Depression

Depression is a psychiatric disorder. It has been described as a black curtain of despair coming down over a person's life. Everyone occasionally feels blue or sad, but these feelings usually pass within a couple of days. With depression, however, the feeling of being "down" lasts for more than two weeks, and many people feel they have no energy and can't concentrate. Others feel irritable all the time for no apparent reason. The symptoms vary from person to person, but when a person has a depressive disorder, it interferes with daily life and normal functioning, and causes pain for both the person with the disorder and those who care about him or her. Depression is a common but serious illness, and most who experience it need treatment to get better.

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

Types

There are several forms of depressive disorders. The most common are major depressive disorder and dysthymic disorder. Some forms of depression are slightly different than these two, or they may develop under unique circumstances. Not all scientists agree on how to describe and define these forms of depression.

Major depressive disorder

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

Dysthymic disorder

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

Psychotic depression

This type of depression occurs when a severe depressive illness is accompanied by some form of psychosis, such as a break with reality, hallucinations, and delusions.

Postpartum depression

Postpartum depression is diagnosed if a new mother develops a major depressive episode within one month after delivery. It is estimated that 10%–15% of women experience postpartum depression after giving birth.^[1]

Seasonal affective disorder

Seasonal affective disorder (SAD) usually occurs during the winter months when there is less natural sunlight. For that reason it may be called "recurrent depressive disorder with seasonal pattern." People feel depressed, sleep more, and may crave starchy foods and sweets. The depression generally lifts during spring and summer. SAD may be effectively treated with light therapy, in which the patient is exposed to a bright lamp for a short time each day.^[2] Antidepressant medication and psychotherapy can reduce SAD symptoms, either alone or in combination with light therapy.

Bipolar disorder

Bipolar disorder, also called manic-depressive illness, is not as common as major depression or dysthymia. Bipolar disorder is characterized by cycling mood changes—from extreme highs (mania) to extreme lows (depression). This kind of depression includes periods of mania and depression. Cycling between these two states can be rapid or only mania can be present without any depressive episodes. A manic episode consists of a persistent elevated or irritable mood that is extreme, which lasts for at least one week.

Signs and Symptoms

People with depressive illnesses do not all experience the same symptoms. The severity, frequency, and duration of symptoms will vary depending on the person and his or her particular illness.

Symptoms include:

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

These problems last two weeks or more. The Diagnostic and Statistical Manual of Mental Disorders, fourth edition (American Psychiatric Association, 1994), also called the DSM-IV, more precisely defines depression with these criteria.

Differences based on gender and age

Depression in women

Depression is more common among women than among men. Biological, life cycle, hormonal, and psychosocial factors unique to women may be linked to the higher depression rate same in women. Researchers have shown that hormones directly affect brain chemistry that controls emotions and mood. For example, women are particularly vulnerable to depression after giving birth, when hormonal and physical changes, along with the new responsibility of caring for a newborn, can be overwhelming. Many new mothers experience a brief episode of the "baby blues," but some will develop postpartum depression, a much more serious condition that requires active treatment and emotional support for the new mother. Some studies suggest that women who experience postpartum depression often have had prior depressive episodes.

Some women may also be susceptible to a severe form of premenstrual syndrome (PMS), sometimes called premenstrual dysphoric disorder (PMDD), a condition resulting from the hormonal changes that typically occur around ovulation and before menstruation begins. During the transition into menopause, some women experience an increased risk for depression. Scientists are exploring how the cyclical rise and fall of estrogen and other hormones may affect the brain chemistry that is associated with depressive illness.^[3]

Finally, many women face the additional stresses of work and home responsibilities, abuse, poverty, and relationship strains. It remains unclear why some women faced with enormous problems develop depression, while others with similar problems do not.

Depression in men

Source: Wikimedia Commons

Men often experience depression differently than women and may have different ways of coping with the symptoms. Men are more likely to acknowledge having fatigue, irritability, loss of interest in once–pleasurable activities, and sleep disturbances, whereas women are more likely to admit to feelings of sadness, worthlessness, and/or excessive guilt.^[4][5]

Men are more likely than women to turn to alcohol or drugs when they are depressed, or become frustrated, discouraged, irritable, angry, and sometimes abusive. Some men throw themselves into their work to avoid talking about their depression with family or friends, or engage in reckless, risky behavior. And even though more women attempt suicide, many more men die by suicide in the United States.^[6]

Depression in older adults

Depression is not a normal part of aging, and studies show that most seniors feel satisfied with their lives, despite increased physical ailments. However, when older adults do have depression, it may be overlooked because they may show different, less obvious symptoms, and may be less inclined to experience or acknowledge feelings of sadness or grief.^[7]

In addition, older adults may have more medical conditions such as heart disease, stroke, or cancer, which may cause depressive symptoms, or they may be taking medications with side effects that contribute to depression. Some older adults may experience what some doctors call vascular depression, also called arteriosclerotic depression or subcortical ischemic depression. Vascular depression may result when blood vessels become less flexible and harden over time, becoming constricted. Such hardening of vessels prevents normal blood flow to the body's organs, including the brain. Those with vascular depression may have, or be at risk for, a co–existing cardiovascular illness or stroke.^[8]

Although many people assume that the highest rates of suicide are among the young, older white males aged 85 and older actually have the highest suicide rate. Many have a depressive illness that their doctors may not detect, despite the fact that these suicide victims often visit their doctors within one month of their deaths.^[9]

Depression in children and adolescents

Research has shown that childhood depression often persists, recurs, and continues into adulthood, especially if it goes untreated. The presence of childhood depression also tends to be a predictor of more severe illnesses in adulthood.^[10]

A child with depression may pretend to be sick, refuse to go to school, cling to a parent, or worry that a parent may die. Older children may sulk, get into trouble at school, be negative and irritable, and feel misunderstood. Because these signs may be viewed as normal mood swings typical of children as they move through developmental stages, it may be difficult to accurately diagnose a young person with depression.

Before puberty, boys and girls are equally likely to develop depressive disorders. By age 15, however, girls are twice as likely as boys to have experienced a major depressive episode.^[11]

Depression in adolescence comes at a time of great personal change—when boys and girls are forming an identity distinct from their parents, grappling with gender issues and emerging sexuality, and making decisions for the first time in their lives. Depression in adolescence frequently co-occurs with other disorders such as anxiety, disruptive behavior, eating disorders, or substance abuse. It can also lead to increased risk for suicide.^[12][13]

Causes

There is no single known cause of depression. Rather, it likely results from a combination of genetic, biochemical, environmental, and psychological factors.

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

Some types of depression tend to run in families, suggesting a genetic link. However, depression can occur in people without family histories of depression as well.^[14] Genetics research indicates that risk for depression results from the influence of multiple genes acting together with environmental or other factors.^[15]

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

Diagnosis

Treatment

Depression, even at its most severe, is a highly treatable disorder. As with many illnesses, the earlier that treatment can begin, the more effective it is and the greater the likelihood that recurrence can be prevented.

The patient should generally start by visiting a doctor. Certain medications, and some medical conditions such as viruses or a thyroid disorder, can cause the same symptoms as depression. A doctor can rule out these possibilities by conducting a physical examination, interview and lab tests. If the doctor can eliminate a medical condition as a cause, he or she should conduct a psychological evaluation or refer the patient to a mental health professional.

The doctor or mental health professional will do a complete evaluation. He or she should discuss any family history of depression and get a complete history of symptoms, such as when they started, how long they have lasted, their severity, and whether they have occurred before and, if so, how they were treated. He or she should also ask if the patient is using alcohol or drugs and whether the patient is thinking about death or suicide.

Once diagnosed, a person with depression can be treated with a number of methods. The most common treatments are medication and psychotherapy.

Medications

Antidepressants

Antidepressants work to alter naturally occurring brain chemicals called neurotransmitters, notably serotonin and norepinephrine. Other antidepressants work on the neurotransmitter dopamine. Scientists studying depression have found that these particular chemicals are involved in regulating mood, but they are unsure of the exact ways in which they work.

• Selective serotonin reuptake inhibitors (SSRIs) are the newest and most popular types of antidepressant medications. SSRIs include fluoxetine (Prozac), citalopram (Celexa), sertraline (Zoloft), and several others.

• Serotonin and norepinephrine reuptake inhibitors (SNRIs) are similar to SSRIs and include venlafaxine (Effexor) and duloxetine (Cymbalta). SSRIs and SNRIs are more often prescribed than the older classes of antidepressants, such as tricyclics and monoamine oxidase inhibitors (MAOIs) because they have been intensively marketed, can be taken in once-daily doses, and are less harmful to the heart. However, medications affect everyone differently—no one-size-fits-all approach to medication exists. Therefore, for some people, MAOIs or tricyclics may be the best choice.

• Monoamine oxidase inhibitors (MAOIs) are an older class of antidepressants. People taking MAOIs must adhere to significant food and medicinal restrictions to avoid potentially serious interactions. They must avoid certain foods that contain high levels of the chemical tyramine, which is found in many cheeses, wines, and pickles, and some medications including decongestants. MAOIs interact with tyramine in such a way that may cause a sharp increase in blood pressure, which could lead to a stroke. A doctor should give a patient taking an MAOI a complete list of prohibited foods, medicines, and substances.

• Tricyclic antidepressants are also an older class of antidepressants, named for their chemical structure. Tricyclics and MAOIs tend to have different side effects than the newer SSRIs and SNRIs, though they are still prescribed and are a better choice for some people.

For all classes of antidepressants, patients must take regular doses for at least three to four weeks before they are likely to experience a full therapeutic effect. They should continue taking the medication for the time specified by their doctor, even if they are feeling better, in order to prevent a relapse of the depression. Medication should be stopped only under a doctor's supervision. Some medications need to be gradually stopped to give the body time to adjust. Although antidepressants are not habit–forming or addictive, abruptly ending an antidepressant can cause withdrawal symptoms or lead to a relapse. Some individuals, such as those with chronic or recurrent depression, may need to stay on the medication indefinitely.

In addition, if one medication does not work, another might. Research has shown that patients who did not get well after taking a first medication increased their chances of becoming symptom-free after they switched to a different medication or added another medication to their existing one.^[16][17]

Sometimes stimulants, anti-anxiety medications, or other medications are used in conjunction with an antidepressant, especially if the patient has a co-existing mental or physical disorder. However, neither anti-anxiety medications nor stimulants are effective against depression when taken alone, and both should be taken only under a doctor's close supervision.

Side effects of antidepressants

Antidepressants may cause mild and often temporary side effects in some people, but they are usually not long-term. However, any unusual reactions or side effects that interfere with normal functioning should be reported to a doctor immediately.

A 2004 review by the Food and Drug Administration (FDA) revealed that 4% of children and adolescents taking antidepressants thought about or attempted suicide (although no suicides occurred), compared to 2% of those receiving placebos. The FDA issued a warning that emphasized that children, adolescents, and young adults taking antidepressants should be closely monitored for signs of suicide, especially during the initial weeks of treatment. Possible side effects to look for are worsening depression, suicidal thinking or behavior, or any unusual changes in behavior such as sleeplessness, agitation, or withdrawal from normal social situations. Results of a comprehensive review of pediatric trials conducted between 1988 and 2006 suggested that the benefits of antidepressant medications likely outweigh their risks to children and adolescents with major depression and anxiety disorders.^[18]

The most common side effects associated with SSRIs and SNRIs include:

• Headache, which is usually temporary and will subside.
• Nausea, which is temporary and usually short-lived.
• Insomnia and nervousness (trouble falling asleep or waking often during the night), which may occur during the first few weeks but often subside over time or if the dose is reduced.
• Agitation (feeling jittery).
• Sexual problems. Both men and women can experience sexual problems including reduced sex drive, erectile dysfunction, delayed ejaculation, or inability to have an orgasm.

Tricyclic antidepressants also can cause side effects including:

• Dry mouth. It is helpful to drink plenty of water, chew gum, and clean teeth daily.
• Constipation. It is helpful to eat more bran cereals, prunes, fruits, and vegetables.
• Bladder problems. Emptying the bladder may be difficult, and the urine stream may not be as strong as usual. Older men with enlarged prostates may be more affected.
• Sexual problems. Sexual functioning may change, and side effects are similar to those from SSRIs.
• Blurred vision. This often passes soon and usually will not require a new corrective lens prescription.
• Drowsiness during the day. This usually passes soon, but driving or operating heavy machinery should be avoided while drowsiness occurs. The more sedating antidepressants are generally taken at bedtime to help sleep and minimize daytime drowsiness.

Therapies

Psychotherapy

Several types of psychotherapy, or "talk therapy," can help people with depression.

Some regimens are short-term (10 to 20 weeks) and other regimens are longer-term, depending on the needs of the individual. Two main types of psychotherapies—cognitive-behavioral therapy (CBT) and interpersonal therapy (IPT)—have been shown to be effective in treating depression. By teaching new ways of thinking and behaving, CBT helps people change negative styles of thinking and behaving that may contribute to their depression. IPT helps people understand and work through troubled personal relationships that may cause their depression or make it worse.

For mild to moderate depression, psychotherapy may be the best treatment option. However, for major depression or for certain people, psychotherapy may not be enough. Studies have indicated that for adolescents, a combination of medication and psychotherapy may be the most effective approach to treating major depression and reducing the likelihood for recurrence.^[19] Similarly, a study examining depression treatment among older adults found that patients who responded to initial treatment of medication and IPT were less likely to have recurring depression if they continued their combination treatment for at least two years.^[20]

Electroconvulsive therapy

For cases in which medication and/or psychotherapy does not help alleviate a person's treatment-resistant depression, electroconvulsive therapy (ECT) may be useful. Formerly known as "shock therapy," ECT once had a bad reputation. But in recent years, it has greatly improved and can provide relief for people with severe depression who have not been able to feel better with other treatments.

Before ECT is administered, a patient takes a muscle relaxant and is put under brief anesthesia. He or she does not consciously feel the electrical impulse administered in ECT. A patient typically will undergo ECT several times a week, and often will need to take an antidepressant or mood stabilizing medication to supplement the ECT treatments and prevent relapse. Although some patients will need only a few courses of ECT, others may need maintenance ECT, usually once a week at first, then gradually decreasing to monthly treatments for up to one year.

ECT may cause some short-term side effects, including confusion, disorientation, and memory loss. But these side effects typically clear soon after treatment. Research showed that after one year of ECT treatments, patients experienced no harmful effects upon thinking.^[21]

Differences based on age

Depression in older adults

The majority of older adults with depression improve when they receive treatment with an antidepressant, psychotherapy, or a combination of both.^[22] Research has shown that medication alone and combination treatment are both effective in reducing the rate of depressive recurrences in older adults.^[23] Psychotherapy alone also can be effective in prolonging periods free of depression, especially for older adults with minor depression, and it is particularly useful for those who are unable or unwilling to take antidepressant medication.^[24][25]

Depression in adolescents

An NIMH-funded clinical trial of 439 adolescents with major depression found that a combination of medication and psychotherapy was the most effective treatment option.^[26] Other NIMH-funded researchers are developing and testing ways to prevent suicide in children and adolescents, including early diagnosis and treatment, and a better understanding of suicidal thinking.

Holistic and alternative treatments

A variety of alternative treatments may work for cases of depression. Some treatments said to be helpful include dietary and nutritional evaluation, herbal therapy, acupuncture, spiritual practices such as yoga and meditation, martial arts and other forms of physical activity, and light therapy.^[27]

St. John's wort

The extract from St. John's wort (Hypericum perforatum), a bushy, wild-growing plant with yellow flowers, has been used for centuries in many folk and herbal remedies. Today in Europe, it is used extensively to treat mild to moderate depression. In the United States, it is one of the top-selling botanical products.

To address increasing American interests in St. John's wort, the National Institutes of Health conducted a clinical trial to determine the effectiveness of the herb in treating adults who have major depression. Involving 340 patients diagnosed with major depression, the eight-week trial randomly assigned one-third of them to a uniform dose of St. John's wort, one-third to a commonly prescribed SSRI, and one-third to a placebo. The trial found that St. John's wort was no more effective than the placebo in treating major depression.^[28] Another study is looking at the effectiveness of St. John's wort for treating mild or minor depression.

Other research has shown that St. John's wort can interact unfavorably with other medications, including those used to control HIV infection. On February 10, 2000, the FDA issued a Public Health Advisory letter stating that the herb appears to interfere with certain medications used to treat heart disease, depression, seizures, certain cancers, and organ transplant rejection. The herb also may interfere with the effectiveness of oral contraceptives.

Living with Depression

Lifestyle changes

A person with depression may feel exhausted, helpless, and hopeless. It may be extremely difficult for them to take any action to help themselves. But it is important to realize that these feelings are part of the depression and do not accurately reflect actual circumstances. As the patient begins to recognize the depression and begins treatment, negative thinking will fade.

Self-help

Below are some activities that may benefit a person with depression.

• Engaging in mild activity or exercise. Going to a movie, a ballgame, or another event or activity that was once enjoyed. Participating in religious, social, or other activities.
• Setting realistic goals.
• Breaking up large tasks into small ones, setting priorities, and only doing what is reasonable to achieve.
• Trying to spend time with other people and confiding in a trusted friend or relative. Avoiding isolation, and letting others be of assistance.
• Expecting the mood to improve gradually, not immediately. Not expecting to suddenly "snap out of" depression. Often during treatment for depression, sleep and appetite will begin to improve before the depressed mood lifts.
• Postponing important decisions, such as getting married or divorced or changing jobs, until symptoms have improved. Discussing decisions with others who have a more objective view of the situation.
• Remembering that positive thinking will replace negative thoughts as depression responds to treatment.

Caring for someone with depression

The first and most important thing one can do to help a friend or relative who has depression is to help him or her get an appropriate diagnosis and treatment. It may be necessary to make an appointment on behalf of the friend or relative and go with him or her to see the doctor.

These are some things that may be helpful.

• Offering emotional support, understanding, patience, and encouragement.
• Engaging the friend or relative in conversation and listening carefully.
• Not disparaging feelings the friend or relative expresses, but pointing out realities and offering hope.
• Never ignoring comments about suicide, and reporting them to the friend's or relative's therapist or doctor.
• Inviting the friend or relative out for walks, outings, and other activities. Note that although diversions and company are needed, too many demands may increase feelings of failure.
• Reminding the friend or relative that with time and treatment, the depression will lift.

Related Problems

Complications

Depression, if left untreated, can lead to disability, problems with work or family, and social isolation. The most dangerous complication of depression is suicide.

Related disorders

Depression often co-exists with other illnesses. Such illnesses may precede the depression, cause it, or be a consequence of it. These other illnesses need to be diagnosed and treated.

Post–traumatic stress disorder (PTSD)

People experiencing PTSD are especially prone to having coexisting depression. PTSD is a debilitating condition that can result after a person experiences a terrifying event or ordeal, such as a violent assault, a natural disaster, an accident, terrorism, or military combat.

People with PTSD often relive the traumatic event in flashbacks, memories, or nightmares. Other symptoms include irritability, anger outbursts, intense guilt, and avoidance of thinking or talking about the traumatic ordeal. In a National Institute of Mental Health (NIMH)–funded study, researchers found that more than 40% of people with PTSD also had depression at one-month and four-month intervals after the traumatic event.^[29]

Other anxiety disorders

Other anxiety disorders, such as obsessive-compulsive disorder, panic disorder, social phobia, and generalized anxiety disorder, often accompany depression.

Dissociative disorders

People with chronic complex dissociative disorders such as dissociative identity disorder and related forms of dissociative disorder not otherwise speficied suffer usually from disthymic disorder and/or major depression. These subjects experience dissociative amnesias, fugues, identity confusion and alterations, and depersonalization. Hallucinations, suicidality, self-mutilative behavior, trauma-related flashbacks, and dissociative somatosensory (conversion) symptoms may accompany this condition.

Substance abuse

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

Other serious illnesses

Depression also often co-exists with other serious medical illnesses such as heart disease, stroke, cancer, HIV/AIDS, diabetes, and Parkinson's disease. Studies have shown that people who have depression in addition to another serious medical illness tend to have more severe symptoms of both depression and the medical illness, more difficulty adapting to their medical condition, and more medical costs than those who do not have co-existing depression.^[30] Research has yielded increasing evidence that treating the depression can also help improve the outcome of treating the co-occurring illness.^[31]

Clinical Trials

Two American government sites listing clinical trials are the National Institute of Mental Health (NIMH) and ClinicalTrials.gov. Trials from Clinicaltrials.gov can be found by clicking this link

Research

Researchers are looking for ways to better understand, diagnose, and treat depression among all groups of people. New potential treatments are being tested that give hope to those who live with depression that is particularly difficult to treat, and researchers are studying the risk factors for depression and how it affects the brain. NIMH continues to fund cutting-edge research into this debilitating disorder.

History

Depression has been recognized for centuries. It was once known as "melancholia," and was attributed, in accordance with the now-discredited theory of humors, to an excess of black bile.

Epidemiology

According to the World Health Organization:

• Depression affects 121 million people worldwide
• It was the fourth leading contributor to the global burden of disease in 2000
• Fewer than 25% of patients receive effective treatment
• 60%-80% of patients can be effectively treated with antidepressant medications and brief, structured forms of psychotherapy

Resources for Support

• Mental health specialists, such as psychiatrists, psychologists, social workers, or mental health counselors
• Health maintenance organizations
• Community mental health centers
• Hospital psychiatry departments and outpatient clinics
• Mental health programs at universities or medical schools
• State hospital outpatient clinics
• Family services, social agencies, or clergy
• Peer support groups
• Private clinics and facilities
• Employee assistance programs
• Local medical and/or psychiatric societies

References

1. ↑ Centers for Disease Control and Prevention (CDC). Prevalence of self-reported postpartum depressive symptoms--17 states, 2004-2005. MMWR Morb Mortal Wkly Rep. 2008 Apr 11;57(14):361-6. Full Text
2. ↑ Golden RN, Gaynes BN, Ekstrom RD, et al. The efficacy of light therapy in the treatment of mood disorders: a review and meta-analysis of the evidence. Am J Psychiatry. 2005 Apr;162(4):656-62. Full Text
3. ↑ Rubinow DR, Schmidt PJ, Roca CA. Estrogen-serotonin interactions: implications for affective regulation. Biological Psychiatry. 1998; 44(9): 839-850. Abstract
4. ↑ Pollack W. Mourning, melancholia and masculinity: recognizing and treating depression in men. In: Pollack W, Levant R, eds. New Psychotherapy for Men. New York: Wiley, 1998; 147-166.
5. ↑ Cochran SV, Rabinowitz FE. Men and Depression: clinical and empirical perspectives. San Diego: Academic Press, 2000.
6. ↑ Kochanek KD, Murphy SL, Anderson RN, Scott C. Deaths: final data for 2002. National Vital Statistics Reports; 53(5). Hyattsville, MD: National Center for Health Statistics, 2004. Abstract
7. ↑ Gallo JJ, Rabins PV. Depression without sadness: alternative presentations of depression in late life. American Family Physician. 1999; 60(3): 820-826. Full Text
8. ↑ Krishnan KR, Taylor WD, et al. Clinical characteristics of magnetic resonance imaging-defined subcortical ischemic depression. Biological Psychiatry. 2004; 55:390-397. Abstract
9. ↑ Conwell Y. Suicide in later life: a review and recommendations for prevention. Suicide and Life Threatening Behavior. 2001; 31(Suppl.): 32-47.
10. ↑ Weissman MM, Wolk S, Goldstein RB, et al. Depressed adolescents grown up. JAMA. 1999;281(18):1701-1713. Full Text
11. ↑ Cyranowski JM, Frank E, Young E, Shear MK. Adolescent onset of the gender difference in lifetime rates of major depression. Arch Gen Psychiatry. 2000;57:21-27. Full Text
12. ↑ Weissman MM, Wolk S, Goldstein RB, et al. Depressed adolescents grown up. JAMA. 1999;281(18):1701-1713. Full Text
13. ↑ Shaffer D, Gould MS, Fisher P, et al. Psychiatric diagnosis in child and adolescent suicide. Archives of General Psychiatry, 1996;53(4):339-348. Full Text
14. ↑ Tsuang MT, Faraone SV. The genetics of mood disorders. Baltimore, MD: Johns Hopkins University Press, 1990.
15. ↑ Tsuang MT, Bar JL, Stone WS, Faraone SV. Gene-environment interactions in mental disorders. World Psychiatry, 2004 June; 3(2): 73-83. Full Text
16. ↑ Rush JA, Trivedi MH, Wisniewski SR, et al. Bupropion-SR, Sertraline, or Venlafaxine-XR after failure of SSRIs for depression. NEJM. 2006 Mar 23;354(12):1231-1242. Full Text
17. ↑ Trivedi MH, Fava M, Wisniewski SR, et al. Medication augmentation after the failure of SSRIs for depression. NEJM. 2006 Mar 23;354(12):1243-1252. Full Text
18. ↑ Bridge JA, Iyengar S, Salary CB, et al. Clinical response and risk for reported suicidal ideation and suicide attempts in pediatric antidepressant treatment, a meta-analysis of randomized controlled trials. JAMA. 2007;297(15):1683-1696. Full Text
19. ↑ March J, Silva S, Petrycki S, et al. Severe J. Treatment for Adolescents with Depression Study (TADS) team. Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: Treatment for Adolescents with Depression Study (TADS) randomized controlled trial. JAMA. 2004;292(7):807-820. Full Text
20. ↑ Reynolds CF III, Dew MA, Pollock BG, et al. Maintenance treatment of major depression in old age. NEJM. 2006 Mar 16;354(11):1130-1138. Full Text
21. ↑ Rami L, Bernardo M, Boget T, et al. Cognitive status of psychiatric patients under maintenance electroconvulsive therapy: a one-year longitudinal study. J Neuropsychiatry Clin Neurosci. 2004;16:465-471. Abstract
22. ↑ Little JT, Reynolds CF III, Dew MA, et al. How common is resistance to treatment in recurrent, nonpsychotic geriatric depression? Am J Psychiatry. 1998;155(8):1035-1038. Full Text
23. ↑ Reynolds CF III, Frank E, Perel JM, et al. Nortriptyline and interpersonal psychotherapy as maintenance therapies for recurrent major depression: a randomized controlled trial in patients older than 59 years. JAMA. 1999;281(1):39-45. Full Text
24. ↑ Lebowitz BD, Pearson JL, Schneider LS, et al. Diagnosis and treatment of depression in late life: consensus statement update. JAMA. 1997;278(14):1186-1190. Abstract
25. ↑ Reynolds CF III, Dew MA, Pollock BG, et al. Maintenance treatment of major depression in old age. NEJM. 2006 Mar 16;354(11):1130-1138. Abstract
26. ↑ March J, Silva S, Petrycki S, et al. Severe J. Treatment for Adolescents with Depression Study (TADS) team. Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: Treatment for Adolescents with Depression Study (TADS) randomized controlled trial.] JAMA. 2004;292(7):807-820. Full Text
27. ↑ The Nightingale Center. Holistic Treatment for Depression
28. ↑ Hypericum Depression Trial Study Group. Effect of Hypericum perforatum (St. John's wort) in major depressive disorder: a randomized controlled trial. JAMA. 2002;287(14):1807-1814. Full Text
29. ↑ Shalev AY, Freedman S, Perry T, et al. Prospective study of posttraumatic stress disorder and depression following trauma.] Am J Psychiatry. 1998;155(5):630-637. Full Text
30. ↑ Cassano P, Fava M. Depression and public health, an overview. J Psychosom Res. 2002;53:849-857. Full Text
31. ↑ Katon W, Ciechanowski P. Impact of major depression on chronic medical illness. J Psychosom Res. 2002;53:859-863.

External Links

NYU Online Depression Screening Test

Depression-Screening.org: Sponsored by National Mental Health Association

Science Daily: Depression News

Psychology Information Online: Cognitive Therapy for Depression

International Foundation for Research and Education on Depression (iFred)

Depression and Bipolar Support Alliance

National Alliance on Mental Illness

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