his 1917 paper ''Mourning and Melancholia''. He theorized that [[object (philosophy)|objective]] loss, such as the loss of a valued relationship through death or a romantic break-up, results in [[subject (philosophy)|subjective]] loss as well; the depressed individual has identified with the object of affection through an [[unconscious mind|unconscious]], [[narcissism|narcissistic]] process called the "libidinal [[cathexis]]" of the [[Id, ego and super-ego|ego]]. Such loss results in severe melancholic symptoms more profound than mourning; not only is the outside world viewed negatively but the ego itself is compromised.<ref>Sigmund Freud, ''On Murder, Mourning, and Melancholia'' (Penguin Classic, 2005, ISBN 978-0141183794).</ref>  He also emphasized early life experiences as a predisposing factor.<ref name=Radden2003/> [[Adolf Meyer (psychiatrist)|Adolf Meyer]] put forward a mixed social and biological framework emphasizing ''reactions'' in the context of an individual's life, and argued that the term "depression" should be used instead of "melancholia."<ref name="Lewis1934">A.J. Lewis, [https://www.cambridge.org/core/journals/journal-of-mental-science/article/melancholia-a-historical-review/1DE306A9C4BE5D7B3732DFBBD18418E6 Melancholia: A historical review] ''Journal of Mental Science'' 80(328) (January 1934): 1-42. Retrieved October 14, 2022.</ref>
  
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:* '''Honest signaling theory''': When social partners have conflicts of interest, 'cheap' signals of need, such as crying, might not be believed. Biologists and economists have proposed that [[Signaling game|signals with inherent costs]] can credibly signal information when there are conflicts of interest. The symptoms of major depression, such as loss of interest in virtually all activities and suicidality, are inherently costly, but, as costly signaling theory requires, the costs differ for individuals in different states. For individuals who are not genuinely in need, the fitness cost of major depression is very high because it threatens the flow of fitness benefits. For individuals who are in genuine need, however, the fitness cost of major depression is low because the individual is not generating many fitness benefits. Thus, only an individual in genuine need can afford to suffer major depression. Major depression therefore serves as an honest, or credible, signal of need. See, e.g., [http://itb1.biologie.hu-berlin.de/~hagen/papers/Dahlem.pdf Hagen 2003], [http://biology.unm.edu/Biology/pwatson/public_html/dp1.htm Watson and Andrews 2002].
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The first version of the American Psychiatric Association's ''Diagnostic and Statistical Manual of Mental Disorders'' (''DSM-I'') published in 1952, contained "depressive reaction" and the ''DSM-II'', published in 1968, contained "depressive neurosis." These were defined as an excessive reaction to internal conflict or an identifiable event, and also included a depressive type of manic-depressive psychosis within the area of "Major affective disorders."<ref>Committee on Nomenclature and Statistics of the American Psychiatric Association, ''Diagnostic and statistical manual of mental disorders: DSM-II'' (American Psychiatric Association, 1968), 36–37, 40. </ref>
  
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:* '''Social navigation or niche change theory''': The social navigation, bargaining, or niche change hypothesis [http://biology.unm.edu/Biology/pwatson/public_html/dp1.htm] suggests that depression, operationally defined as a combination of prolonged anhedonia and psychomotor retardation or agitation, provides a focused sober perspective on socially imposed constraints hindering a person’s pursuit of major fitness enhancing projects. Simultaneously, publicly displayed symptoms, which reduce the depressive's ability to conduct basic life activities, serve as a social signal of need; the signal's costliness for the depressive certifies its honesty. Finally, for social partners who find it uneconomical to respond helpfully to an honest signal of need, the same depressive symptoms also have the potential to extort relevant concessions and compromises. Depression’s extortionary power comes from the fact that it retards the flow of just those goods and services such partners have come to expect from the depressive under status quo socioeconomic arrangements.<p>Thus depression may be a social adaptation especially useful in motivating a variety of social partners, all at once, to help the depressive initiate major fitness-enhancing changes in their socioeconomic life. There are extraordinarily diverse circumstances under which this may become necessary in human social life, ranging from loss of rank or a key social ally which makes the current social niche uneconomic to having a set of creative new ideas about how to make a livelihood which begs for a new niche. The social navigation hypothesis emphasizes that an individual can become tightly ensnared in an overly restrictive matrix of social exchange contracts, and that this situation sometimes necessitates a radical contractual upheaval that is beyond conventional methods of negotiation. Regarding the treatment of depression, this hypothesis calls into question any assumptions by the clinician that the typical cause of depression is related to maladaptive perverted thinking processes or other purely endogenous sources. The social navigation hypothesis calls instead for a penetrating analysis of the depressive’s talents and dreams, identification of relevant social constraints (especially those with a relatively diffuse non-point source within the social network of the depressive), and practical social problem-solving therapy designed to relax those constraints enough to allow the depressive to move forward with their life under an improved set of social contracts.<ref>{{cite journal | last = Watson | first = PJ | coauthors = Andrews PW | title = Toward a revised evolutionary adaptationist analysis of depression: the social navigation hypothesis | journal = Journal of Affective Disorders |date= October 2002| volume = 72 | pages = 1-14}}</ref>
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The term "Major Depressive Disorder'' was introduced by a group of US clinicians in the mid-1970s as part of proposals for diagnostic criteria based on patterns of symptoms (called the "Research Diagnostic Criteria," building on the earlier [[Feighner Criteria]]).<ref name= Spitzer>Robert L. Spitzer, [http://www.garfield.library.upenn.edu/classics1989/A1989U309700001.pdf The Development of Diagnostic Criteria in Psychiatry] ''Research diagnostic criteria (RDC)'', 1975. Retrieved October 14, 2022.</ref>  The [[American Psychiatric Association]] added "major depressive disorder" to the ''DSM-III'', published in 1980, as a split of the previous [[depressive neurosis]] in the ''DSM-II'', which also encompassed the conditions now known as [[dysthymia]] (or Persistent Depressive Disorder or PDD) and [[adjustment disorder with depressed mood]].<ref>Johan Rosqvist and Michel Hersen (eds.), ''Handbook of Psychological Assessment, Case Conceptualization, and Treatment, Volume 1: Adults'' (Wiley, 2007, ISBN 978-0471779995).</ref>  
  
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:* '''Bargaining theory''': This theory is similar to the honest signaling, niche change, and social navigation theory. It basically adds one additional element to honest signaling theory. The fitness of social partners is generally correlated. When a wife suffers depression and reduces her investment in offspring, for example, the husband's fitness is also put at risk. Thus, not only do the symptoms of major depression serve as costly and therefore honest signals of need, they also compel social partners to respond to that need in order to prevent their own fitness from being reduced. See, e.g., [http://itb1.biologie.hu-berlin.de/~hagen/papers/ppd.pdf Hagen 1999], [http://itb1.biologie.hu-berlin.de/~hagen/papers/Dahlem.pdf Hagen 2003].
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To maintain consistency, the [[World Health Organization]]'s ''International Classification of Diseases  (ICD-10)'' used the same criteria, with only minor alterations. It used the ''DSM'' diagnostic threshold to mark a "mild depressive episode," adding higher threshold categories for moderate and severe episodes.<ref name="DSMvsICD">Alan M. Gruenberg, Reed D. Goldstein, and Harold Alan Pincus, "Classification of Depression: Research and Diagnostic Criteria: DSM-IV and ICD-10" in Julio Licinio and Ma-Li Wong (eds.), ''Biology of Depression: From Novel Insights to Therapeutic Strategies'' (Wiley-Blackwell, 2005, ISBN 3527307850), 1–12.</ref> The ancient idea of "melancholia: still survives in the notion of a melancholic subtype.
  
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:* '''Darwinian Psychiatry''': This "failure of model-integration" theory is focused on behavioral systems (i.e., reproduction, survival, kin-investment, reciprocation), in which individuals have a marked ''functional'' consequences due to both ultimate and proximate condition-producing causes (plural). Using the '''15% Principle,''' it distinguishes between (and incorporates) physiological, phenotpyical, trait variational, dysfunctional algorithms, dysfunctional automatic, and adverse environmental systems, wherein individuals act adaptively, albeit suboptimally, even with dysregulation, and is then assigned a ratio to each of the manifold contributing factors, creating a profile of both proximate and ultimate causal factors for which depressive features are locked-in adaptations. Joining "evolved capacities" and "adequate functioning," it argues that many features of clinical depression are adaptive, albeit suboptimally and dysfunctionally. Using "homeostasis" as a benchmark of healthy life-strategies, depressions are regarded as minimally conservative of individual energies in which the failure to adapt, or precipitating incidents, rapid resolutions, creative capacities, physiological responses, trait variation, interpersonal conflicts, maturational disruptions, and suboptimal information-processing trigger depressive responses in individuals in order to achieve more modest goals within each of the four major behavioral systems. (Reactive depressions, or "response-to-loss" models, are a separate adaptive responses to functioning, usually transient and self-correcting.) The depressive's cost-benefit analyses are also incorporated in the final assessment, and then psychiatric treatment strategies are designed to treat all the multi-causal factors together as a holistic phenomenon through empirically-validated modalities. See, <ref> Micahel McGuire and Alfonso Troisi, Darwiniam Psychiatry. New York: Oxford University Press, 1998, esp. chaps. 1-7</ref>
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==Symptoms==
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[[File:A woman diagnosed as suffering from melancholia. Colour lith Wellcome L0026686.jpg|thumb|300px\An 1892 lithograph of a woman diagnosed with [[melancholia]]]]
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Major depression significantly affects a person's family and [[Social predictors of depression|personal relationships]], work or school life, sleeping and eating habits, and general health.<ref name=NIMHPub>[https://www.nimh.nih.gov/sites/default/files/documents/health/publications/depression/21-mh-8079-depression_0.pdf Depression] ''National Institute of Mental Health'' (NIMH), 2021. Retrieved October 16, 2022. </ref> A person having a [[major depressive episode]] usually exhibits a low mood, which pervades all aspects of life, and an inability to experience pleasure in previously enjoyable activities. They may be preoccupied with—or [[Rumination (psychology)|ruminate]] over—thoughts and feelings of worthlessness, inappropriate guilt or regret, helplessness or hopelessness.<ref name=DSM-5/>  
  
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==Treatment==
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Other symptoms of depression include poor concentration and memory, withdrawal from social situations and activities, reduced [[libido|sex drive]], irritability, and thoughts of death or [[suicide]]. [[Insomnia]] is common; in the typical pattern, a person wakes very early and cannot get back to sleep. [[Hypersomnia]], or oversleeping, can also happen. In severe cases, depressed people may have [[psychosis|psychotic]] symptoms. These symptoms include [[delusion]]s or, less commonly, [[hallucination]]s, usually unpleasant.<ref name=DSM-5/>
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Treatment of depression varies broadly and is different for each individual. Various types and combinations of treatments may have to be tried, but without hope in a complete solution to the problem. There are two primary modes of treatment, typically used in conjunction: [[medication]] and [[psychotherapy]]. A third treatment, [[electroconvulsive therapy]] (ECT), may be used when chemical treatment fails.
 
  
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Alternative treatments used for depression include exercise and the use of vitamins, herbs, or other nutritional supplements.{{Fact|date=February 2007}}
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A depressed person may report multiple physical symptoms such as [[fatigue]], headaches, or digestive problems. [[Appetite]] often decreases, resulting in weight loss, although increased appetite and weight gain occasionally occur. Family and friends may notice [[psychomotor agitation|agitation]] or [[psychomotor retardation|lethargy]]. Elderly people may not present with classical depressive symptoms; they may have [[Cognition#Psychology|cognitive]] symptoms of recent onset, such as forgetfulness, and a more noticeable slowing of movements. Depressed children may often display an irritable rather than a depressed mood; most lose interest in school and show a steep decline in academic performance.<ref name=DSM-5/>
  
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The effectiveness of treatment often depends on factors such as the amount of optimism and hope the sufferer is able to maintain, the control s/he has over stressors, the severity of symptoms, the amount of time the sufferer has been depressed, the results of previous treatments, and the degree of support of family, friends, and significant others.{{Fact|date=February 2007}}
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==Causes==
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[[File:Diathesis_stress_model_cup_analogy.png|thumb|400px|A cup analogy demonstrating the [[diathesis–stress model]] that under the same amount of stressors, person 2 is more vulnerable than person 1, because of their predisposition.<ref>Benjamin L. Hankin and John R.Z. Abela, ''Development of Psychopathology: A Vulnerability-Stress Perspective'' (SAGE Publications, Inc, 2005, ISBN 1412904900).</ref>]]
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Major depressive disorder is believed to be caused by a combination of [[genetics|genetic]], environmental, and psychological factors: In other words, biological, psychological, and social factors all play a role in causing depression. Risk factors include a [[Family history (medicine)|family history]] of the condition, major life changes, certain medications, [[chronic health problem]]s, and [[substance use disorder]]s.<ref name=NIH2016/><ref name=DSM-5/>
  
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Although treatment is generally effective{{Fact|date=February 2007}}, in some cases the condition does not respond. Treatment-resistant depression warrants a full assessment, which may lead to the addition of psychotherapy, higher medication dosages, changes of medication or combination therapy, a trial of [[Electroconvulsive therapy|ECT]]/electroshock, or even a change in the diagnosis, with subsequent treatment changes. Although this process helps many, some people's symptoms continue unabated.
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The [[diathesis–stress model]] specifies that depression results when a preexisting vulnerability, or [[Diathesis (medicine)|diathesis]], is activated by stressful life events. The preexisting vulnerability can be either [[genetics|genetic]], implying an interaction between [[nature and nurture]], or [[Schema (psychology)|schematic]], resulting from views of the world learned in childhood.<ref>George M. Slavich, [https://www.psychologicalscience.org/observer/deconstructing-depression-a-diathesis-stress-perspective Deconstructing depression: A diathesis-stress perspective] ''Association for Psychological Science (APS)'', September 3, 2004. Retrieved October 16, 2022.</ref>
  
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In emergencies, [[psychiatric hospital|psychiatric hospitalization]] is used simply to keep suicidal people safe until they cease to be dangers to themselves. Another treatment program is [[partial hospitalization]], in which the patient sleeps at home but spends the day, either five or seven days a week, in a psychiatric hospital setting in intense treatment. This treatment usually involves [[group therapy]], [[psychotherapy|individual therapy]], [[psychopharmacology]], and academics (in child and adolescent programs).
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American psychiatrist [[Aaron Beck]] suggested that a triad of automatic and spontaneous negative thoughts about the [[Self-image|self]], the [[Social environment|world or environment]], and the future may lead to other depressive signs and symptoms.<ref name=Beck>Aaron T. Beck, A. John Rush, Brian F. Shaw, and Gary Emery, ''Cognitive Therapy of Depression'' (The Guilford Press, 1987, ISBN 978-0898629194).</ref>
  
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===Medication===
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[[Adverse childhood experiences]] (incorporating [[Child abuse|childhood abuse]], neglect and [[Dysfunctional family|family dysfunction]]) markedly increase the risk of major depression.<ref name=DSM-5/> Childhood trauma also correlates with severity of depression, poor responsiveness to treatment, and length of illness.  
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Medication that relieves the symptoms of depression has been available for several decades. These drugs are listed in order of historical development. Typical first-line therapy for depression is the use of an [[selective serotonin reuptake inhibitor]], such as [[citalopram]] (Celexa), [[fluoxetine]] (Prozac), [[paroxetine]] (Paxil), and [[sertraline]] (Zoloft). Under some circumstances, medication and psychotherapy may be more effective than either treatment separately.<ref>{{cite journal | last = Thase | first = ME | title = When are psychotherapy and pharmacotherapy combinations the treatment of choice for major depressive disorder? | journal = Psychiatr Q. | volume = 70 | issue=4 | pages = 333-346 |date= 1999 | url = http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10587988&dopt=Abstract}}</ref>
 
  
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''[[Monoamine oxidase inhibitor]]s'' (MAOIs) such as Nardil may be used if other antidepressant medications are ineffective. Because there are potentially fatal interactions between this class of medication and certain foods and drugs, they are rarely prescribed anymore. MAOI's are used to block the enzyme monoamine oxidase which breaks down neurotransmitters such as serotonin and norepinephrine (noradrenaline). MAOI's are as effective as tricyclics, if not slightly more effective {{Fact|date=February 2007}}. A new MAOI has recently been introduced. [[Moclobemide]] (Manerix), known as a [[reversible inhibitor of monoamine oxidase A]] (RIMA), follows a very specific chemical pathway and does not require a special diet.  
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There has been a continuing discussion of whether neurological disorders and mood disorders may be linked to [[creativity]], a discussion that goes back to [[Aristotle|Aristotelian]] times.<ref>Nancy C. Andreasen, [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3181877/ The relationship between creativity and mood disorders] ''Dialogues in Clinical Neuroscience'' 10(2) (2008): 251–255. Retrieved October 16, 2022.</ref> British literature gives many examples of reflections on depression.<ref> Carol F. Heffernan, ''The Melancholy Muse: Chaucer, Shakespeare and Early Medicine'' (Duquesne University Press, 1995, ISBN 978-0820702629). </ref> English philosopher [[John Stuart Mill]] experienced a several-months-long period of what he called "a dull state of nerves," when one is "unsusceptible to enjoyment or pleasurable excitement; one of those moods when what is pleasure at other times, becomes insipid or indifferent." He quoted English poet [[Samuel Taylor Coleridge]]'s "Dejection" as a perfect description of his case: "A grief without a pang, void, dark and drear, / A drowsy, stifled, unimpassioned grief, / Which finds no natural outlet or relief / In word, or sigh, or tear."<ref>John Stuart Mill, ''Autobiography'' (Adamant Media Corporation, 2000, ISBN 978-1421242002).</ref> English writer [[Samuel Johnson]] used the term "the black dog" in the 1780s to describe his own depression, and it was subsequently popularized by British Prime Minister Sir [[Winston Churchill]], who also had the disorder.<ref>Kerrie Eyers (ed.), ''Tracking the Black Dog'' (University of New South Wales, 2006, ISBN 978-0868408125). </ref>
  
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''[[Tricyclic antidepressant]]s'' are the oldest and include such medications as [[amitriptyline]] and [[desipramine]]. Tricyclics block the reuptake of certain neurotransmitters such as norepinephrine (noradrenaline) and serotonin. They are used less commonly now because of their side effects, which include increased [[heart]] rate, drowsiness, dry mouth,constipation, urinary retention, blurred vision,dizziness, confusion, and sexual dysfunction. Most importantly, they have a high potential to be lethal in moderate overdose. However, tricyclic antidepressants are still used because of their high potency, especially in severe cases of clinical depression.
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Depression can also come secondary to a chronic or terminal medical condition, such as [[HIV/AIDS]] or [[asthma]], and may be labeled "secondary depression."<ref>Paula J. Clayton and C.E. Lewis, [https://pubmed.ncbi.nlm.nih.gov/6455456/ The significance of secondary depression] ''Journal of Affective Disorders'' 3(1) (March 1981): 25–35. Retrieved October 16, 2022.</ref> It is unknown whether the underlying diseases induce depression through effect on quality of life, or through shared etiologies (such as degeneration of the [[basal ganglia]] in [[Parkinson's disease]] or immune dysregulation in asthma). Depression may also be [[iatrogenic]] (the result of [[healthcare]]), such as depression as a side effect of prescribed medications. Depression occurring after giving birth, [[postpartum depression]], is thought to be the result of [[Hormone|hormonal]] changes associated with [[pregnancy]]. [[Seasonal affective disorder]] is a type of depression associated with seasonal changes in sunlight where people who have normal mental health throughout most of the year exhibit depressive symptoms at the same time each year, most often in winter.
  
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''[[Selective serotonin reuptake inhibitor]]s'' (SSRIs) are a family of antidepressant considered to be the current standard of drug treatment. It is thought that one cause of depression is an inadequate amount of [[serotonin]], a chemical used in the brain to transmit signals between neurons. SSRIs are said to work by preventing the reabsorption of serotonin by the nerve cell, thus maintaining the levels the brain needs to function effectively, although two researchers recently demonstrated that the advertised connection between seratonin deficiency and symptoms of depression is a marketing technique rather than a scientific portrayal of how the drugs actually work. [http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371/journal.pmed.0020392]. Recent research indicates that these drugs may interact with transcription factors known as "clock genes"[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15994025&query_hl=24], which may be important for the addictive properties of drugs of abuse and possibly in obesity[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16094306&query_hl=27][http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16288309&query_hl=24].
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==Diagnosis==
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There is no laboratory test for clinical depression, and so diagnosis is based on the person's reported experiences, behavior reported by relatives or friends, and a [[mental status examination]], although tests may be conducted to rule out physical conditions that can cause similar symptoms.<ref>  Lauren L. Patton and Michael Glick (eds.), ''The ADA Practical Guide to Patients with Medical Conditions 2nd Edition'' (Wiley-Blackwell, 2015, ISBN 978-1118924402).</ref>
  
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This family of drugs includes [[fluoxetine]] (Prozac), [[paroxetine]] (Paxil), [[escitalopram]] (Lexapro), [[citalopram]] (Celexa), and [[sertraline]] (Zoloft). These antidepressants typically have fewer adverse side effects than the tricyclics or the MAOIs, although such effects as drowsiness, dry mouth, nervousness, anxiety, insomnia, decreased appetite, and decreased ability to function sexually may occur. Some side effects may decrease as a person adjusts to the drug, but other side effects may be persistent.
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===Clinical assessment===
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[[File:A wretched man with an approaching depression; represented b Wellcome V0011145.jpg|thumb|right|300px|Caricature of a man with depression]]
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A diagnostic assessment may be conducted by a suitably trained [[general practitioner]], or by a [[psychiatrist]] or [[psychologist]], who records the person's current circumstances, biographical history, current symptoms, family history, and alcohol and drug use. The assessment also includes a [[mental state examination]], which is an assessment of the person's current mood and thought content, in particular the presence of themes of hopelessness or [[pessimism]], [[self-harm]] or [[suicide]], and an absence of positive thoughts or plans.<ref name=NIMHPub/>
  
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''[[Norepinephrine (noradrenaline) reuptake inhibitor]]s'' (NRIs) such as [[reboxetine]] (Edronax)  act via norepinephrine (also known as ''noradrenaline''). NRIs are thought to have a positive effect on concentration and motivation in particular.{{Fact|date=February 2007}}
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[[Rating scale]]s are not used to diagnose depression, but they provide an indication of the severity of symptoms for a time period, so a person who scores above a given cut-off point can be more thoroughly evaluated for a depressive disorder diagnosis. Several rating scales are used for this purpose, including the [[Hamilton Rating Scale for Depression]], the [[Beck Depression Inventory]], and the [[Suicide Behaviors Questionnaire-Revised]].
  
−
''[[Norepinephrine-dopamine reuptake inhibitor]]s'' such as [[bupropion]] (Wellbutrin, Zyban) inhibit the neuronal reuptake of [[dopamine]] and [[norepinephrine]] (noradrenaline)[http://www.psychiatrist.com/pcc/pccpdf/v06n04/v06n0403.pdf].
+
Specialist mental health services are rare in rural areas, especially in developing countries, and thus diagnosis and management is left largely to [[primary care|primary-care]] clinicians. Since primary-care physicians have more difficulty with under-recognition and under-treatment of depression compared to psychiatrists, they often miss cases where people experience physical symptoms accompanying their depression.  
  
−
''[[Serotonin-norepinephrine reuptake inhibitor]]s'' (SNRIs) such as [[venlafaxine]] (Effexor) and [[duloxetine]] (Cymbalta) are a newer form of antidepressant that works on both noradrenaline and serotonin. They typically have similar side effects to the SSRIs, although there may be a withdrawal syndrome on discontinuation that may necessitate dosage tapering.
+
A doctor generally performs a medical examination and selected investigations to rule out other causes of depressive symptoms. These can include blood tests to exclude [[hypothyroidism]] and [[Metabolic disorder|metabolic disturbance]], or a [[systemic infection]] or chronic disease.[[Testosterone]] levels may be evaluated to diagnose [[hypogonadism]], a cause of depression in men. Adverse affective reactions to medications or alcohol misuse may be ruled out, as well. Subjective cognitive complaints appear in older depressed people, but they can also be indicative of the onset of a [[dementia|dementing disorder]], such as [[Alzheimer's disease]], which can be rule out through [[Neuropsychological assessment|Cognitive testing]] and brain imaging.
  
−
''[[Noradrenergic and specific serotonergic antidepressant]]s'' (NASSAs) form a newer class of antidepressants which purportedly work to increase [[norepinephrine]] ([[noradrenaline]]) and [[serotonin]] neurotransmission by blocking presynaptic alpha-2 [[adrenergic receptor]]s while at the same time minimizing [[serotonin]] related side-effects by blocking certain [[serotonin]] receptors. The only example of this class in clinical use is [[mirtazapine]] (Avanza, Zispin, Remeron).
+
===DSM and ICD criteria===
 +
The most widely used criteria for diagnosing depressive conditions are found in the [[American Psychiatric Association]]'s ''[[Diagnostic and Statistical Manual of Mental Disorders]]'' (DSM) and the [[World Health Organization]]'s ''[[ICD|International Statistical Classification of Diseases and Related Health Problems]]'' (ICD). The latter system is typically used in European countries, while the former is used in the US and many other non-European nations, and the authors of both have worked towards conforming one with the other. Both DSM and ICD mark out typical (main) depressive symptoms.<ref name="DSMvsICD" />
  
−
===Dietary supplements===
+
;ICD-11
−
{{unreferenced|section|date=December 2006}}
+
Under mood disorders, ICD-11 classifies major depressive disorder as either "single episode depressive disorder" (where there is no history of depressive episodes, or of mania)<ref name=ICD-11Single>[https://icd.who.int/browse11/l-m/en#/http://id.who.int/icd/entity/578635574 6A70 Single episode depressive disorder] ''ICD-11''. Retrieved October 17, 2022.</ref> or "recurrent depressive disorder" (where there is a history of prior episodes, with no history of mania).<ref name=ICD-iiRecurrent> [https://icd.who.int/browse11/l-m/en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f1194756772 6A71 Recurrent depressive disorder] ''ICD-11''. Retrieved October 17, 2022.</ref> These two disorders are classified as "Depressive disorders," in the category of "Mood disorders". The symptoms, which must affect work, social, or domestic activities and be present nearly every day for at least two weeks, are a depressed mood or [[anhedonia]], accompanied by other symptoms such as "difficulty concentrating, feelings of worthlessness or excessive or inappropriate guilt, hopelessness, recurrent thoughts of death or suicide, changes in appetite or sleep, psychomotor agitation or retardation, and reduced energy or fatigue."<ref name=ICD-11Single/><ref name=ICD-iiRecurrent/> The ICD-11 system allows further specifiers for the current depressive episode: the severity (mild, moderate, severe, unspecified); the presence of psychotic symptoms (with or without psychotic symptoms); and the degree of remission if relevant (currently in partial remission, currently in full remission).<ref name=ICD-11Single/><ref name=ICD-iiRecurrent/>
  
−
''[[5-HTP]]'' supplements are claimed to provide more raw material to the body's natural serotonin production process. There is a reasonable indication that 5-HTP may not be effective for those who haven't already responded well to an [[selective serotonin reuptake inhibitor|SSRI]] because of their similar function: SSRIs allow the brain to use its serotonin more effectively, while 5-HTP induces production of more serotonin.{{Fact|date=February 2007}}
+
;DSM-5
 +
Major depressive disorder is classified as a mood disorder in DSM-5. There are two main depressive symptoms: a depressed mood, and loss of interest/pleasure in activities (anhedonia). These symptoms, as well as five out of the nine more specific symptoms listed, must frequently occur for more than two weeks (to the extent in which they impair functioning) for the diagnosis. Further qualifiers are used to classify both the episode itself and the course of the disorder. The category [[Depressive Disorder Not Otherwise Specified|Unspecified Depressive Disorder]] is diagnosed if the depressive episode's manifestation does not meet the criteria for a major depressive episode.<ref name=DSM-5/>
  
−
''[[S-adenosyl methionine]]'' (SAM-e) is a derivative of the amino acid [[methionine]] that is found throughout the human body, where it acts as a methyl donor and participates in other biochemical reactions. It is available as a prescription antidepressant in Europe and an over-the-counter dietary supplement in the United States. Clinical trials have shown SAM-e to be as effective as standard antidepressant medication, with fewer side effects; however, some studies have reported an increased incidence of [[mania]] resulting from SAM-e use compared to other antidepressants.<ref>{{cite journal | first = Roberto | last = Delle Chiaie | coauthors = Paolo Pancheri and Pierluigi Scapicchio | year = 2002 | title = Efficacy and tolerability of oral and intramuscular S-adenosyl- L-methionine 1,4-butanedisulfonate (SAMe) in the treatment of major depression: comparison with imipramine in 2 multicenter studies | journal = Am J Clin Nutr | volume = 76 | issue = 5 | pages = 1172S?1176S }}</ref><ref>{{cite journal | last = Mischoulon | first = D | coauthors = Fava M. | year = 2002 | title = Role of S-adenosyl-L-methionine in the treatment of depression: a review of the evidence | journal = Am J Clin Nutr | volume = 76 | issue = 5 | pages = 1158S?61S }}</ref> Its mode of action is unknown.  
+
A major depressive episode is characterized by the presence of a severely depressed mood that persists for at least two weeks. Episodes may be isolated or recurrent and are categorized as mild (few symptoms in excess of minimum criteria), moderate, or severe (marked impact on social or occupational functioning). An episode with psychotic features—commonly referred to as "[[psychotic depression]]"—is automatically rated as severe. If the person has had an episode of [[mania]] or [[hypomania|markedly elevated mood]], a diagnosis of [[bipolar disorder]] is made instead.  
  
−
''[[Omega-3 fatty acids]]'' (found naturally in [[oily fish]], [[flax seed]]s, [[hemp|hemp seeds]], [[walnut]]s, and [[canola oil]]) have also been found to be effective when used as a dietary supplement (although only fish-based [[omega-3 fatty acids]] have shown antidepressant efficacy [http://www.umm.edu/altmed/ConsSupplements/Omega3FattyAcidscs.html]).
+
[[Grief|Bereavement]] is not an exclusion criterion in DSM-5, and it is up to the clinician to distinguish between normal reactions to a loss and MDD. Excluded are a range of related diagnoses, including [[dysthymia]], which involves a chronic but milder mood disturbance; [[recurrent brief depression]], consisting of briefer depressive episodes; [[minor depressive disorder]], whereby only some symptoms of major depression are present; and [[Adjustment disorder|adjustment disorder with depressed mood]], which denotes low mood resulting from a psychological response to an identifiable event or stressor.<ref name=DSM-5/>
  
−
''[[Dehydroepiandrosterone]]'' (DHEA), available as a supplement  in the U.S., has been shown to be effective in small trials [http://ajp.psychiatryonline.org/cgi/content/full/156/4/646].
+
The DSM-5 recognizes six further subtypes of MDD, called "specifiers," in addition to noting the length, severity, and presence of psychotic features:<ref name=DSM-5/>
 +
* "[[Melancholic depression]]" is characterized by a loss of pleasure in most or all activities, a failure of reactivity to pleasurable stimuli, a quality of depressed mood more pronounced than that of [[grief]] or loss, a worsening of symptoms in the morning hours, early-morning waking, [[psychomotor retardation]], excessive weight loss (not to be confused with [[anorexia nervosa]]), or excessive guilt.
 +
* "[[Atypical depression]]" is characterized by mood reactivity (paradoxical anhedonia) and positivity, significant [[weight gain]] or increased appetite (comfort eating), excessive sleep or sleepiness ([[hypersomnia]]), a sensation of heaviness in limbs known as leaden paralysis, and significant long-term social impairment as a consequence of hypersensitivity to perceived [[social rejection|interpersonal rejection]].
 +
* "[[Catatonia|Catatonic]] depression" is a rare and severe form of major depression involving disturbances of motor behavior and other symptoms. Here, the person is mute and almost stuporous, and either remains immobile or exhibits purposeless or even bizarre movements. Catatonic symptoms also occur in [[schizophrenia]] or in manic episodes, or may be caused by [[neuroleptic malignant syndrome]].
 +
*"Depression with [[Anxiety|anxious]] distress" was added into the DSM-5 as a means to emphasize the common co-occurrence between depression or [[mania]] and anxiety, as well as the risk of suicide of depressed individuals with anxiety.
 +
*"Depression with [[Postpartum depression|peri-partum]] onset" refers to the intense, sustained, and sometimes disabling depression experienced by women after giving birth or while a woman is pregnant. To qualify as depression with peripartum onset, onset must occur during pregnancy or within one month of delivery.
 +
* "[[Seasonal affective disorder]]" (SAD) is a form of depression in which depressive episodes come on in the autumn or winter, and resolve in spring. The diagnosis is made if at least two episodes have occurred in colder months with none at other times, over a two-year period or longer.
  
−
''[[Chocolate]]'' improves mood, probably by raising [[serotonin]]. [http://serendip.brynmawr.edu/bb/neuro/neuro04/web1/kcoveleskie.html]. Indeed, chocolate contains [[serotonin]] and there are case reports of interactions between chocolate and antidepressant drugs[http://www.biomedcentral.com/1471-244X/4/36].
+
===Differential diagnoses===
 +
Other disorders need to be ruled out before diagnosing major depressive disorder. They include depressions due to physical illness, [[medications]], and [[substance use disorder]]s. Depression due to physical illness is diagnosed as a [[mood disorder due to a general medical condition]]. This condition is determined based on history, laboratory findings, or [[physical examination]]. When the depression is caused by a medication, non-medical use of a psychoactive substance, or exposure to a [[toxin]], it is then diagnosed as a specific mood disorder (previously called ''substance-induced mood disorder'').<ref name=DSM-5/>
  
−
''[[Magnesium]]'' supplementation has gathered some attention as a possible treatment for depression [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15567428][http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15577090]. Some case reports demonstrate rapid recovery from major depression using magnesium treatment. "The possibility that magnesium deficiency is the cause of most major depression and related mental health problems including IQ loss and addiction is enormously important to public health and is recommended for immediate further study." [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16542786&query_hl=2&itool=pubmed_DocSum]
+
To confirm major depressive disorder as the most likely diagnosis, other potential diagnoses must be considered, including dysthymia, [[adjustment disorder]] with depressed mood, or [[bipolar disorder]]. Dysthymia is a chronic, milder mood disturbance in which a person reports a low mood almost daily over a span of at least two years. The symptoms are not as severe as those for major depression. [[Adjustment disorder|Adjustment disorder with depressed mood]] is a mood disturbance appearing as a psychological response to an identifiable event or stressor, in which the resulting emotional or behavioral symptoms are significant but do not meet the criteria for a major depressive episode.<ref name=DSM-5/>
  
−
''[[St John's Wort]]'' [Hypericum perforatum] Traditionally used by 'wise women' and midwives for hundreds of years, to 'chase away the devil' of melancholia and anxiety. It is a mood-enhancing herbal substance which acts like an antidepressant and increases the availability of serotonin, norepinephrine and dopamine at the neuron synapses.{{Fact|date=February 2007}} Also popular for treating insomnia, mood swings, fatigue, PMS and menopause. Except under medical supervision, St. John's Wort should not be used with SSRIs or MAOIs due to the risk of [[serotonin syndrome]].[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10333988&dopt=Abstract]
+
===Cultural differences===
 +
There are cultural differences in the extent to which serious depression is considered an illness requiring personal professional treatment, or an indicator of something else, such as the need to address social or moral problems, the result of biological imbalances, or a reflection of individual differences in the understanding of distress that may reinforce feelings of powerlessness, and emotional struggle.<ref>Alison Karasz, [https://pubmed.ncbi.nlm.nih.gov/15652693/ Cultural differences in conceptual models of depression] ''Social Science & Medicine'' 60(7) (Aoruk 2995): 1625–1635. Retrieved October 14, 2022.</ref>
  
−
''[[Ginkgo Biloba]]'' Effective natural antidepressant [http://www.umm.edu/altmed/ConsHerbs/GinkgoBilobach.html] said to stabilise cell membranes, inhibiting lipid breakdown and aiding cell use of oxygen and glucose - so subsequently a mental and vascular stimulant that improves neurotransmitter production. Also popular for treating mental concentration (such as for Alzheimer's and stroke patients).<ref name="Kathy Fray" />
+
A diagnosis of illness is less common in some countries, such as China. It has been suggested that the Chinese traditionally deny or [[Somatization|somatize]] emotional depression. Alternatively, it may be that Western cultures reframe and elevate some expressions of human distress to disorder status. Australian professor [[Gordon Parker (psychiatrist)|Gordon Parker]] and others have argued that the Western concept of depression [[Medicalization|medicalizes]] sadness or misery.<ref>Gordon Parker, [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1949440/ Is depression overdiagnosed? Yes] ''BMJ'' 335(7615) (August 2007): 328. Retrieved October 17, 2022.</ref> Similarly, Hungarian-American psychiatrist [[Thomas Szasz]] and others argue that depression is a metaphorical illness that is inappropriately regarded as an actual disease,<ref>Warren Steibel, [http://www.szasz.com/isdepressionadiseasetranscript.html Is depression a disease?] ''Debatesdebates'', May 13, 1998, Retrieved October 17, 2022. </ref> or that there is a failure to take into consideration the influence of social constructs.<ref> Dan G. Blazer, ''The Age of Melancholy: "Major Depression" and its Social Origin'' (Routledge, 2005, ISBN 978-0415951883).</ref>
  
−
''[[Siberian Ginseng]]'' [Eleutherococcus senticosus] Although not a true [[panax ginseng]] it is a mood enhancement supplment against stress. Also popular for treating depression, insomnia, moodiness, fatigue, poor memory, lack of focus, mental tension and endurance.<ref name="Kathy Fray" />
+
==Management==
 +
The pathophysiology of depression is not completely understood. The most common and effective treatments are [[psychotherapy]], medication, and [[electroconvulsive therapy]] (ECT); a combination of treatments being the most effective approach.  
  
−
''[[Zinc]]'' has had an antidepressant effect in an experiment [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14730113&query_hl=1&itool=pubmed_docsum].
+
[[American Psychiatric Association]] treatment guidelines recommend that initial treatment should be individually tailored based on factors including severity of symptoms, co-existing disorders, prior treatment experience, and personal preference. Options may include pharmacotherapy, psychotherapy, exercise, ECT, [[transcranial magnetic stimulation]] (TMS), or [[light therapy]]. Antidepressant medication is recommended as an initial treatment choice in people with mild, moderate, or severe major depression, and should be given to all people with severe depression unless ECT is planned.<ref name=APAGuideline>[https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/mdd-1410197717630.pdf Practice Guideline for the Treatment of Patients With Major Depressive Disorder Third Edition] ''American Psychiatric Association'', 2010. Retrieved October 17, 2022.</ref>
  
−
''[[Biotin]]'': a deficiency has caused a severe depression. The patient's symptoms improved after the deficiency was corrected. [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=6406708&query_hl=2&itool=pubmed_docsum]
+
===Talk therapies===
 +
Talk therapy, or [[psychotherapy]] can be delivered to individuals, groups, or families by mental health professionals, including psychotherapists, psychiatrists, psychologists, clinical [[social work]]ers, counselors, and psychiatric nurses. With more complex and chronic forms of depression, a combination of medication and psychotherapy may be used.
  
−
''[[Vitamin B-12]]'':  Symptoms of a vitamin B-12 deficiency can include depression and other psychiatric disorders. [http://ajp.psychiatryonline.org/cgi/content/abstract/157/5/715]
+
The most commonly used form of psychotherapy for depression is [[Cognitive Behavioral Therapy]] (CBT), which teaches clients to challenge self-defeating, but enduring ways of thinking (cognitions) and change counter-productive behaviors. CBT and interpersonal psychotherapy (IPT) are preferred treatments for adolescent depression; in people under 18, according to the [[National Institute for Health and Clinical Excellence]], medication should be offered only in conjunction with a psychological therapy, such as CBT, [[Interpersonal psychotherapy|interpersonal therapy]], or [[family therapy]].<ref>National Institute for Health and Clinical Excellence (NICE), [https://www.nice.org.uk/guidance/ng134/chapter/Recommendations How to use antidepressants in children and young people] ''Depression in children and young people: identification and management NICE guideline'', June 25, 2019. Retrieved October 17, 2022. </ref> Several variants of cognitive behavior therapy have been used in treating depression, the most notable being [[rational emotive behavior therapy]]<ref name=Beck/> and [[mindfulness-based cognitive therapy]].<ref>Helen F. Coelho, Peter H. Canter, and Edzard Ernst, [https://pubmed.ncbi.nlm.nih.gov/18085916/ Mindfulness-based cognitive therapy: evaluating current evidence and informing future research] ''Journal of Consulting and Clinical Psychology'' 75(6) (December 2007): 1000–1005. Retrieved October 17, 2022.</ref>
  
−
The amino acids [[phenylalanine]] and [[tyrosine]] have also a favorable effect on easy forms of depression. They enhance the neurotransmitters dopamine and noradrenalin.{{Fact|date=February 2007}}
+
[[Psychoanalysis]], founded by [[Sigmund Freud]], emphasizes the resolution of [[unconscious]] mental conflicts, and has been used to treat patients with major depression. A more widely practiced therapy, called [[psychodynamic psychotherapy]], is in the tradition of psychoanalysis but less intensive, meeting once or twice a week. It also tends to focus more on the person's immediate problems, and has an additional social and interpersonal focus.<ref name=Barlow>David H. Barlow,  Vincent Mark Durand, and Stefan G. Hofmann, ''Abnormal Psychology: An Integrative Approach (8th edition)'' (Cengage Learning, 2017, ISBN 978-1305950443).</ref>
  
−
===Augmentor drugs===
+
===Antidepressants===
−
Some antidepressants have been found to work more effectively in some patients when used in combination with another drug. Such "augmentor" drugs include [[tryptophan]] (Tryptan) and [[buspirone]] (Buspar).
+
Antidepressants are commonly prescribed to treat major depressive disorder. The treatment is usually continued for 16 to 20 weeks after remission, to minimize the chance of recurrence, and even up to one year of continuation is often recommended. People with chronic depression may need to take medication indefinitely to avoid relapse.<ref name=NIMHPub/>
  
−
''[[Tranquillizer]]s and [[sedative]]s'', typically the benzodiazepines, may be prescribed to ease anxiety and promote sleep. Because of their high potential for fostering dependence, these medications are intended only for short-term or occasional use. Medications often are used not for their primary function but to exploit what are normally [[Adverse effect (medicine)|side effects]]. [[Quetiapine]] fumarate (Seroquel) is designed primarily to treat [[schizophrenia]] and bipolar disorder, but a frequently reported side-effect is [[somnolence]]. Therefore, this drug can be used in place of an antianxiety agent such as [[clonazepam]] (Klonopin, Rivotril).
+
The UK [[National Institute for Health and Care Excellence]] (NICE) guidelines indicate that antidepressants should not be routinely used for the initial treatment of mild depression, because the risk to benefit ratio is poor. The guidelines recommended that antidepressant treatment be considered for:
  
−
''[[Antipsychotic]]s'' such as [[risperidone]] (Risperdal), [[olanzapine]] (Zyprexa), and [[Quetiapine]] (Seroquel) are prescribed as mood stabilizers and are also effective in treating anxiety. Their use as mood stabilizers is a recent phenomenon and is controversial with some patients. [[Antipsychotics]] (typical or atypical) may also be prescribed in an attempt to augment an antidepressant, to make antidepressant blood concentration higher, or to relieve [[psychotic]] or [[Paranoia|paranoid]] symptoms often accompanying clinical depression. However, they may have serious side effects, particularly at high dosages, which may include blurred [[Visual perception|vision]], [[muscle]] spasms, restlessness, [[tardive dyskinesia]], and weight gain.
+
* People with a history of moderate or severe depression
 +
* Those with mild depression that has been present for a long period
 +
* As a second-line treatment for mild depression that persists after other interventions
 +
* As a first-line treatment for moderate or severe depression
  
−
Antidepressants by their nature behave similarly to psychostimulants. Antianxiety medications by their nature are depressants. Close medical supervision is critical to proper treatment if a patient presents with both illnesses because the medications tend to work against each other.
+
The guidelines further note that antidepressant treatment should be used in combination with psychosocial interventions in most cases, should be continued for at least six months to reduce the risk of relapse, and that [[selective serotonin reuptake inhibitor]] (SSRIs) are typically better tolerated than other antidepressants.<ref>National Collaborating Centre for Mental Health (NCCMH), ''Depression: The NICE Guideline on the Treatment and Management of Depression in Adults'' (RCPsych Publications, 2010, ISBN 978-1904671855). </ref> To find the most effective antidepressant medication with minimal side-effects, the dosages can be adjusted, and if necessary, combinations of different classes of antidepressants can be tried.
  
−
Psycho-stimulants are sometimes added to an antidepressant regimen if the patient suffers from anhedonia, hypersomnia and/or excessive eating as well as low motivation. These symptoms which are common in atypical depression can be quickly resolved with the addition of low to moderate dosages of amphetamine or methylphenidate (brand names Adderall and Ritalin, respectively)as these chemicals enhance motivation and social behavior, as well as suppress appetite and sleep. These chemicals are also known to restore sex drive. Extreme caution must be used however with certain populations. Stimulants are known to trigger manic episodes in people suffering from bipolar disorder. They are also easily abused as they are effective substitutes for [[Methamphetamine]] when used recreationaly. Close supervision of those with substance abuse disorders is urged. Emotionally labile patients should avoid stimulants, as they exacerbate mood shifting.
+
[[American Psychiatric Association]] treatment guidelines recommended antidepressant medication as an initial treatment choice in people with mild, moderate, or severe major depression, that should be given to all people with severe depression unless ECT is planned.<ref name=APAGuideline/>
−
 
 
−
''[[Lithium pharmacology|Lithium]]'' remains the standard treatment for bipolar disorder and is often used in conjunction with other medications, depending on whether mania or depression is being treated.  Lithium's potential side effects include thirst, [[tremor]]s, light-headedness, and [[nausea]] or [[diarrhea]].  Some of the [[anticonvulsants]], such as [[carbamazepine]] (Tegretol), [[sodium valproate]] (Epilim), and [[lamotrigine]] (Lamictal), are also used as mood stabilizers, particularly in bipolar disorder.
 
−
 
 
−
===Psychotherapy===
 
−
In [[psychotherapy]], or ''counseling'', one receives assistance in understanding and resolving habits or problems that may be contributing to or the cause of the depression. This may be done individually or with a group and is conducted by mental health professionals such as psychiatrists, psychologists, clinical social workers, or psychiatric nurses.
 
−
 
 
−
Effective psychotherapy may result in different habitual thinking and action which leads to a lower relapse rate than antidepressant drugs alone.  Medication, however, may yield quicker results and be strongly indicated in a crisis.  Medication and psychotherapy are generally complementary, and both may be used at the same time. 
 
−
 
 
−
It is important to ask about potential therapists' training and approach; a very close bond often forms between practitioner and client, and it is important that the client feel understood by the clinician.  Moreover, some approaches have been convincingly demonstrated to be much more effective in treating depression. 
 
−
 
 
−
Counselors can help a person make changes in thinking patterns, deal with relationship problems, detect and deal with relapses, and understand the factors that contribute to depression.
 
−
 
 
−
There are many counseling approaches, but all are aimed at improving one's personal and interpersonal functioning. Cognitive behaviour therapy has been demonstrated in carefully controlled studies to be among the foremost of the recent wave of methods which achieve more rapid and lasting results than traditional "talk therapy" analysis.  ''[[Cognitive therapy]]'', often combined with behavioral therapy, focuses on how people think about themselves and their relationships. It helps depressed people learn to replace negative depressive thoughts with realistic ones, as well as develop more effective coping behaviors and skills. Therapy can be used to help a person develop or improve ''[[interpersonal skills]]'' in order to allow him or her to communicate more effectively and reduce stress.  Interpersonal psychotherapy focuses on the social and interpersonal triggers that cause their depression.  ''[[Narrative therapy]]'' gives attention to each person's "dominant story" by means of therapeutic conversations, which also may involve exploring unhelpful ideas and how they came to prominence. Possible social and cultural influences may be explored if the client deems it helpful.  ''Behavioral therapy'' is based on the assumption that behaviors are learned. This type of therapy attempts to teach people more healthful types of behaviors. ''[[Supportive therapy]]'' encourages people to discuss their problems and provides them with emotional support. The focus is on sharing information, ideas, and strategies for coping with daily life. ''[[Family therapy]]'' helps people live together more harmoniously and undo patterns of destructive behavior.
 
−
 
 
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===Transcranial magnetic stimulation===
 
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[[Repetitive transcranial magnetic stimulation]] (rTMS) is under study as a possible treatment for depression. Initially designed as a tool for physiological studies of the brain, this technique shows promise as a means of alleviating depression. In this therapy, a powerful magnetic field is used to stimulate the left prefrontal [[cortex (neuroanatomy)|cortex]], an area of the brain that typically shows abnormal activity in depressed people.
 
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[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=15307288&dopt=Citation Recent work] in Poland suggested that weak, variable magnetic fields may offer relief from depression in those who have not responded to medication.  However, some of the existing work has been [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11985347&dopt=Abstract questioned], with claims that the effect is not as significant once environmental conditions are [[control group|controlled]] for.
 
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===Vagus nerve stimulation===
 
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[[Vagus nerve stimulation]] therapy is a treatment used since 1997 to control [[seizure]]s in [[epileptic]] patients and has recently been approved for treating resistant cases of treatment-resistant depression (TRD). The VNS Therapy device is implanted in a patient's chest with wires that connect it to the [[vagus nerve]], which it stimulates to reach a region of the brain associated with moods. The device delivers controlled electrical currents to the vagus nerve at regular intervals.
 
  
 
===Electroconvulsive therapy===
 
===Electroconvulsive therapy===
−
Electroconvulsive therapy (ECT), also known as ''electroshock'' or ''electroshock treatment,'' uses short bursts of a controlled current of [[electricity]] (typically fixed at 0.9 ampere) into the brain to induce a brief, artificial [[seizure]] while the patient is under [[general anesthesia]].
+
[[Electroconvulsive therapy]] (ECT), along with antidepressants and psychotherapy, is one of the three major treatments of depression. It has been found to reduce depression symptoms regardless of whether antidepressants are involved. ECT is a standard [[psychiatry|psychiatric]] treatment in which [[seizure]]s are electrically induced in a person with depression to provide relief from psychiatric illnesses. ECT is used with [[informed consent]] as a last line of intervention for major depressive disorder.<ref>Ming Li, Xiaoxiao Yao, et al, [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7044268/ Effects of Electroconvulsive Therapy on Depression and Its Potential Mechanism] ''Frontiers in Psychology'', 11(80) (2020). Retrieved October 17, 2022.</ref>
  
−
ECT has acquired a fearsome reputation, in part from its use as a tool of [[Political repression|repression]] in the former [[USSR]] and its barbaric fictional depiction in films such as ''[[One Flew Over the Cuckoo's Nest (film)|One Flew Over the Cuckoo's Nest]]'' and ''[[Requiem for a Dream]]'', but remains a common treatment where other means of treatment have failed or where the use of drugs is unacceptable (e.g. in the case of pregnant patients). Also, in contrast to direct electroshock of years ago, most countries now allow ECT to be administered only under anaesthesia. In a typical regimen of treatment, a patient receives three treatments per week over three or four weeks. Repeat sessions may be needed. [[Short-term memory]] loss, disorientation, and headache are very common side effects. In some cases, permanent memory loss has occurred, but detailed neuropsychological testing in clinical studies has not been able to prove permanent effects on memory. ECT offers the benefit of a very fast response; however, this response has been shown not to last unless maintenance electroshock or maintenance medication is used. Whereas antidepressants usually take around a month to take effect, the results of ECT have been shown to be much faster.  For this reason, it is the treatment of choice in emergencies (e.g., in catatonic depression in which the patient has ceased oral intake of fluid or nutrients).
+
===Lifestyle===
 +
[[Physical exercise]] has been found to be effective for major depression, and may be recommended to people who are willing, motivated, and healthy enough to participate in an exercise program as treatment. Sleep and diet may also play a role in depression, and interventions in these areas may be an effective add-on to conventional methods.<ref>Adrian L. Lopresti, Sean D. Hood, Peter D. Drummond, [https://pubmed.ncbi.nlm.nih.gov/23415826/ A review of lifestyle factors that contribute to important pathways associated with major depression: diet, sleep and exercise] ''Journal of Affective Disorders'' 148(1) (May 2013): 12–27. Retrieved October 17, 2022. </ref>
  
−
There remains much controversy over electroshock. Advocacy groups and scientific critics, such as Dr [[Peter Breggin]][http://www.breggin.com/Electroshockscientific.pbreggin.1998.pdf], call for restrictions on its use or complete abolishment. Like all forms of psychiatric treatment, electroshock can be given without a patient's consent, but this is subject to legal conditions dependent on the jurisdiction. In Oregon patient consent is necessary by statute. Treatment with ECT has been used as a threat by psychiatric ward staffers against unruly patients.{{Fact|date=February 2007}}
+
==Prognosis==
 +
Major depressive episodes often resolve over time, whether or not they are treated. However, the majority of those with a first major depressive episode will have at least one more during their lifetime.
  
−
===Other methods of treatment===
+
===Ability to work===
−
====Light therapy====
+
Depression may affect people's ability to work. The combination of usual clinical care and support with return to work (like working less hours or changing tasks) leads to fewer depressive symptoms and improved work capacity. Additional psychological interventions (such as online cognitive behavioral therapy) as well as streamlining care or adding specific providers for depression care improve ability to work.
−
Bright light (both sunlight and artificial light) is shown to be effective in [[seasonal affective disorder]], and sometimes may be effective in other types of depression, especially atypical depression or depression with "seasonal [[phenotype]]" (overeating, oversleeping, weight gain, [[apathy]]).
 
  
−
'''Important note:''' An antidepressant effect is caused by stimulation of the [[retina]] by the [[visible light]], not by  the [[ultra-violet]] portion. Thus, it is not necessary (and may be even dangerous in some cases) to get [[sunburn]]. It can be enough just to walk at daytime or to take light therapy using a light box. However, recent discoveries of the existence and importance of the third kind of photoreceptor in our eyes, the intrinsically photosensitive [[retinal ganglion cells]] (ipRGC), critical to human chronobiology, strongly suggest that bluish light is more helpful, and manufacturers are beginning to respond to this finding.{{Fact|date=February 2007}}
+
===Life expectancy and the risk of suicide===
 +
Depressed individuals have a shorter [[life expectancy]] than those without depression, in part because people who are depressed are at risk of dying of [[suicide]]. Approximately half the people who die of suicide have a mood disorder such as major depression, and the risk is especially high if a person has a marked sense of hopelessness or has both depression and [[borderline personality disorder]].<ref name=Barlow/><ref> Stephen Strakowski and Erik Nelson,   ''Major Depressive Disorder'' (Oxford University Press, 2015, ISBN 978-0190206185) </ref>
  
−
====Exercise====
+
Those suffering from major depression also have a higher [[mortality rate|rate of dying]] from other causes. People with major depression are at risk death from [[cardiovascular disease]], especially since they less likely to follow medical recommendations for its treatment and prevention, further increasing their risk of medical complications.
−
It is widely believed that physical activity and [[exercise]] help depressed patients and promote quicker and better relief from depression. They are also thought to help antidepressants and psychotherapy work better and faster. It can be difficult to find the motivation to exercise if the depression is severe, but sufferers should be encouraged to take part in some form of regularly scheduled physical activity. A workout need not be strenuous; many find [[walking]], for example, to be of great help. Exercise produces higher levels of chemicals in the brain, notably [[dopamine]], [[serotonin]], and  norepinephrine. In general this leads to improvements in mood, which is effective in countering depression.[http://dukenews.duke.edu/2000/09/exercise922.html]
 
  
−
Note that before beginning an exercise regime, it is wise to consult a doctor. He or she can establish whether a person has any health problems that could contraindicate some types of exercise.
+
==Epidemiology==
 +
Major depressive disorder affects millions of people throughout the world. Women are more affected than men, although although it is unclear why this is so.
  
−
====Meditation====
+
People are most likely to develop their first depressive episode between the ages of 30 and 40, and there is a second, smaller peak of incidence between ages 50 and 60.<ref>W.W. Eaton et al, Natural history of Diagnostic Interview Schedule/DSM-IV major depression. The Baltimore Epidemiologic Catchment Area follow-up] ''Archives of General Psychiatry'' 54(11) (November 1997): 993–999. Retrieved October 17, 2022.</ref> The risk of major depression is increased with neurological conditions such as [[stroke]], [[Parkinson's disease]], or [[multiple sclerosis]], and during the first year after childbirth.<ref>Hugh Rickards, [https://jnnp.bmj.com/content/76/suppl_1/i48 Depression in neurological disorders: Parkinson's disease, multiple sclerosis, and stroke] ''Journal of Neurology, Neurosurgery, and Psychiatry'' 76(Suppl 1) (March 2005): i48–52. Retrieved October 17, 2022. </ref>
−
[[Meditation]] is increasingly seen as a useful treatment for some cases of depression.[http://www.wildmind.org/meditation/stress/mbsr/mbsr-abstract08.html] The current professional opinion on meditation is that it represents at least a complementary method of treating depression, a view that has been endorsed by the Mayo Clinic.[http://www.mayoclinic.com/health/meditation/HQ01070] Since the late 1990s, much research has been carried out to determine how meditation affects the brain (see the main article on [[meditation]]). Although the effects on the mind are complex, they are often quite positive, encouraging a calm, [[Human self-reflection|reflective]], and [[rational]] state of mind that can be of great help against depression.{{Fact|date=February 2007}} Although many [[religion]]s include meditative practice, it is not necessary to be a member of any faith to meditate.
+
 +
===Comorbidity===
 +
Major depression frequently [[Comorbidity|co-occurs]] with other psychiatric problems, as well as increased rates of [[alcohol]] and [[drug abuse]]. For example, [[Post-traumatic stress disorder]] and depression often co-occur.<ref name=NIMHPub/> Depression often occurs in individuals with [[attention deficit hyperactivity disorder]] (ADHD), complicating the diagnosis and treatment of both.<ref> Edward M. Hallowell and John J. Ratey, ''Delivered from Distraction: Getting the Most out of Life with Attention Deficit Disorder'' (Ballantine Books, 2005, ISBN 978-0345442314).</ref>
  
−
===Deep brain stimulation===
+
[[Anxiety disorder|anxiety]] symptoms can have a major impact on the course of a depressive illness, with delayed recovery, increased risk of relapse, greater disability, and increased suicidal behavior.<ref>Robert M.A. Hirschfeld, [https://pubmed.ncbi.nlm.nih.gov/15014592/ The Comorbidity of Major Depression and Anxiety Disorders: Recognition and Management in Primary Care]  ''Primary Care Companion to the Journal of Clinical Psychiatry'' 3(6) (December 2001): 244–254. Retrieved October 18, 2022.</ref>
  
−
Though still experimental, a new form of treatment called [[deep brain stimulation]] offers some hope in the relief of treatment resistant clinical depression. Published in the journal Neuron (2005), Helen Mayberg described the implanting of electrodes in a region of the brain known as [[Area 25]] [http://www.neuron.org/content/article/fulltext?uid=PIIS089662730500156X  (Neuron)]. The electrodes act in an inhibitory fashion, on an otherwise overactive region of the brain. Further research is required before it becomes available as a method of treatment, but it offers hope for those suffering from treatment resistant depression.
+
Depression and [[pain]] often co-occur, although it is under-recognized, and therefore under-treated, in patients presenting with pain. Depression often coexists with physical disorders common among the elderly, such as [[stroke]], other [[cardiovascular diseases]], [[Parkinson's disease]], and [[chronic obstructive pulmonary disease]].
  
−
===Archaic methods===
+
==Social stigma==
−
[[Insulin shock therapy]] is an old and largely abandoned treatment of severe depressions, [[psychoses]], [[Catatonia|catatonic states]], and other [[mental disorders]]. It consists of induction of hypoglycemic coma by [[intravenous infusion]] of [[insulin]]. The treatment is potentially unsafe and can be lethal in some cases (about 1% of patients undergoing [[insulin coma]]), even with proper monitoring. In contrast, [[ECT]] is considered to be very safe.  
+
Historical figures were often reluctant to discuss or seek treatment for depression due to [[social stigma]] about the condition, or due to ignorance of diagnosis or treatments. Nevertheless, analysis or interpretation of letters, journals, artwork, writings, or statements of family and friends of some historical personalities has led to the presumption that they may have had some form of depression. People who may have had depression include English author [[Mary Shelley]],<ref>Miranda Seymour, ''Mary Shelley'' (Grove Press, 2002, ISBN 978-0802139481).</ref> American-British writer [[Henry James]],<ref> Leon Edel (ed.), ''The Letters of Henry James 1883–1895'' (Belknap Press, 1980, ISBN 978-0674387829).</ref> and American president [[Abraham Lincoln]].<ref>Michael Burlingame, ''The Inner World of Abraham Lincoln'' (University of Illinois Press, 1997, ISBN 978-0252066672).</ref>
  
−
Nevertheless, insulin shock therapy is still officially used in [[Russia]] and some other countries and can be administered to a very treatment-resistant patient with written consent in many [[Western countries]].{{Fact|date=February 2007}}
+
Some pioneering psychologists, such as Americans [[William James]]<ref>William James, ''Letters of William James'' (Kessinger Publishing, LLC, 2003, ISBN 978-0766175662)</ref> and [[John B. Watson]],<ref>David Cohen, ''J.B. Watson: The Founder of Behaviourism'' (Routledge Kegan & Paul, 1979, ISBN 978-0710000545).</ref> dealt with their own depression.
  
−
'''Atropinic shock therapy''', also known as atropinic coma therapy, is an old and rarely used method. It consists of induction of atropinic coma by rapid intravenous infusion of [[atropine]].
+
Social stigma of major depression continues to  be widespread, and contact with mental health services reduces this only slightly. Public opinions on treatment differ markedly to those of health professionals; alternative treatments are held to be more helpful than pharmacological ones, which are viewed poorly.<ref>Gavin Andrews and Scott Henderson (eds.), ''Unmet Need in Psychiatry: Problems, Resources, Responses'' (Cambridge University Press, 2006, ISBN 978-0521027236).</ref>
  
−
Atropinic shock treatment is considered safe, but it entails prolonged coma (4-5 hours), with careful monitoring and preparation, and it has many unpleasant side effects, such as blurred vision. It can be used with written consent in Western countries in very treatment-resistant patients and is still officially used in Russia and some other countries.{{Fact|date=February 2007}}
+
==Notes==
−
 
+
<references/>
−
[[Trepanation]], drilling a hole through the skull to "release" the negative spirits or increase brain bloodflow, was used in many ancient cultures{{Fact|date=February 2007}}.
 
  
−
===Self medication===
+
==References==
−
{{Unreferenced|section|date=December 2006}}
 
−
{{original research}}
 
−
Some people with clinical depression may attempt to dull their feelings of despair by consuming alcohol, tobacco, or illicit drugs. Some people with depression may resort to [[alcohol]], heavy [[tobacco smoking]], [[cannabis (drug)|cannabis]], [[cocaine]], [[opiate]]s or [[amphetamine]]s for their mood-altering effects. These attempts at self-medication may lead to a pattern of [[alcoholism]] and [[drug abuse]] that further exacerbates the depression.
 
  
−
"Comfort foods" are also used by some. While some foods like [[chocolate]] contain psychoactive substances, [[lipid|fat]] and [[sugar]] are most commonly the active ingredients.
+
* American Psychiatric Association. ''Diagnostic and Statistical Manual of Mental Disorders, 5th Edition: DSM-5''. American Psychiatric Publishing, Inc., 2013. ISBN 978-0890425558
−
 
+
* Andrews, Gavin, and Scott Henderson (eds.). ''Unmet Need in Psychiatry: Problems, Resources, Responses''. Cambridge University Press, 2006. ISBN 978-0521027236
−
==Adverse reactions==
+
* Barlow, David H., Vincent Mark Durand, and Stefan G. Hofmann. ''Abnormal Psychology: An Integrative Approach (8th edition)''. Cengage Learning, 2017. ISBN 978-1305950443
−
''[[Aspartame]]'' was associated with a significant difference in number and severity of symptoms for patients with a history of depression in an experiment [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8373935&query_hl=2]. However, the main findings of this 1993 study have not been replicated since, and its methodology has been criticized on the basis that unrelated symptoms were aggregated artificially, thereby boosting the statistical difference between the aspartame and the placebo conditions[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11754527&query_hl=2&itool=pubmed_docsum].
+
* Beck, Aaron T., A. John Rush, Brian F. Shaw, and Gary Emery. ''Cognitive Therapy of Depression''. The Guilford Press, 1987. ISBN 978-0898629194
−
 
+
* Blazer, Dan G. ''The Age of Melancholy: "Major Depression" and its Social Origin''. Routledge, 2005. ISBN 978-0415951883
−
==Relapse==
+
* Burlingame, Michael. ''The Inner World of Abraham Lincoln''. University of Illinois Press, 1997. ISBN 978-0252066672
−
[[Relapse]] is more likely if treatment has not resulted in full remission of symptoms.<sup>[[Clinical depression#References|4]]</sup> In fact, current guidelines for antidepressant use recommend 4 to 6 months of continuing treatment after symptom resolution to prevent relapse.
+
* Cohen, David. ''J.B. Watson: The Founder of Behaviourism''. Routledge Kegan & Paul, 1979. ISBN 978-0710000545
−
 
+
* Committee on Nomenclature and Statistics of the American Psychiatric Association. ''Diagnostic and statistical manual of mental disorders: DSM-II''. American Psychiatric Association, 1968. {{ASIN|B0030A4JAE}}
−
Combined evidence from many [[randomized controlled trials]] indicates that continuing antidepressant medications after recovery substantially reduces (halves) the chances of relapse. This preventive effect probably lasts for at least the first 36 months of use.<ref>{{cite journal | last = Geddes | first = JR | coauthors = Carney SM, Davies C, Furukawa TA, Kupfer DJ, Frank E, Goodwin GM | title = Relapse prevention with antidepressant drug treatment in depressive disorders: a [[systematic review]] | journal = Lancet|date= [[22 February]] [[2003]] | volume = 361 | issue = 9358 | pages = 653?61 | id = PMID 12606176 }}</ref>
+
* Edel, Leon (ed.). ''The Letters of Henry James 1883–1895''. Belknap Press, 1980. ISBN 978-0674387829
−
 
+
* Eyers, Kerrie (ed.). ''Tracking the Black Dog''. University of New South Wales, 2006. ISBN 978-0868408125
−
Anecdotal evidence suggests that chronic disease is accompanied by relapses after prolonged treatment with antidepressants ([[tachyphylaxis]]). Psychiatric texts suggest that physicians respond to relapses by increasing dosage, complementing the medication with a different class, or changing the medication class entirely.  The reason for relapse in these cases is as poorly understood as the change in brain physiology induced by the medications themselves.  Possible reasons may include aging of the brain or worsening of the condition.  Most SSRI psychiatric medications were developed for short-term use (a year or less) but are widely prescribed for indefinite periods.[http://cms.psychologytoday.com/articles/pto-19990301-000032.html] <!-- A reference was finally cited for this claim; I had to guess whether the "these drugs" in the sentence in question referred to anti-depressants or to SSRIs specifically; I took the conservative interpretation. —>
+
* Freud, Sigmund. ''On Murder, Mourning, and Melancholia''. Penguin Classic, 2005. ISBN 978-0141183794
−
 
+
* Hallowell, Edward M., and John J. Ratey. ''Delivered from Distraction: Getting the Most out of Life with Attention Deficit Disorder''. Ballantine Books, 2005. ISBN 978-0345442314
−
==Social attitudes towards depression==
+
* Hankin, Benjamin L., and John R.Z. Abela. ''Development of Psychopathology: A Vulnerability-Stress Perspective''. SAGE Publications, Inc, 2005. ISBN 1412904900
−
===Employment===
+
* Heffernan, Carol F. ''The Melancholy Muse: Chaucer, Shakespeare and Early Medicine''. Duquesne University Press, 1995. ISBN 978-0820702629
−
{{worldwide}}Some employers are reluctant to consider hiring people with a history of depression, but discrimination on this basis may be [[Disability Discrimination Act 1995|illegal]] in the [[United States]]. U.S. military standards do not allow more than six months of treatment for depression before someone becomes ineligible, though a waiver is possible in some circumstances.{{reference needed}}
+
* James, William. ''Letters of William James''. Kessinger Publishing, LLC, 2003. ISBN 978-0766175662
−
 
+
* Licinio, Julio, and Ma-Li Wong (eds.). ''Biology of Depression: From Novel Insights to Therapeutic Strategies''. Wiley-Blackwell, 2005. ISBN 3527307850
−
===Mental health stigma===
+
* Mill, John Stuart. ''Autobiography''. Adamant Media Corporation, 2000. ISBN 978-1421242002
−
{{original research}}
+
* National Collaborating Centre for Mental Health (NCCMH). ''Depression: The NICE Guideline on the Treatment and Management of Depression in Adults''. RCPsych Publications, 2010. ISBN 978-1904671855
−
Stigmatization and discrimination often stand in the way of recovery from depression and mental illness. Many people think that there is something shameful about being afflicted with mental illness, and this stigma can lead to discrimination. Such discrimination  may make it more difficult to get an education or attain worthwhile employment. Stigma also often discourages people with mental illnesses from getting needed treatment.
+
* Patton, Lauren L., and Michael Glick (eds.). ''The ADA Practical Guide to Patients with Medical Conditions 2nd Edition''. Wiley-Blackwell, 2015. ISBN 978-1118924402
−
 
+
* Richards, C. Steven, and Michael W. O'Hara (eds.). ''The Oxford Handbook of Depression and Comorbidity''. Oxford University Press, 2014. ISBN 978-0199797004
−
Stigma may also lead people to assume that those with depression or bipolar disorder are more likely to be violent or otherwise dangerous to society, which can lead to unnecessary fear and avoidance of those with mental illnesses. This avoidance can be isolating and compound the effects of depression.
+
* Rosqvist, Johan, and Michel Hersen (eds.). ''Handbook of Psychological Assessment, Case Conceptualization, and Treatment, Volume 1: Adults''. Wiley, 2007. ISBN 978-0471779995
−
 
+
* Seymour, Miranda. ''Mary Shelley''. Grove Press, 2002. ISBN 978-0802139481
−
Because mental illness does not have the visible symptoms most non-mental disorders do, treatment has often been considered less important or deserved than for physical illness. Many insurance plans do not cover mental health services to the same degree as other illnesses. When mental illnesses are covered, coverage may be limited, inappropriate, or inadequate. Many jurisdictions are introducing legislation to provide parity in coverage between mental and non-mental illness.
+
* Wolpert, Lewis. ''Malignant Sadness: The Anatomy of Depression''. Free Press, 2000. ISBN 978-0684870588
−
 
 
−
==See also==
 
−
* [[Asperger syndrome]]
 
−
* [[Atypical depression]]
 
−
* [[Beck Depression Inventory]]
 
−
* [[Bipolar disorder]]
 
−
* [[Chemical imbalance theory]]
 
−
* [[Cyclothymia]]
 
−
* [[Dysthymia]]
 
−
* [[Emotion and memory]]
 
−
* [[Geriatric Depression Scale]]
 
−
* [[Hamilton Depression Rating Scale]]
 
−
* [[Hypoadrenia]] (also covers 'adrenal exhaustion', sometimes called 'adrenal fatigue')
 
−
* [[List of people who have suffered from depression]]
 
−
* [[Mania]]
 
−
* [[Maslow's hierarchy of needs]]
 
−
* [[Melancholic Depression]]
 
−
* [[Post-traumatic stress disorder]]
 
−
* [[Seasonal affective disorder]] (SAD)
 
−
* [[Stress (medicine)|Stress]]
 
−
 
 
−
===Books by psychologists and psychiatrists===
 
−
* Beck, A. T., Rush, A. J., Shaw, B. F., Emery, G. (1987). ''Cognitive therapy of depression''. New York: Guilford.
 
−
* Burns, David D. (1999). ''Feeling Good : The New Mood Therapy''. Avon.
 
−
* Griffin, J., Tyrrell, I. (2004) ''How to lift Depression – Fast''. HG Publishing. ISBN 1-899398-41-4
 
−
* Jacobson, Edith: "Depression; Comparative Studies of Normal, Neurotic, and Psychotic Conditions", International Universities Press, 1976, ISBN 0-8236-1195-7
 
−
* Klein, D. F., & Wender, P. H. (1993). ''Understanding depression: A complete guide to its diagnosis and treatment''. New York: Oxford University Press.
 
−
* Kramer, Peter D. (2005). ''Against Depression''. New York: Viking Adult.
 
−
* Plesman, J. (1986). [http://books.google.com/books?lr=&ie=ISO-8859-1&q=foreword+Jurriaan+Plesman&btnG=Search Getting off the Hook], Sydney Australia. A self-help book available on the internet.
 
−
* Rowe, Dorothy (2003). ''Depression: The way out of your prison''. London: Brunner-Routledge.
 
−
* Sarbadhikari, S. N. (ed.) (2005) ''Depression and Dementia: Progress in Brain Research, Clinical Applications and Future Trends''. Hauppauge, [[Nova Science Publishers]]. ISBN 1-59454-114-0.
 
−
* Weissman, M. M., Markowitz, J. C., & Klerman, G. L. (2000). ''Comprehensive guide to interpersonal psychotherapy''. New York: Basic Books.
 
−
* Bieling, Peter J. & Anthony, Martin M. (2003) ''Ending The Depression Cycle.'' New Harbinger Publications. ISBN 1572243333
 
−
 
 
−
===Books by people suffering or having suffered from depression===
 
−
* [[Elizabeth Wurtzel|Wurtzel, Elizabeth]]. (1997) ''[[Prozac Nation|Prozac Nation: Young and Depressed in America: A Memoir]].'' Riverhead Books. ISBN 1-57322-512-6
 
−
* Lewinsohn, P. M., Munoz, R. F, Youngren, M. A., Zeiss, A. M. (1992). ''Control your depression''. New York: Fireside/Simon&Schuster.
 
−
* [[John Bentley Mays|Mays, John Bentley]] (1995). ''In the Jaws of the Black Dogs: A Memoir of Depression''. Toronto, Canada: Penguin Books. ISBN 0-14-024650-9
 
−
* [[Agate Nesaule|Nesaule, Agate]] (1995). ''A Woman in Amber: Healing the Trauma of War and Exile'' New York: Penguin Books. ISBN 1-56947-046-4 (hc.); ISBN 0-14-026190-7 (pbk.)
 
−
* Sealey, Robert (2002). ''Finding Care for Depression, Mental Episodes & Brain Disorders'', Toronto: Sear Publications www.searpubl.ca
 
−
* [[Brooke Shields|Shields, Brooke]] (2005). ''Down Came the Rain: My Journey Through Postpartum Depression''. Hyperion. ISBN 1-4013-0189-4.
 
−
* Smith, Jeffery (2001). ''Where the Roots Reach for Water: A Personal and Natural History of Melancholia''. New York: North Point Press.
 
−
* [[Andrew Solomon|Solomon, Andrew]] (2001). ''The Noonday Demon: An Atlas of Depression''. New York: Scribner.
 
−
* [[William Styron|Styron, William]] (1992). ''Darkness Visible: A Memoir of Madness''. New York: Vintage Books/Random House.
 
−
* [[Lewis Wolpert|Wolpert, Lewis]] (2001). ''Malignant sadness: The anatomy of depression''. London: Faber and Faber.
 
−
* [[Eckhart Tolle|Tolle, Eckhart]] (1999). ''The Power of Now: A Guide to Spiritual Enlightenment'', New World Library. ISBN 1-57731-152-3 (hc.); ISBN 1-57731-480-8 (pbk.)
 
−
* [[Sylvia Plath|Plath, Sylvia]] (1963). ''The Bell Jar''. Perennial. ISBN 0-06-093018-7
 
−
* Maschio, Jill. (2006). "When Your Mind Is Clear, the Sun Shines All the Time: A Guidebook for Overcoming Depression" Norman, OK: Illumines Publishing. ISBN 0-9777483-4-0
 
−
 
 
−
===Historical account===
 
−
*David Healy, ''The Antidepressant Era'', Paperback Edition, Harvard University Press 1999, ISBN 0-674-03958-0
 
−
 
 
−
==Sources==
 
−
<!-- Dead note "oldref_4": {{cite journal | url = http://jama.ama-assn.org/cgi/content/full/289/23/3152 | last = Keller | first = M.B. | date = 2003 | title = Past, Present, and Future Directions for Defining Optimal Treatment Outcome in Depression | journal = JAMA | volume = 289 | pages = 3152?3160 }} —>
 
−
<references/>
 
  
 
==External links==
 
==External links==
−
* {{dmoz|Health/Mental_Health/Disorders/Mood/Depression|Depression}}
+
All links retrieved January 7, 2024.
−
* [http://www.nami.org National Alliance on Mental Illness]  Support, advocacy, and education
 
−
* [http://www.ndmda.org National Depressive and Manic Depressive Association] - National Depressive and Manic Depressive Association
 
−
* [http://www.depressiontreatmenthelp.org/teen_depression.php Teen Depression] - Discussion of rising trend of depression among children and teens.
 
−
* [http://www.sciencedaily.com/news/mind_brain/depression/ Depression Research News] - ScienceDaily's Depression Research News
 
−
*[http://www.helpguide.org/mental/depression_signs_types_diagnosis_treatment.htm  Depression: Signs, Symptoms, Causes, and Treatment Strategies]
 
  
 +
* [https://www.mayoclinic.org/diseases-conditions/depression/expert-answers/clinical-depression/faq-20057770 Clinical depression: What does that mean?] ''Mayo Clinic''
 +
* [https://www.webmd.com/depression/guide/major-depression Major Depression (Clinical Depression)] ''WebMD''
 +
* [https://www.nimh.nih.gov/health/topics/depression Depression] ''National Institute of Mental Health''
 +
* [https://www.verywellmind.com/what-is-clinical-depression-1067309 What Is Clinical Depression?] ''Very Well Mind''
  
 +
{{Credit|Major_depressive_disorder|1112057266}}
  
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[[Category:Social sciences]]
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[[Category:Psychology]]
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{{Credit1|Clinical_depression|106617238|}}
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[[Category:Health and disease]]

Latest revision as of 22:08, 7 January 2024

Clinical depression
Vincent Willem van Gogh 002.jpg
Other namesMajor depressive disorder, major depression, unipolar depression, unipolar disorder, recurrent depression
Sorrowing Old Man (At Eternity's Gate)
by Vincent van Gogh (1890)
SymptomsLow mood, low self-esteem, loss of interest in normally enjoyable activities, low energy, pain without a clear cause[1]
ComplicationsSelf-harm, suicide[2]
Usual onset20s[3]
Duration> 2 weeks[1]
CausesEnvironmental (adverse life experiences, stressful life events), genetic and psychological factors[3]
Risk factorsFamily history, major life changes, certain medications, chronic health problems, substance use disorder[1][3]
Differential diagnosisBipolar disorder, ADHD, sadness[3]
TreatmentPsychotherapy, antidepressant medication, electroconvulsive therapy, exercise[1]
MedicationAntidepressants

Clinical Depression, also known as Major Depressive Disorder (MDD), is a mental disorder characterized by pervasive low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities over a protracted period of time.

The diagnosis of major depressive disorder is based on the person's reported experiences, behavior reported by relatives or friends, and a mental status examination. The course of the disorder varies widely, from one episode lasting months to a lifelong disorder with recurrent major depressive episodes. Major depressive disorder is believed to be caused by a combination of genetic, environmental, and psychological factors. Risk factors include a family history of the condition, major life changes, certain medications, chronic health problems, and substance use disorders. Those suffering from clinical depression are typically treated with psychotherapy and antidepressant medication.

Despite efforts to educate the public about mental disorders, social stigma continues to make it difficult both for those suffering from serious depression to admit their problems and for health professionals to diagnose and treat them. The view held by some psychiatrists that such depression is merely a social construct or imagined illness that is inappropriately regarded as an actual disease compounds these difficulties. Compassion as well as support for effective treatment is needed to allow those suffering from depression to receive appropriate and effective treatment so that they may be successful members of society.

Terminology

The 16th American president, Abraham Lincoln, had "melancholy", a condition that now may be referred to as "clinical depression."[4]

Clinical depression, also known as Major depressive disorder (MDD), is classified as a mental disorder. However, the term "depression" is used in a number of different ways. It is often used to mean the syndrome but may refer to other mood disorders or simply to a low mood. People's conceptualizations of depression vary widely: "Because of the lack of scientific certainty," one commentator has observed, "the debate over depression turns on questions of language. What we call it—'disease,' 'disorder,' 'state of mind'—affects how we view, diagnose, and treat it."[5]

History

Diagnoses of depression go back at least as far as Hippocrates.

The Ancient Greek physician Hippocrates described a syndrome of melancholia (μελαγχολία, melankholía) as a distinct disease with particular mental and physical symptoms; he characterized all "fears and despondencies, if they last a long time" as being symptomatic of the ailment.[6] It was a similar but far broader concept than today's depression; prominence was given to a clustering of the symptoms of sadness, dejection, and despondency, and often fear, anger, delusions, and obsessions were included.[7]

The term "depression" was derived from the Latin verb deprimere, meaning "to press down."[8] From the fourteenth century, "to depress" meant to subjugate or to bring down in spirits. It was used in 1665 in English author Richard Baker's Chronicle to refer to someone having "a great depression of spirit," and by English author Samuel Johnson in a similar sense in 1753.[9] An early usage referring to a psychiatric symptom was by French psychiatrist Louis Delasiauve in 1856, and by the 1860s it was appearing in medical dictionaries to refer to a physiological and metaphorical lowering of emotional function.[10] Since Aristotle, melancholia had been associated with men of learning and intellectual brilliance, a hazard of contemplation and creativity. The newer concept abandoned these associations and through the nineteenth century, and became more associated with women.[7]

Although "melancholia" remained the dominant diagnostic term, "depression" gained increasing currency in medical treatises and was a synonym by the end of the century; German psychiatrist Emil Kraepelin may have been the first to use it as the overarching term, referring to different kinds of melancholia as "depressive states."[9] Freud likened the state of melancholia to mourning in his 1917 paper Mourning and Melancholia. He theorized that objective loss, such as the loss of a valued relationship through death or a romantic break-up, results in subjective loss as well; the depressed individual has identified with the object of affection through an unconscious, narcissistic process called the "libidinal cathexis" of the ego. Such loss results in severe melancholic symptoms more profound than mourning; not only is the outside world viewed negatively but the ego itself is compromised.[11] He also emphasized early life experiences as a predisposing factor.[7] Adolf Meyer put forward a mixed social and biological framework emphasizing reactions in the context of an individual's life, and argued that the term "depression" should be used instead of "melancholia."[12]

The first version of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-I) published in 1952, contained "depressive reaction" and the DSM-II, published in 1968, contained "depressive neurosis." These were defined as an excessive reaction to internal conflict or an identifiable event, and also included a depressive type of manic-depressive psychosis within the area of "Major affective disorders."[13]

The term "Major Depressive Disorder was introduced by a group of US clinicians in the mid-1970s as part of proposals for diagnostic criteria based on patterns of symptoms (called the "Research Diagnostic Criteria," building on the earlier Feighner Criteria).[14] The American Psychiatric Association added "major depressive disorder" to the DSM-III, published in 1980, as a split of the previous depressive neurosis in the DSM-II, which also encompassed the conditions now known as dysthymia (or Persistent Depressive Disorder or PDD) and adjustment disorder with depressed mood.[15]

To maintain consistency, the World Health Organization's International Classification of Diseases (ICD-10) used the same criteria, with only minor alterations. It used the DSM diagnostic threshold to mark a "mild depressive episode," adding higher threshold categories for moderate and severe episodes.[16] The ancient idea of "melancholia: still survives in the notion of a melancholic subtype.

Symptoms

300px\An 1892 lithograph of a woman diagnosed with melancholia

Major depression significantly affects a person's family and personal relationships, work or school life, sleeping and eating habits, and general health.[17] A person having a major depressive episode usually exhibits a low mood, which pervades all aspects of life, and an inability to experience pleasure in previously enjoyable activities. They may be preoccupied with—or ruminate over—thoughts and feelings of worthlessness, inappropriate guilt or regret, helplessness or hopelessness.[3]

Other symptoms of depression include poor concentration and memory, withdrawal from social situations and activities, reduced sex drive, irritability, and thoughts of death or suicide. Insomnia is common; in the typical pattern, a person wakes very early and cannot get back to sleep. Hypersomnia, or oversleeping, can also happen. In severe cases, depressed people may have psychotic symptoms. These symptoms include delusions or, less commonly, hallucinations, usually unpleasant.[3]

A depressed person may report multiple physical symptoms such as fatigue, headaches, or digestive problems. Appetite often decreases, resulting in weight loss, although increased appetite and weight gain occasionally occur. Family and friends may notice agitation or lethargy. Elderly people may not present with classical depressive symptoms; they may have cognitive symptoms of recent onset, such as forgetfulness, and a more noticeable slowing of movements. Depressed children may often display an irritable rather than a depressed mood; most lose interest in school and show a steep decline in academic performance.[3]

Causes

A cup analogy demonstrating the diathesis–stress model that under the same amount of stressors, person 2 is more vulnerable than person 1, because of their predisposition.[18]

Major depressive disorder is believed to be caused by a combination of genetic, environmental, and psychological factors: In other words, biological, psychological, and social factors all play a role in causing depression. Risk factors include a family history of the condition, major life changes, certain medications, chronic health problems, and substance use disorders.[1][3]

The diathesis–stress model specifies that depression results when a preexisting vulnerability, or diathesis, is activated by stressful life events. The preexisting vulnerability can be either genetic, implying an interaction between nature and nurture, or schematic, resulting from views of the world learned in childhood.[19]

American psychiatrist Aaron Beck suggested that a triad of automatic and spontaneous negative thoughts about the self, the world or environment, and the future may lead to other depressive signs and symptoms.[20]

Adverse childhood experiences (incorporating childhood abuse, neglect and family dysfunction) markedly increase the risk of major depression.[3] Childhood trauma also correlates with severity of depression, poor responsiveness to treatment, and length of illness.

There has been a continuing discussion of whether neurological disorders and mood disorders may be linked to creativity, a discussion that goes back to Aristotelian times.[21] British literature gives many examples of reflections on depression.[22] English philosopher John Stuart Mill experienced a several-months-long period of what he called "a dull state of nerves," when one is "unsusceptible to enjoyment or pleasurable excitement; one of those moods when what is pleasure at other times, becomes insipid or indifferent." He quoted English poet Samuel Taylor Coleridge's "Dejection" as a perfect description of his case: "A grief without a pang, void, dark and drear, / A drowsy, stifled, unimpassioned grief, / Which finds no natural outlet or relief / In word, or sigh, or tear."[23] English writer Samuel Johnson used the term "the black dog" in the 1780s to describe his own depression, and it was subsequently popularized by British Prime Minister Sir Winston Churchill, who also had the disorder.[24]

Depression can also come secondary to a chronic or terminal medical condition, such as HIV/AIDS or asthma, and may be labeled "secondary depression."[25] It is unknown whether the underlying diseases induce depression through effect on quality of life, or through shared etiologies (such as degeneration of the basal ganglia in Parkinson's disease or immune dysregulation in asthma). Depression may also be iatrogenic (the result of healthcare), such as depression as a side effect of prescribed medications. Depression occurring after giving birth, postpartum depression, is thought to be the result of hormonal changes associated with pregnancy. Seasonal affective disorder is a type of depression associated with seasonal changes in sunlight where people who have normal mental health throughout most of the year exhibit depressive symptoms at the same time each year, most often in winter.

Diagnosis

There is no laboratory test for clinical depression, and so diagnosis is based on the person's reported experiences, behavior reported by relatives or friends, and a mental status examination, although tests may be conducted to rule out physical conditions that can cause similar symptoms.[26]

Clinical assessment

Caricature of a man with depression

A diagnostic assessment may be conducted by a suitably trained general practitioner, or by a psychiatrist or psychologist, who records the person's current circumstances, biographical history, current symptoms, family history, and alcohol and drug use. The assessment also includes a mental state examination, which is an assessment of the person's current mood and thought content, in particular the presence of themes of hopelessness or pessimism, self-harm or suicide, and an absence of positive thoughts or plans.[17]

Rating scales are not used to diagnose depression, but they provide an indication of the severity of symptoms for a time period, so a person who scores above a given cut-off point can be more thoroughly evaluated for a depressive disorder diagnosis. Several rating scales are used for this purpose, including the Hamilton Rating Scale for Depression, the Beck Depression Inventory, and the Suicide Behaviors Questionnaire-Revised.

Specialist mental health services are rare in rural areas, especially in developing countries, and thus diagnosis and management is left largely to primary-care clinicians. Since primary-care physicians have more difficulty with under-recognition and under-treatment of depression compared to psychiatrists, they often miss cases where people experience physical symptoms accompanying their depression.

A doctor generally performs a medical examination and selected investigations to rule out other causes of depressive symptoms. These can include blood tests to exclude hypothyroidism and metabolic disturbance, or a systemic infection or chronic disease.Testosterone levels may be evaluated to diagnose hypogonadism, a cause of depression in men. Adverse affective reactions to medications or alcohol misuse may be ruled out, as well. Subjective cognitive complaints appear in older depressed people, but they can also be indicative of the onset of a dementing disorder, such as Alzheimer's disease, which can be rule out through Cognitive testing and brain imaging.

DSM and ICD criteria

The most widely used criteria for diagnosing depressive conditions are found in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM) and the World Health Organization's International Statistical Classification of Diseases and Related Health Problems (ICD). The latter system is typically used in European countries, while the former is used in the US and many other non-European nations, and the authors of both have worked towards conforming one with the other. Both DSM and ICD mark out typical (main) depressive symptoms.[16]

ICD-11

Under mood disorders, ICD-11 classifies major depressive disorder as either "single episode depressive disorder" (where there is no history of depressive episodes, or of mania)[27] or "recurrent depressive disorder" (where there is a history of prior episodes, with no history of mania).[28] These two disorders are classified as "Depressive disorders," in the category of "Mood disorders". The symptoms, which must affect work, social, or domestic activities and be present nearly every day for at least two weeks, are a depressed mood or anhedonia, accompanied by other symptoms such as "difficulty concentrating, feelings of worthlessness or excessive or inappropriate guilt, hopelessness, recurrent thoughts of death or suicide, changes in appetite or sleep, psychomotor agitation or retardation, and reduced energy or fatigue."[27][28] The ICD-11 system allows further specifiers for the current depressive episode: the severity (mild, moderate, severe, unspecified); the presence of psychotic symptoms (with or without psychotic symptoms); and the degree of remission if relevant (currently in partial remission, currently in full remission).[27][28]

DSM-5

Major depressive disorder is classified as a mood disorder in DSM-5. There are two main depressive symptoms: a depressed mood, and loss of interest/pleasure in activities (anhedonia). These symptoms, as well as five out of the nine more specific symptoms listed, must frequently occur for more than two weeks (to the extent in which they impair functioning) for the diagnosis. Further qualifiers are used to classify both the episode itself and the course of the disorder. The category Unspecified Depressive Disorder is diagnosed if the depressive episode's manifestation does not meet the criteria for a major depressive episode.[3]

A major depressive episode is characterized by the presence of a severely depressed mood that persists for at least two weeks. Episodes may be isolated or recurrent and are categorized as mild (few symptoms in excess of minimum criteria), moderate, or severe (marked impact on social or occupational functioning). An episode with psychotic features—commonly referred to as "psychotic depression"—is automatically rated as severe. If the person has had an episode of mania or markedly elevated mood, a diagnosis of bipolar disorder is made instead.

Bereavement is not an exclusion criterion in DSM-5, and it is up to the clinician to distinguish between normal reactions to a loss and MDD. Excluded are a range of related diagnoses, including dysthymia, which involves a chronic but milder mood disturbance; recurrent brief depression, consisting of briefer depressive episodes; minor depressive disorder, whereby only some symptoms of major depression are present; and adjustment disorder with depressed mood, which denotes low mood resulting from a psychological response to an identifiable event or stressor.[3]

The DSM-5 recognizes six further subtypes of MDD, called "specifiers," in addition to noting the length, severity, and presence of psychotic features:[3]

  • "Melancholic depression" is characterized by a loss of pleasure in most or all activities, a failure of reactivity to pleasurable stimuli, a quality of depressed mood more pronounced than that of grief or loss, a worsening of symptoms in the morning hours, early-morning waking, psychomotor retardation, excessive weight loss (not to be confused with anorexia nervosa), or excessive guilt.
  • "Atypical depression" is characterized by mood reactivity (paradoxical anhedonia) and positivity, significant weight gain or increased appetite (comfort eating), excessive sleep or sleepiness (hypersomnia), a sensation of heaviness in limbs known as leaden paralysis, and significant long-term social impairment as a consequence of hypersensitivity to perceived interpersonal rejection.
  • "Catatonic depression" is a rare and severe form of major depression involving disturbances of motor behavior and other symptoms. Here, the person is mute and almost stuporous, and either remains immobile or exhibits purposeless or even bizarre movements. Catatonic symptoms also occur in schizophrenia or in manic episodes, or may be caused by neuroleptic malignant syndrome.
  • "Depression with anxious distress" was added into the DSM-5 as a means to emphasize the common co-occurrence between depression or mania and anxiety, as well as the risk of suicide of depressed individuals with anxiety.
  • "Depression with peri-partum onset" refers to the intense, sustained, and sometimes disabling depression experienced by women after giving birth or while a woman is pregnant. To qualify as depression with peripartum onset, onset must occur during pregnancy or within one month of delivery.
  • "Seasonal affective disorder" (SAD) is a form of depression in which depressive episodes come on in the autumn or winter, and resolve in spring. The diagnosis is made if at least two episodes have occurred in colder months with none at other times, over a two-year period or longer.

Differential diagnoses

Other disorders need to be ruled out before diagnosing major depressive disorder. They include depressions due to physical illness, medications, and substance use disorders. Depression due to physical illness is diagnosed as a mood disorder due to a general medical condition. This condition is determined based on history, laboratory findings, or physical examination. When the depression is caused by a medication, non-medical use of a psychoactive substance, or exposure to a toxin, it is then diagnosed as a specific mood disorder (previously called substance-induced mood disorder).[3]

To confirm major depressive disorder as the most likely diagnosis, other potential diagnoses must be considered, including dysthymia, adjustment disorder with depressed mood, or bipolar disorder. Dysthymia is a chronic, milder mood disturbance in which a person reports a low mood almost daily over a span of at least two years. The symptoms are not as severe as those for major depression. Adjustment disorder with depressed mood is a mood disturbance appearing as a psychological response to an identifiable event or stressor, in which the resulting emotional or behavioral symptoms are significant but do not meet the criteria for a major depressive episode.[3]

Cultural differences

There are cultural differences in the extent to which serious depression is considered an illness requiring personal professional treatment, or an indicator of something else, such as the need to address social or moral problems, the result of biological imbalances, or a reflection of individual differences in the understanding of distress that may reinforce feelings of powerlessness, and emotional struggle.[29]

A diagnosis of illness is less common in some countries, such as China. It has been suggested that the Chinese traditionally deny or somatize emotional depression. Alternatively, it may be that Western cultures reframe and elevate some expressions of human distress to disorder status. Australian professor Gordon Parker and others have argued that the Western concept of depression medicalizes sadness or misery.[30] Similarly, Hungarian-American psychiatrist Thomas Szasz and others argue that depression is a metaphorical illness that is inappropriately regarded as an actual disease,[31] or that there is a failure to take into consideration the influence of social constructs.[32]

Management

The pathophysiology of depression is not completely understood. The most common and effective treatments are psychotherapy, medication, and electroconvulsive therapy (ECT); a combination of treatments being the most effective approach.

American Psychiatric Association treatment guidelines recommend that initial treatment should be individually tailored based on factors including severity of symptoms, co-existing disorders, prior treatment experience, and personal preference. Options may include pharmacotherapy, psychotherapy, exercise, ECT, transcranial magnetic stimulation (TMS), or light therapy. Antidepressant medication is recommended as an initial treatment choice in people with mild, moderate, or severe major depression, and should be given to all people with severe depression unless ECT is planned.[33]

Talk therapies

Talk therapy, or psychotherapy can be delivered to individuals, groups, or families by mental health professionals, including psychotherapists, psychiatrists, psychologists, clinical social workers, counselors, and psychiatric nurses. With more complex and chronic forms of depression, a combination of medication and psychotherapy may be used.

The most commonly used form of psychotherapy for depression is Cognitive Behavioral Therapy (CBT), which teaches clients to challenge self-defeating, but enduring ways of thinking (cognitions) and change counter-productive behaviors. CBT and interpersonal psychotherapy (IPT) are preferred treatments for adolescent depression; in people under 18, according to the National Institute for Health and Clinical Excellence, medication should be offered only in conjunction with a psychological therapy, such as CBT, interpersonal therapy, or family therapy.[34] Several variants of cognitive behavior therapy have been used in treating depression, the most notable being rational emotive behavior therapy[20] and mindfulness-based cognitive therapy.[35]

Psychoanalysis, founded by Sigmund Freud, emphasizes the resolution of unconscious mental conflicts, and has been used to treat patients with major depression. A more widely practiced therapy, called psychodynamic psychotherapy, is in the tradition of psychoanalysis but less intensive, meeting once or twice a week. It also tends to focus more on the person's immediate problems, and has an additional social and interpersonal focus.[36]

Antidepressants

Antidepressants are commonly prescribed to treat major depressive disorder. The treatment is usually continued for 16 to 20 weeks after remission, to minimize the chance of recurrence, and even up to one year of continuation is often recommended. People with chronic depression may need to take medication indefinitely to avoid relapse.[17]

The UK National Institute for Health and Care Excellence (NICE) guidelines indicate that antidepressants should not be routinely used for the initial treatment of mild depression, because the risk to benefit ratio is poor. The guidelines recommended that antidepressant treatment be considered for:

  • People with a history of moderate or severe depression
  • Those with mild depression that has been present for a long period
  • As a second-line treatment for mild depression that persists after other interventions
  • As a first-line treatment for moderate or severe depression

The guidelines further note that antidepressant treatment should be used in combination with psychosocial interventions in most cases, should be continued for at least six months to reduce the risk of relapse, and that selective serotonin reuptake inhibitor (SSRIs) are typically better tolerated than other antidepressants.[37] To find the most effective antidepressant medication with minimal side-effects, the dosages can be adjusted, and if necessary, combinations of different classes of antidepressants can be tried.

American Psychiatric Association treatment guidelines recommended antidepressant medication as an initial treatment choice in people with mild, moderate, or severe major depression, that should be given to all people with severe depression unless ECT is planned.[33]

Electroconvulsive therapy

Electroconvulsive therapy (ECT), along with antidepressants and psychotherapy, is one of the three major treatments of depression. It has been found to reduce depression symptoms regardless of whether antidepressants are involved. ECT is a standard psychiatric treatment in which seizures are electrically induced in a person with depression to provide relief from psychiatric illnesses. ECT is used with informed consent as a last line of intervention for major depressive disorder.[38]

Lifestyle

Physical exercise has been found to be effective for major depression, and may be recommended to people who are willing, motivated, and healthy enough to participate in an exercise program as treatment. Sleep and diet may also play a role in depression, and interventions in these areas may be an effective add-on to conventional methods.[39]

Prognosis

Major depressive episodes often resolve over time, whether or not they are treated. However, the majority of those with a first major depressive episode will have at least one more during their lifetime.

Ability to work

Depression may affect people's ability to work. The combination of usual clinical care and support with return to work (like working less hours or changing tasks) leads to fewer depressive symptoms and improved work capacity. Additional psychological interventions (such as online cognitive behavioral therapy) as well as streamlining care or adding specific providers for depression care improve ability to work.

Life expectancy and the risk of suicide

Depressed individuals have a shorter life expectancy than those without depression, in part because people who are depressed are at risk of dying of suicide. Approximately half the people who die of suicide have a mood disorder such as major depression, and the risk is especially high if a person has a marked sense of hopelessness or has both depression and borderline personality disorder.[36][40]

Those suffering from major depression also have a higher rate of dying from other causes. People with major depression are at risk death from cardiovascular disease, especially since they less likely to follow medical recommendations for its treatment and prevention, further increasing their risk of medical complications.

Epidemiology

Major depressive disorder affects millions of people throughout the world. Women are more affected than men, although although it is unclear why this is so.

People are most likely to develop their first depressive episode between the ages of 30 and 40, and there is a second, smaller peak of incidence between ages 50 and 60.[41] The risk of major depression is increased with neurological conditions such as stroke, Parkinson's disease, or multiple sclerosis, and during the first year after childbirth.[42]

Comorbidity

Major depression frequently co-occurs with other psychiatric problems, as well as increased rates of alcohol and drug abuse. For example, Post-traumatic stress disorder and depression often co-occur.[17] Depression often occurs in individuals with attention deficit hyperactivity disorder (ADHD), complicating the diagnosis and treatment of both.[43]

anxiety symptoms can have a major impact on the course of a depressive illness, with delayed recovery, increased risk of relapse, greater disability, and increased suicidal behavior.[44]

Depression and pain often co-occur, although it is under-recognized, and therefore under-treated, in patients presenting with pain. Depression often coexists with physical disorders common among the elderly, such as stroke, other cardiovascular diseases, Parkinson's disease, and chronic obstructive pulmonary disease.

Social stigma

Historical figures were often reluctant to discuss or seek treatment for depression due to social stigma about the condition, or due to ignorance of diagnosis or treatments. Nevertheless, analysis or interpretation of letters, journals, artwork, writings, or statements of family and friends of some historical personalities has led to the presumption that they may have had some form of depression. People who may have had depression include English author Mary Shelley,[45] American-British writer Henry James,[46] and American president Abraham Lincoln.[47]

Some pioneering psychologists, such as Americans William James[48] and John B. Watson,[49] dealt with their own depression.

Social stigma of major depression continues to be widespread, and contact with mental health services reduces this only slightly. Public opinions on treatment differ markedly to those of health professionals; alternative treatments are held to be more helpful than pharmacological ones, which are viewed poorly.[50]

Notes

  1. ↑ 1.0 1.1 1.2 1.3 1.4 Depression National Institute of Mental Health (NIMH). Retrieved October 10, 2022.
  2. ↑ C. Steven Richards and Michael W. O'Hara (eds.), The Oxford Handbook of Depression and Comorbidity (Oxford University Press, 2014, ISBN 978-0199797004).
  3. ↑ 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 3.11 3.12 3.13 American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 5th Edition: DSM-5 (American Psychiatric Publishing, Inc., 2013, ISBN 978-0890425558).
  4. ↑ Joshua Wolf Shenk, Lincoln's Great Depression The Atlantic, October 2005. Retrieved October 14, 2022.
  5. ↑ Field Maloney, The Depression Wars: Would Honest Abe Have Written the Gettysburg Address on Prozac? Slate, November 3, 2005. Retrieved October 14, 2022.
  6. ↑ Hippocrates, Aphorisms, Section 6.23.
  7. ↑ 7.0 7.1 7.2 Jennifer Radden, Is This Dame Melancholy? Equating Today's Depression and Past Melancholia Philosophy, Psychiatry, & Psychology 10(1) (2003): 37–52. Retrieved October 14, 2022.
  8. ↑ Depress Dictionary.com. Retrieved October 14, 2022.
  9. ↑ 9.0 9.1 Lewis Wolpert, Malignant Sadness: The Anatomy of Depression (Free Press, 2000, ISBN 978-0684870588).
  10. ↑ G.E. Berrios, Melancholia and depression during the 19th century: a conceptual history The British Journal of Psychiatry 153(3) (September 1988): 298–304. Retrieved October 14, 2022.
  11. ↑ Sigmund Freud, On Murder, Mourning, and Melancholia (Penguin Classic, 2005, ISBN 978-0141183794).
  12. ↑ A.J. Lewis, Melancholia: A historical review Journal of Mental Science 80(328) (January 1934): 1-42. Retrieved October 14, 2022.
  13. ↑ Committee on Nomenclature and Statistics of the American Psychiatric Association, Diagnostic and statistical manual of mental disorders: DSM-II (American Psychiatric Association, 1968), 36–37, 40.
  14. ↑ Robert L. Spitzer, The Development of Diagnostic Criteria in Psychiatry Research diagnostic criteria (RDC), 1975. Retrieved October 14, 2022.
  15. ↑ Johan Rosqvist and Michel Hersen (eds.), Handbook of Psychological Assessment, Case Conceptualization, and Treatment, Volume 1: Adults (Wiley, 2007, ISBN 978-0471779995).
  16. ↑ 16.0 16.1 Alan M. Gruenberg, Reed D. Goldstein, and Harold Alan Pincus, "Classification of Depression: Research and Diagnostic Criteria: DSM-IV and ICD-10" in Julio Licinio and Ma-Li Wong (eds.), Biology of Depression: From Novel Insights to Therapeutic Strategies (Wiley-Blackwell, 2005, ISBN 3527307850), 1–12.
  17. ↑ 17.0 17.1 17.2 17.3 Depression National Institute of Mental Health (NIMH), 2021. Retrieved October 16, 2022.
  18. ↑ Benjamin L. Hankin and John R.Z. Abela, Development of Psychopathology: A Vulnerability-Stress Perspective (SAGE Publications, Inc, 2005, ISBN 1412904900).
  19. ↑ George M. Slavich, Deconstructing depression: A diathesis-stress perspective Association for Psychological Science (APS), September 3, 2004. Retrieved October 16, 2022.
  20. ↑ 20.0 20.1 Aaron T. Beck, A. John Rush, Brian F. Shaw, and Gary Emery, Cognitive Therapy of Depression (The Guilford Press, 1987, ISBN 978-0898629194).
  21. ↑ Nancy C. Andreasen, The relationship between creativity and mood disorders Dialogues in Clinical Neuroscience 10(2) (2008): 251–255. Retrieved October 16, 2022.
  22. ↑ Carol F. Heffernan, The Melancholy Muse: Chaucer, Shakespeare and Early Medicine (Duquesne University Press, 1995, ISBN 978-0820702629).
  23. ↑ John Stuart Mill, Autobiography (Adamant Media Corporation, 2000, ISBN 978-1421242002).
  24. ↑ Kerrie Eyers (ed.), Tracking the Black Dog (University of New South Wales, 2006, ISBN 978-0868408125).
  25. ↑ Paula J. Clayton and C.E. Lewis, The significance of secondary depression Journal of Affective Disorders 3(1) (March 1981): 25–35. Retrieved October 16, 2022.
  26. ↑ Lauren L. Patton and Michael Glick (eds.), The ADA Practical Guide to Patients with Medical Conditions 2nd Edition (Wiley-Blackwell, 2015, ISBN 978-1118924402).
  27. ↑ 27.0 27.1 27.2 6A70 Single episode depressive disorder ICD-11. Retrieved October 17, 2022.
  28. ↑ 28.0 28.1 28.2 6A71 Recurrent depressive disorder ICD-11. Retrieved October 17, 2022.
  29. ↑ Alison Karasz, Cultural differences in conceptual models of depression Social Science & Medicine 60(7) (Aoruk 2995): 1625–1635. Retrieved October 14, 2022.
  30. ↑ Gordon Parker, Is depression overdiagnosed? Yes BMJ 335(7615) (August 2007): 328. Retrieved October 17, 2022.
  31. ↑ Warren Steibel, Is depression a disease? Debatesdebates, May 13, 1998, Retrieved October 17, 2022.
  32. ↑ Dan G. Blazer, The Age of Melancholy: "Major Depression" and its Social Origin (Routledge, 2005, ISBN 978-0415951883).
  33. ↑ 33.0 33.1 Practice Guideline for the Treatment of Patients With Major Depressive Disorder Third Edition American Psychiatric Association, 2010. Retrieved October 17, 2022.
  34. ↑ National Institute for Health and Clinical Excellence (NICE), How to use antidepressants in children and young people Depression in children and young people: identification and management NICE guideline, June 25, 2019. Retrieved October 17, 2022.
  35. ↑ Helen F. Coelho, Peter H. Canter, and Edzard Ernst, Mindfulness-based cognitive therapy: evaluating current evidence and informing future research Journal of Consulting and Clinical Psychology 75(6) (December 2007): 1000–1005. Retrieved October 17, 2022.
  36. ↑ 36.0 36.1 David H. Barlow, Vincent Mark Durand, and Stefan G. Hofmann, Abnormal Psychology: An Integrative Approach (8th edition) (Cengage Learning, 2017, ISBN 978-1305950443).
  37. ↑ National Collaborating Centre for Mental Health (NCCMH), Depression: The NICE Guideline on the Treatment and Management of Depression in Adults (RCPsych Publications, 2010, ISBN 978-1904671855).
  38. ↑ Ming Li, Xiaoxiao Yao, et al, Effects of Electroconvulsive Therapy on Depression and Its Potential Mechanism Frontiers in Psychology, 11(80) (2020). Retrieved October 17, 2022.
  39. ↑ Adrian L. Lopresti, Sean D. Hood, Peter D. Drummond, A review of lifestyle factors that contribute to important pathways associated with major depression: diet, sleep and exercise Journal of Affective Disorders 148(1) (May 2013): 12–27. Retrieved October 17, 2022.
  40. ↑ Stephen Strakowski and Erik Nelson, Major Depressive Disorder (Oxford University Press, 2015, ISBN 978-0190206185)
  41. ↑ W.W. Eaton et al, Natural history of Diagnostic Interview Schedule/DSM-IV major depression. The Baltimore Epidemiologic Catchment Area follow-up] Archives of General Psychiatry 54(11) (November 1997): 993–999. Retrieved October 17, 2022.
  42. ↑ Hugh Rickards, Depression in neurological disorders: Parkinson's disease, multiple sclerosis, and stroke Journal of Neurology, Neurosurgery, and Psychiatry 76(Suppl 1) (March 2005): i48–52. Retrieved October 17, 2022.
  43. ↑ Edward M. Hallowell and John J. Ratey, Delivered from Distraction: Getting the Most out of Life with Attention Deficit Disorder (Ballantine Books, 2005, ISBN 978-0345442314).
  44. ↑ Robert M.A. Hirschfeld, The Comorbidity of Major Depression and Anxiety Disorders: Recognition and Management in Primary Care Primary Care Companion to the Journal of Clinical Psychiatry 3(6) (December 2001): 244–254. Retrieved October 18, 2022.
  45. ↑ Miranda Seymour, Mary Shelley (Grove Press, 2002, ISBN 978-0802139481).
  46. ↑ Leon Edel (ed.), The Letters of Henry James 1883–1895 (Belknap Press, 1980, ISBN 978-0674387829).
  47. ↑ Michael Burlingame, The Inner World of Abraham Lincoln (University of Illinois Press, 1997, ISBN 978-0252066672).
  48. ↑ William James, Letters of William James (Kessinger Publishing, LLC, 2003, ISBN 978-0766175662)
  49. ↑ David Cohen, J.B. Watson: The Founder of Behaviourism (Routledge Kegan & Paul, 1979, ISBN 978-0710000545).
  50. ↑ Gavin Andrews and Scott Henderson (eds.), Unmet Need in Psychiatry: Problems, Resources, Responses (Cambridge University Press, 2006, ISBN 978-0521027236).

References
ISBN links support NWE through referral fees

  • American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th Edition: DSM-5. American Psychiatric Publishing, Inc., 2013. ISBN 978-0890425558
  • Andrews, Gavin, and Scott Henderson (eds.). Unmet Need in Psychiatry: Problems, Resources, Responses. Cambridge University Press, 2006. ISBN 978-0521027236
  • Barlow, David H., Vincent Mark Durand, and Stefan G. Hofmann. Abnormal Psychology: An Integrative Approach (8th edition). Cengage Learning, 2017. ISBN 978-1305950443
  • Beck, Aaron T., A. John Rush, Brian F. Shaw, and Gary Emery. Cognitive Therapy of Depression. The Guilford Press, 1987. ISBN 978-0898629194
  • Blazer, Dan G. The Age of Melancholy: "Major Depression" and its Social Origin. Routledge, 2005. ISBN 978-0415951883
  • Burlingame, Michael. The Inner World of Abraham Lincoln. University of Illinois Press, 1997. ISBN 978-0252066672
  • Cohen, David. J.B. Watson: The Founder of Behaviourism. Routledge Kegan & Paul, 1979. ISBN 978-0710000545
  • Committee on Nomenclature and Statistics of the American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-II. American Psychiatric Association, 1968. ASIN B0030A4JAE
  • Edel, Leon (ed.). The Letters of Henry James 1883–1895. Belknap Press, 1980. ISBN 978-0674387829
  • Eyers, Kerrie (ed.). Tracking the Black Dog. University of New South Wales, 2006. ISBN 978-0868408125
  • Freud, Sigmund. On Murder, Mourning, and Melancholia. Penguin Classic, 2005. ISBN 978-0141183794
  • Hallowell, Edward M., and John J. Ratey. Delivered from Distraction: Getting the Most out of Life with Attention Deficit Disorder. Ballantine Books, 2005. ISBN 978-0345442314
  • Hankin, Benjamin L., and John R.Z. Abela. Development of Psychopathology: A Vulnerability-Stress Perspective. SAGE Publications, Inc, 2005. ISBN 1412904900
  • Heffernan, Carol F. The Melancholy Muse: Chaucer, Shakespeare and Early Medicine. Duquesne University Press, 1995. ISBN 978-0820702629
  • James, William. Letters of William James. Kessinger Publishing, LLC, 2003. ISBN 978-0766175662
  • Licinio, Julio, and Ma-Li Wong (eds.). Biology of Depression: From Novel Insights to Therapeutic Strategies. Wiley-Blackwell, 2005. ISBN 3527307850
  • Mill, John Stuart. Autobiography. Adamant Media Corporation, 2000. ISBN 978-1421242002
  • National Collaborating Centre for Mental Health (NCCMH). Depression: The NICE Guideline on the Treatment and Management of Depression in Adults. RCPsych Publications, 2010. ISBN 978-1904671855
  • Patton, Lauren L., and Michael Glick (eds.). The ADA Practical Guide to Patients with Medical Conditions 2nd Edition. Wiley-Blackwell, 2015. ISBN 978-1118924402
  • Richards, C. Steven, and Michael W. O'Hara (eds.). The Oxford Handbook of Depression and Comorbidity. Oxford University Press, 2014. ISBN 978-0199797004
  • Rosqvist, Johan, and Michel Hersen (eds.). Handbook of Psychological Assessment, Case Conceptualization, and Treatment, Volume 1: Adults. Wiley, 2007. ISBN 978-0471779995
  • Seymour, Miranda. Mary Shelley. Grove Press, 2002. ISBN 978-0802139481
  • Wolpert, Lewis. Malignant Sadness: The Anatomy of Depression. Free Press, 2000. ISBN 978-0684870588

External links

All links retrieved January 7, 2024.

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