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09-SEPTEMBER-2008 02:07:44 - Major depressive disorder Redirected from Clinical depression Depression Classification and external resources Vincent van Gogh's 1890 painting On the Threshold of Eternity ICD-10 F32., F33. ICD-9 296 OMIM 608516 DiseasesDB 3589 MedlinePlus 003213 eMedicine med/532 Major depressive disorder, also known as major depression, unipolar depression, clinical depression, or simply depression, is a mental disorder characterized by a pervasive low mood and loss of interest or pleasure in usual activities. The diagnosis is made if a person has suffered one or more major depressive episodes. The most common time of onset is between the ages of 30 and 40, with a later peak between 50 and 60, and the condition appears to be more common in women. Diagnosis is based on the patient's self-reported experiences and observed behavior. There is no laboratory test for major depression, although physicians often test for physical conditions that may cause similar symptoms before arriving at a diagnosis. The course varies widely, from a one-off occurrence to a life-long disorder with recurrent episodes. Both psychological and biological causes have been proposed, and the question of whether there are two separate conditions, a biological and a reactive depression, or a continuum of a single entity, has been hotly debated since the 1920s. Current classification has favored the latter since the creation of the term major depressive disorder in 1980. The neurotransmitters serotonin and noradrenaline have been implicated, and most antidepressants work to increase the active levels of these in the brain. A host of psychological factors has also been implicated, and various forms of psychotherapy are used to address them. Electroconvulsive therapy is sometimes used in severe cases. Hospitalization may be necessary in cases where there is a significant risk of suicide or self-neglect. The term depression is commonly used to describe a temporary depressed mood, when a person may feel sad or down. Ideas about what causes and constitutes depression have evolved over the centuries. Major depression can be a serious and often disabling condition that can significantly affect a person's work, family and school life, sleeping and eating habits, and general health. However, psychiatrist Gordon Parker and others argue it may be overdiagnosed, and that current diagnostic standards have the effect of medicalising sadness or misery. Around 3.4% of people with major depression commit suicide, and there is also a higher rate of dying from other causes. Up to 60% of those who commit suicide have a mood disorder, such as depression, and their risk may be especially high if they feel a marked sense of hopelessness or have both depression and borderline personality disorder. Contents 1 Signs and symptoms 1.1 Comorbidity 2 Diagnosis 2.1 Physical investigations 2.2 Clinical assessment 2.3 Rating scales 2.4 DSM IV-TR and ICD-10 criteria 2.4.1 Major depressive episode 2.4.2 Subtypes 2.5 Differential diagnoses 3 Causes 3.1 Psychological 3.2 Biological 4 Treatment 4.1 Psychotherapy 4.2 Medication 4.2.1 Augmentation 4.3 Electroconvulsive therapy 4.4 Other conventional methods of treatment 4.5 Alternative treatment methods 5 Prognosis 6 Epidemiology 7 History 7.1 Prehistory to antiquity 7.2 Medieval to Renaissance eras 7.3 17th to 19th centuries 7.4 20th century to the present day 8 Sociocultural aspects 9 References 9.1 Cited texts 10 External links Signs and symptoms A person suffering a major depressive episode almost always reports a pervasive low mood, and loss of interest or pleasure in favorite activities. They may ruminate over or be preoccupied with feelings of worthlessness, inappropriate or exaggerated guilt or regret, helplessness or hopelessness.1 Other symptoms include poor concentration and memory, withdrawal from social situations, family gatherings and activities with friends, reduced libido sex drive, and thoughts of death or suicide. Insomnia is a common symptom; the typical pattern is one of early morning wakening where the person reports waking up very early and being unable to get back to sleep.2 Hypersomnia, or oversleeping, is less common.2 Appetite is often decreased, with resulting weight loss, although increase and weight gain occasionally occurs.1 The patient may report persistent physical symptoms such as fatigue, headaches, digestive problems, or chronic pain, or describe feeling slowed down or sluggish. Family or friends may note the person appears agitated or slowed down.2 World map of suicide rates per 100,000. World map of suicide rates per 100,000. People are most likely to suffer their first depressive episode between the ages of 30 and 40.3 The risk is increased in the first year after childbirth post-natal depression, and after cardiovascular and neurological illnesses such as stroke,4 Parkinson's disease,4 and multiple sclerosis.4 Depressive episodes following a heart attack might even correspond with an increased risk of further cardiac complications, including death.5 There is a second, smaller peak of incidence later in life between the ages of 50 and 60;3 older people are more likely to present with cognitive symptoms such as forgetfulness and a more noticeable slowing of movements. The term pseudodementia was coined for this syndrome, due to its clinical resemblance to dementia.6 Diagnosis in children or adolescents may be delayed or missed as the symptoms are dismissed as normal moodiness. Their mood may be predominantly irritable rather than depressed.1 Children may show different symptoms depending on the situation;7 most will exhibit a loss of interest in school and decline in academic performance, and possibly drastic change in appearance. They may also begin abusing drugs or alcohol, particularly over the age of 12. Although much more rarely than adults, children with major depression may have suicidal thoughts or attempt suicide before the age of 12.7 Comorbidity Major depression frequently co-occurs with other psychiatric problems; the National Comorbidity Survey US reports that 58% of those with major depression also suffer from lifetime anxiety. 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. Psychiatrist Ellen Frank found that depressed patients with lifetime panic symptoms experienced significant delays in their remission, and had higher levels of residual impairment.8 Robert Sapolsky similarly argues that the relationship between stress, anxiety, and depression could be measured and demonstrated biologically.9 There are increased rates of alcohol and drug abuse and particularly dependence,10 and around a third of individuals diagnosed with attention-deficit hyperactivity disorder develop comorbid depression.11 Diagnosis Physical investigations Before a diagnosis of major depressive disorder is made, a physician generally performs a medical examination and selected investigations to rule out a medical illness as a cause of symptoms. These include blood tests measuring TSH to exclude hypo- or hyperthyroidism; basic electrolytes and serum calcium to rule out a metabolic disturbance; and full blood count including ESR to rule out a systemic infection or chronic disease.12 Testosterone levels may be used to diagnose hypogonadism, a cause of depression in men.13 Two commonly ordered investigations are EEG to exclude epilepsy, and a CT scan of the head to exclude brain lesions.14 Early dementia may present with depressive symptoms in older patients. No biological tests are used to confirm major depression as such. Investigations are not generally repeated for a subsequent episode unless there is a specific medical indication. These may include measuring serum sodium to rule out hyponatremia low sodium if the person presents with polyuria and has been taking a selective serotonin reuptake inhibitor SSRI.15 Clinical assessment If no medical cause is found, a psychiatric assessment may be done by the physician, or by referral to a psychiatrist or psychologist.16 Assessment is usually done on an outpatient basis; admission to an inpatient facility is considered for patients who pose a risk to themselves or others. This will include a complete history of the person's current circumstances, biographical history and current symptoms, a discussion of alcohol and drug use, and a family medical history to see if other family members have suffered from a mood disorder. A mental state examination will include assessing the person's current mood and exploring thought content, in particular thoughts of hopelessness, self-harm or suicide.16 Rating scales Several rating scales are used in research or as screening tools, and have been widely promoted in primary healthcare to improve detection of depression. However, their benefit has been questioned,17 and there is strong evidence routine screening does little to improve detection rates.18 The Beck Depression Inventory is one of the most widely used diagnostic tools for self-diagnosis of depression, although its main purpose is not the diagnosis of depression, but determining the presence and severity of symptoms.19 Originally designed by psychiatrist Aaron T. Beck in 1961, it is a 21-question patient-completed survey that covers items related to the basic symptoms of depression, such as hopelessness and irritability, cognitions such as guilt or feelings of being punished, as well as physical symptoms such as fatigue, weight loss, and lack of interest in sex.20 Two Patient Health Questionnaires available are self-administered questionnaires. The PHQ-2 has only two questions that asks about the frequency of depressed mood and a loss of interest in doing things, with a positive to either question indicating the need for further testing.21 The PHQ-9 is a slightly more detailed nine question survey covering some of the major symptoms of depression and the frequency a person has experienced them. It is based directly on the diagnostic criteria listed in the DSM-IV and often used as a follow up to a positive PHQ-2 test.22 Other scales commonly used include the Geriatric Depression Scale in older populations, which is also valid in patients with mild to moderate dementia,23 the widely used Hamilton Depression Rating Scale HRSD-21 designed by psychiatrist Max Hamilton in 1960,24 and the Montgomery-Åsberg Depression Rating Scale MADRS.25 DSM IV-TR and ICD-10 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, the current version being DSM-IV-TR, and the World Health Organization's International Statistical Classification of Diseases and Related Health Problems, currently the ICD-10. The latter system is typically used in European countries, while the DSM criteria are used in the USA and many other non-European nations,26 and are frequently referenced in research studies. The DSM IV-TR diagnosis hinges on the presence of a major depressive episode, which may be either single or recurrent.1 Further qualifiers are used to classify both the episode itself and the course of the disorder. There is also a category of Depressive Disorder Not Otherwise Specified. The ICD-10 system does not use the term Major depressive disorder, but lists similar criteria for the diagnosis of a Depressive episode mild, moderate or severe; multiple episodes without mania may be classed as Recurrent Depressive Disorder.27 Major depressive episode Main article: Major depressive episode A major depressive episode has been defined as a severely depressed mood that persists for at least two weeks.1 Episodes may be isolated or recurrent and categorized as mild few symptoms in excess of minimum criteria, moderate, or severe marked impact on social or occupational functioning; any episode with psychotic features is automatically rated as severe. If the patient has already had an episode of mania or markedly elevated mood, a diagnosis of bipolar disorder is made instead.28 Depression without periods of mania is sometimes referred to as unipolar depression because the mood remains at one emotional state or pole.29 The DSM excludes cases where the symptoms are a result of bereavement, although it is possible for normal bereavement to evolve into a depressive episode if characteristic features develop.30 Subtypes Diagnosticians recognize several subtypes or course specifiers: Atypical depression is characterized by mood reactivity paradoxical anhedonia and positivity, significant weight gain or increased appetite comfort eating, excessive sleep or somnolence hypersomnia, leaden paralysis, or significant social impairment as a consequence of hypersensitivity to perceived interpersonal rejection.31 Contrary to its name, atypical depression is the most common form of depression.32 Melancholic depression 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, excessive weight loss not to be confused with anorexia nervosa, or excessive guilt.33 Psychotic depression is the term for a major depressive episode, particularly of melancholic nature, where the patient experiences psychotic symptoms such as delusions or, less commonly, hallucinations. These are most commonly mood-congruent content coincident with depressive themes.34 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 stuporose, and either immobile or exhibits purposeless or even bizarre movements. Catatonic symptoms also occur in schizophrenia, a manic episode, or be due to neuroleptic malignant syndrome.35 Postpartum depression is listed as a course specifier in the DSM. It refers to the intense, sustained and sometimes disabling depression experienced by women after giving birth. Postpartum depression, which has incidence rate of 10-15%, typically sets in within three months of labor, and lasts as long as three months.36 Seasonal affective disorder is a specifier. Some people have a seasonal pattern, with depressive episodes coming on in the autumn or winter, and resolving 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.37 Differential diagnoses In the process of differential diagnosis, alternative diagnoses are ruled out so that the applicable condition can be identified. Some potential diagnoses that may be considered before diagnosing MDD include the following: Dysthymia, which is a chronic, milder mood disturbance where 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, although people with dysthymia are vulnerable to secondary episodes of major depression sometimes referred to as double depression.38 Recurrent brief depression RBD, distinguished from Major Depressive Disorder primarily by differences in duration. People with RBD have depressive episodes about once per month, with individual episodes lasting less than two weeks and typically less than 2-3 days. Diagnosis of RBD requires that the episodes occur over the span of at least one year and, in female patients, independently of the menstrual cycle. People with clinical depression can develop RBD, and vice versa, and both illnesses have similar risks.39 Minor depression, which refers to a depression that does not meet full criteria for major depression but in which at least two symptoms are present for two weeks.40 Adjustment disorder with depressed mood, the name given to a psychological response to identifiable stress that causes significant emotional or behavioral symptoms but does not meet criteria for more specific disorders.41 Causes Current theories regarding the risk factors and causes of major depression fall into two categories, the psychological and the biological, although there is much overlap and integration. Debate has persisted for most of the twentieth century over whether a unitary or binary model of depression is a truer reflection of the syndrome;42 in the former, there is a continuum of depression ranked only by severity and the result of a psychobiological final common pathway,43 whereas the latter conceptualizes a distinction between biological and reactive depressive syndromes.44 The publishing of DSM-III has seen the unitarian model gain a more universal acceptance.42 Psychological Psychological factors include the complex development of personality and how a person has learned to cope with external environmental factors, such as stress.45 Events such as the death of a parent, issues with biological development, school related problems, abandonment or rejection, neglect, chronic illness, and physical, psychological, or sexual abuse increase the risk of depression later in life. Post-traumatic stress disorder PTSD and depression often co-occur, and both can result from childhood trauma.46 Stressful or traumatic life experiences or circumstances, including rape, assault, combat, or the death of a relative or friend, may trigger a depressive episode directly-although temporary grief-related depression is not considered a disorder. A depressive episode may also be triggered by other major changes such as unemployment, divorce, or a loss of religious faith.47 Ongoing issues, such as financial difficulties or poverty, major health problems, addictions such as problem gambling or drug addiction, sexual difficulties, or work-related stress can also contribute to depression. According to sociologist George W. Brown and psychologist Tirril Harris,48 certain 'vulnerability factors'-namely early maternal loss, lack of a confiding relationship, greater than three children under the age of 14 at home and unemployment-can interact with 'provoking agents' to increase the risk of depression.49 S. B. Patten argues that confiding relationships are especially important.49 Low self-esteem, learned helplessness, and self-defeating or distorted thinking are connected with depression. There is debate as to whether these are causes or effects of depression. In either case, it is known that depressed persons who are able to make corrections in their thinking patterns often show improved mood and self-esteem.50 Cognitive psychology and cognitive-behavioural theory take the view that depression arises from deficits in memory and information processing which give rise to cognitive biases and distortions. According to Martin Seligman, depression in humans may be similar to learned helplessness in other animals, who remain in unpleasant situations from which they could escape, but over which they had initially had no control.51 Learned helplessness and depression may be related to what Julian Rotter called an external locus of control, a tendency to attribute outcomes to external events outside one's control.52 However, depressed people tend to blame themselves for negative events in particular, and to believe that the relevance of these events persists through time and pervades their entire lives and selfhoods.5354 This tendency is characteristic of a depressive attributional style, or pessimistic explanatory style, and the causal attributions made in such a style have been termed internal, stable, and global,53 or personal, permanent, and pervasive. According to Albert Bandura, people become depressed through a distorted self-concept and a lack of self-efficacy, in other words a habitual sense of inability to influence events and achieve personal goals.5556 A related idea, Aaron T. Beck's cognitive triad, is that depression entails cognitive errors about oneself, one's world, and one's future.53 Milder depression, however, has been associated with what has been called depressive realism, or the sadder-but-wiser effect, a view of the world that is relatively undistorted by positive biases.5758 From the psychoanalytic perspective, depression may be intertwined with self-criticism. In particular, wrote Sigmund Freud, the super-ego becomes over-severe, abuses the poor ego, humiliates it and ill-treats it, threatens it with the direst punishments.59 Freud also argued that objective loss, as occurs through death or a romantic break-up, could result in subjective loss as well, when the depressed subject had identified with the object of its affection through an unconscious but narcissistic process called the libidinal cathexis of the ego. Such loss results in a profoundly painful dejection, cessation of interest in the outside world, loss of the capacity to love, inhibition of all activity, and a lowering of self-regarding feelings that is more severe than mourning. In mourning 'it is the world that has become poor and empty; in depression it is the ego itself.'6061 Rollo May and other existential psychologists have argued that depression can stem from an inadequate grasp of personal freedom and responsibility. Rollo May and other existential psychologists have argued that depression can stem from an inadequate grasp of personal freedom and responsibility. Existential psychologists argue that depression is the inability to construct a future.62 In order to construct a future, people must become acutely aware of both their mortality and their freedom, and they must exercise the latter within the explicit framework of the former. This awareness and responsibility produce normal anxiety,63 whereas the lack of these things leads to neurotic anxiety,63 self-alienation,64 inauthentic living,65 and depression. Humanistic psychologists agree with many facets of existentialism, but argue that depression results from a specific incongruity between society and the individual's innate drive to self-actualize.66 Evolutionary psychology suggests that major depression can result from the overactivation or dysfunction of psychological mechanisms that are sensitive to certain kinds of material or social loss or defeat.676869 Some aspects of this approach have received empirical support and clinical application;7071 other components are still at a hypothetical stage. Biological Most experts believe that both biological and psychological factors play a role in causing depression. The heritability of depression-the degree to which it is genetically determined-has been estimated at around 40% for women and 30% for men.72 From the evolutionary standpoint, major depression might be expected to reduce the reproductive fitness of the individual suffering from it. Some evolutionary explanations for the apparent contradiction between this hypothesis and the high heritability and prevalence of major depression rest on the idea that some components of depression are adaptations.7369 Illustration of the major elements in a prototypical synapse. Synapses are gaps between nerve cells. These cells convert their electrical impulses into bursts of chemical relayers, called neurotransmitters, which travel across the synapses to receptors on adjacent cells, triggering electrical impulses to travel down the latter cells. Illustration of the major elements in a prototypical synapse. Synapses are gaps between nerve cells. These cells convert their electrical impulses into bursts of chemical relayers, called neurotransmitters, which travel across the synapses to receptors on adjacent cells, triggering electrical impulses to travel down the latter cells. Many modern antidepressant drugs change synaptic levels of certain neurotransmitters, especially serotonin and norepinephrine; this has implicated neurochemical factors. Serotonin in particular may regulate other neurotransmitter systems, and decreased serotonin activity may permit these systems to act in unusual and erratic ways. Facets of depression may be emergent properties of this dysregulation.74 However, the precise relationships between serotonin, Selective serotonin reuptake inhibitors, and depression are largely unknown, and tend to be greatly oversimplified when presented to the public.75 Many depressed individuals exhibit markedly higher levels of monoamine oxidase A MAO-A in the brain compared to people without depression.76 MAO-A is an enzyme that decreases the concentration of monoamines such as serotonin, norepinephrine and dopamine. There may be a link between depression and neurogenesis of the hippocampus,77 a center for both mood and memory. Loss of hippocampal neurons is found in some depressed individuals and correlates with impaired memory and dysthymic mood. Drugs may increase serotonin levels in the brain, stimulating neurogenesis and thus increasing the total mass of the hippocampus. This increase may help to restore mood and memory.7879 Depression may also be caused in part by an overactive hypothalamic-pituitary-adrenal axis HPA axis that resembles the neuro-endocrine response to stress. These HPA axis abnormalities participate in the development of depressive symptoms, and antidepressants serve to regulate HPA axis function.80 Depression may be affected by variations in the circadian rhythm. The REM stage of sleep, in which dreaming occurs, tends to be especially quick to arrive, and especially intense, for depressed people. Although the precise relationship between sleep and depression is mysterious, it appears to be particularly strong among those whose depressive episodes are not precipitated by unusual stress. In such cases, clients may be especially unaffected by therapeutic intervention.81 Treatment Main article: Treatment for depression The three most commonly indicated treatments for depression are psychotherapy, medication, and electroconvulsive therapy. Psychotherapy is the treatment of choice in people under 18; medication is offered only in conjunction with the former and generally not as a first line agent. Furthermore, pathology in the parents needs to be looked for and addressed.82 Psychotherapy Main article: Psychotherapy Albert Ellis invented Rational Emotive Behavior Therapy, the earliest form of Cognitive Behavioral Therapy. Albert Ellis invented Rational Emotive Behavior Therapy, the earliest form of Cognitive Behavioral Therapy. There are a number of different psychotherapies for depression, which may be provided to individuals or groups. Psychotherapy can be delivered by a variety of mental health professionals, including psychotherapists, psychiatrists, psychologists, clinical social workers, counselors, and psychiatric nurses. The most studied form of psychotherapy for depression is Cognitive behavioral therapy CBT. Several clinical trials have shown that CBT is as effective as antidepressant medications, even among more severely depressed clients. CBT is thought to work by teaching clients to learn a set of cognitive and behavioral skills, which they can employ on their own. This type of therapy attempts to teach people healthier behaviors. Earlier research suggested that cognitive-behavioral therapy was not as effective as antidepressant medication in the treatment of depression; however, more recent research suggests that it can perform as well as medication in the treatment outpatients with moderate to severe depression.83 With more complex and chronic forms of depression the most effective treatment is often considered to be a combination of medication and psychotherapy.84 For the treatment of adolescent depression, CBT performed no better than placebo, and significantly worse than fluoxetine.85 Combining fluoxetine with CBT appeared to bring no additional benefit8687 or, at the most, only marginal benefit.88 Two randomized, controlled trials of mindfulness-based cognitive therapy MBCT, which includes elements of mation, have been reviewed. MBCT was significantly more effective than usual care for the prevention of recurrent depression in patients who had had three or more depressive episodes. According to the review, the usual care did not include antidepressant treatment or any psychotherapy, and the improvement observed may have reflected the non-specific or placebo effects.89 Interpersonal psychotherapy focuses on the social and interpersonal triggers that may cause depression. There is evidence that it is an effective treatment for depression. Here, the therapy takes a structured course with a set number of weekly sessions often 12 as in the case of CBT, however the focus is on relationships with others. 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.90 Psychoanalysis, a school of thought founded by Sigmund Freud that emphasizes the resolution of unconscious mental conflicts,91 is used by its practitioners to treat clients presenting with major depression.92 A more widely practiced, eclectic technique, called psychodynamic psychotherapy, is loosely based on psychoanalysis and has an additional social and interpersonal focus.93 In a meta-analysis of three controlled trials, psychodynamic psychotherapy was found to be as effective as medication for mild to moderate depression.94 Medication Main article: Antidepressant To find the most effective pharmaceutical treatment, often the dosages of medications must be adjusted, different combinations of antidepressants must be tried, or the antidepressant must be changed. Response rates to the first agent administered may be as low as 50%.95 It may take anywhere from three to eight weeks after the start of medication before its therapeutic effects can be fully discovered. Patients are generally advised not to stop taking an antidepressant suddenly and to continue its use for at least four months to prevent the chance of recurrence. For patients who have chronic depression, medication may be continued for the remainder of their lives.16 Isoniazid, the first compound called antidepressant Isoniazid, the first compound called antidepressant Selective serotonin reuptake inhibitors SSRIs, such as sertraline Zoloft, escitalopram Lexapro, fluoxetine Prozac, paroxetine, and citalopram are the primary medications considered for patients, due to their relatively mild side effects and broad effect on the symptoms of depression and anxiety. Those who do not respond to the first SSRI tried can be switched to another SSRI antidepressant. Such a switch results in improvement in almost 50% of cases.96 Fluoxetine is the only antidepressant recommended for people under the age of 18.97 Another popular option is to switch the patient to the atypical antidepressant bupropion Wellbutrin or to add bupropion to the existing therapy98 with the latter strategy possibly more effective.99100 The causing or worsening of insomnia is not uncommon with SSRIs; a sedating antidepressant mirtazapine Zispin, Remeron can be used in such cases.101102103 Venlafaxine Effexor may be moderately more effective than SSRIs;104 however, it is not recommended as a first-line treatment because of the higher rate of side effects,105, and its use is specifically discouraged in children and adolescents.106 Tricyclic antidepressants are less well tolerated than SSRIs and are usually reserved for the treatment of inpatients, for whom the tricyclic antidepressant amitriptyline, in particular, appears to be more effective.107108 Their adverse side effect profile and toxicity in overdose limit their use. Monoamine oxidase inhibitors have historically been plagued by questionable efficacy and life-threatening adverse effects. They are still used only rarely, although newer agents of this class, with a better side effect profile, have been developed.109 In a meta-analysis of 35 clinical trials of four newer antidepressants, antidepressants were statistically superior to placebo, but they often did not exceed the NICE criteria for a clinically significant effect. In particular, the effect size was very small for moderate depression but increased with severity reaching 'clinical significance' for very severe depression.110 This result is consistent with the earlier clinical studies in which only patients with severe depression benefited from the treatment with a tricyclic antidepressant, imipramine, or from psychotherapy more than from the placebo treatment.111112113 Another meta-analysis concluded that both antidepressants and psychotherapy are effective treatments for depressive disorders, with the subgroup of SSRIs being slightly more efficacious. On the other hand, significantly more patients drop off from the antidepressant treatment than from psychotherapy, likely because of the side effects of antidepressants.114 Augmentation Physicians often add a medication with a different mode of action to bolster the effect of an antidepressant in cases of treatment resistance; a 2002 large community study of 244,859 depressed Veterans Administration patients found that 22% had received a second agent, most commonly a second antidepressant.115 Lithium has been used to augment antidepressant therapy in those who have failed to respond to antidepressants alone.116 Furthermore, lithium dramatically decreases the suicide risk in recurrent depression.117 Addition of atypical antipsychotics when the patient has not responded to an antidepressant is also known to increase the effectiveness of antidepressant drugs, albeit at the cost of more frequent side effects.118 There is some evidence for the addition of a thyroid hormone, triiodothyronine, in patients with normal thyroid function.119 Electroconvulsive therapy Main article: Electroconvulsive therapy Electroconvulsive therapy ECT is a treatment where seizures are electrically induced in anesthetized patients for therapeutic effect. ECT is most often used as a last resort intervention for severe major depression which has not responded to other treatment.120 It is also works more quickly than antidepressant therapy, and is thus the treatment of choice in emergencies such as catatonic depression where the patient has ceased oral intake of fluid or nutrients, or severe suicidality.120 There is strong evidence it is the most effective treatment for depression,121 and to result in improved quality of life in both short- and long-term.122 Antidepressant therapy is generally continued after treatment, although some patients require maintenance monthly ECT to remain well. Short-term memory loss, disorientation, and headache are common side effects. Long-term memory loss may occur in some instances.123 The American Psychiatric Association and the National Institute for Health and Clinical Excellence have concluded that the procedure does not cause brain damage.124125 Other conventional methods of treatment St John's wort extract is used extensively in Europe to treat mild and moderate depression. It is a prescription antidepressant in several European countries but is classified as herbal supplement and sold over the counter in the U.S. Opinions on its efficacy for major depression differ. A systematic meta-analysis of 37 trials conducted by Cochrane Collaboration indicated statistically significant weak-to-moderate effect as compared to placebo. The same meta-analysis found that St John's wort efficacy for major depression is not different from prescription antidepressants.126 NCCAM and other NIH-affiliated organizations hold that St John's wort has minimal or no effects beyond placebo in the treatment of major depression, based primarily on one study with negative outcome conducted by NCCAM.127128 S-Adenosyl methionine SAM-e is available as a prescription antidepressant in Europe and an over-the-counter dietary supplement in the United States. Fairly strong evidence from 16 clinical trials suggests it to be more effective than placebo and as effective as standard antidepressant medication for the treatment of major depression.129130 Repetitive transcranial magnetic stimulation rTMS use in treatment-resistant depression is supported by multiple controlled studies, and it has been approved for this indication in Europe, Canada and Australia, but not in the U.S.131 A 2008 meta-analysis based on 32 trials found a robust effect of this method on depression, and it appeared similarly effective for both uncomplicated depression and depression resistant to medication.132 However, it was inferior to ECT in a side-by-side randomized trial.133 Vagus nerve stimulation VNS is an approved therapy for treatment-resistant depression and is used as an adjunct to existing antidepressant treatment. The support for this method comes mainly from open-label trials, which indicate that a several month period may be required to see a benefit.131 The only large double-blind trial conducted lasted only 10 weeks and yielded inconclusive results; VNS failed to show superiority over a sham treatment on the primary efficacy outcome but the result were more favorable for the secondary outcome.134 Alternative treatment methods Bright light therapy is sometimes used to treat depression, especially in its seasonal form. Bright light therapy is sometimes used to treat depression, especially in its seasonal form. A meta-analysis of bright light therapy commissioned by the American Psychiatric Association found it to be more effective than placebo-usually, dim light-for both seasonal affective disorder and for nonseasonal depression, with effect sizes similar to those for conventional antidepressants. For non-seasonal depression, adding light therapy to the standard antidepressant treatment was not effective.135 A meta-analysis of light therapy for non-seasonal depression conducted by Cochrane Collaboration, studied a different set of trials, where light was used mostly as an addition to medication or sleep deprivation. A moderate statistically significant effect of light therapy was found; however, it disappeared if a different statistical technique was used.136 Both analyses noted poor quality of most studies and their small size, and urged caution in the interpretation of their results. The short 1-2 week duration of most trials makes it unclear whether the effect of light therapy could be sustained in the longer term. A 2004 Cochrane Review concluded that there was insufficient evidence to judge the efficacy of acupuncture in the management of depression. Although acupuncture showed no difference in the improvement of depression compared with conventional medication, the methodological quality of the evidence base was found to be poor.137 Exercise, when used in conjunction with medication by non-suicidal patients, can have beneficial effects in preventing the return of depression. Patients who completed 30 minutes of brisk exercise at least three times a week were found to have a significantly lower incidence of relapse.138 The support for the use of deep brain stimulation in treatment-resistant depression comes from a handful of case studies, and this treatment is still in a very early investigational stage.131 Tryptophan and 5-hydroxytryptophan may be more effective than placebo in alleviating depression according to the Cochrane Collaboration meta-analysis. However, only two out of 108 trials were of sufficient quality to be included in this analysis.139 Omega-3 fatty acids have been studied in clinical trials for major depression primarily as an adjunctive to antidepressant therapy. A meta-analysis of eight such trials indicated a statistically significant superiority of combinations with omega-3 fatty acids over single antidepressants; however, the authors warned that, due to multiple problems with these trials, a reliable conclusion is difficult to achieve.140 Dehydroepiandrosterone DHEA, available as a supplement in the U.S., has been shown to be more effective than placebo for major depression in two small double-blind trials: in one-as an adjunctive to antidepressant treatment141, in another-as monotherapy.142 Chromium picolinate was found to be equivalent to placebo for atypical depression overall but possibly efficacious in the sub-group of patients with severe carbohydrate craving.143 Zinc supplementation was found in a small study to augment the effect of antidepressants.144 Cranial electrotherapy stimulation CES, electrosleep devices currently on the market have been granted marketing authorization by the FDA based on the legacy waver, that is because a sufficiently similar device had been marketed before 1976, when the new regulations requiring controlled testing were introduced.145 The FDA considers them to be the class III devices-devices for which insufficient information exists to ... provide reasonable assurance of safety and effectiveness146 The effects of CES on depression were inconclusive or negative in multiple double-blind studies of psychiatric patients.147148149150148151 In one of them, four out of six clinically depressed patients dropped out of the study because of the massive worsening of depressive symptoms, with two of them becoming actively suicidal.151 One of the authors of the latter study cautioned that CES should not be used as a treatment of choice for the patients with the primary diagnosis of depression, and should be used with caution if this diagnosis is suspected.152 Nevertheless, the CES practitioners continue to employ it as a treatment of choice for depression.153154 Prognosis Major depressive episodes often tend to resolve over time whether they are treated or not. Outpatients on a waiting list show a 10-15% decrease in symptoms over a few months, and around 20% will no longer meet full criteria.155 The median duration of an episode has been estimated to be at least 23 weeks, with the highest rate of recovery in the first three months.156 Studies recruiting from the general population indicate around half those who have a major depressive episode whether treated or not do not have any further episodes, but around half have at least one more and a minority experience chronic recurrence.157 Studies recruiting from selective inpatient sources suggest low recovery and high chronicity, but studies of mostly outpatients show that nearly all recover, with a median episode duration of 11 months. Recurrence occurs in 40% to 70% within several years, however, and overall about one tenth have poor, one third have intermediate, and one half have favorable outcomes. Around 90% of those with severe or psychotic depression, most of whom also meet criteria for other mental disorders, experience recurrence.158159 There is a higher than average suicide risk in major depression. Articles and textbooks have often quoted a suicide rate of 15%, based on reviews of more severely depressed hospitalized patients. However, this was generalized to all people with major depression, both in and out of hospital. A reexamination indicated an approximate figure of 3.4%, with differing rates of around 7% for men and 1% for women.160161 Up to 60% of those who commit suicide have a mood disorder, such as major depression, and their risk is especially high if they feel a marked sense of hopelessness or have both depression and borderline personality disorder.162 There is also a higher rate of dying from other causes.163 Major depression can be a serious and often disabling condition that can significantly affect a person's work, family and school life, sleeping and eating habits, and general health.16 Recurrence is more likely if symptoms have not fully resolved with treatment. Current guidelines recommend continuing antidepressants for 4 to 6 months after remission to prevent relapse. Combined evidence from many randomized controlled trials indicates that continuing antidepressant medications after recovery can reduce the chance of relapse by 70% 41% on placebo vs. 18% on antidepressant. The preventive effect probably lasts for at least the first 36 months of use. Thus, in a significant minority of patients depression recurs despite the prolonged treatment with antidepressants.164 The reason for recurrence in these cases is as poorly understood and could be a true pharmacologic failure or a worsening of the disease, a relapse that overrides medication. Because of the difficulties of carrying out controlled clinical trials of longer duration, the approval of most antidepressants for the prevention of recurrence is based on up to a year-long trials.165 Epidemiology Lifetime prevalence estimates in community epidemiological surveys carried out by the World Health Organization in ten countries varied widely, from 3% in Japan to 16.9% in the US, with the majority between 8% to 12%.166 North American population studies have shown that 3-5% of males and 8-10% of females are suffering from a major depressive episode over a 12 month period.167168 The National Comorbidity Survey Replication NCS-R, conducted from 2001 through 2002, found that 16.2% of people had suffered a major depressive episode in their lives.169 Overall, major depression annually affects about 8.2% of the Canadian population and about 8.7% of the United States population. Researchers who compared epidemiological factors in Canada and the United States found the rate of major depression to be twice as high for Americans without medical insurance than either for Americans with insurance or for Canadians-for whom health care is publicly funded-in general.170 Population studies have consistently shown major depression to be more common in women, although it is unclear why this is so, and whether factors unaccounted for are contributing to this.171 Major depression is currently the leading cause of disease burden in North America and high-income countries, and fourth leading cause worldwide. In the year 2030, it is predicted to be the second leading cause of disease burden worldwide after HIV, according to the World Health Organization.172 History See also: History of mental disorders and Classification of mental disorders Prehistory to antiquity Notes in Ancient Egyptian document known as the Ebers papyrus appear to refer to emotional distress of the heart or mind, which has been interpreted as sadness or depression.173 Passages of the Hebrew Bible/Old Testament, composed and compiled between the 12th and the 2nd century BC, have been interpreted as describing mood disorders in figures such as Job, King Saul and in the psalms of David.174 The four temperaments clockwise from top right; choleric; melancholic; sanguine; phlegmatic, according to an ancient theory of mental states The four temperaments clockwise from top right; choleric; melancholic; sanguine; phlegmatic, according to an ancient theory of mental states The modern idea of depression appears similar in some ways to the much older concept of melancholia, which derives its name from the Greek theory of the four humours: disease being caused by an imbalance in one or other of the four basic bodily fluids, or humors. Personality types were similarly thought to be determined by the dominant humor in a particular person. The theory was first put forward by Greek scholar Empedocles 490-430 BC, and was influentially adopted by Hippocrates 460-377 BC. Melancholia was thought to be caused by an excess of black bile; derived literally from the Ancient Greek μέλας, melas, black, + χολή, kholé, bile;175 a person whose constitution tended to have a preponderance of black bile was thought to have a melancholic disposition. Melancholia was described as a distinct disease with particular mental and physical symptoms by Hippocrates in his Aphorisms, where he characterized all fears and despondencies, if they last a long time as being symptomatic of melancholia.176 Between 150-200 AD, Aretaeus of Cappadocia noted that sufferers were dull or stern; dejected or unreasonably torpid, without any manifest cause. Although humoral theory fell out of favor in some quarters, it was later revived in Greece and the Roman Empire Galen AD 129-ca. 200, who proposed that melancholy was caused by animal spirits. Such accounts show similarities to more modern concepts that developed from the 19th century. Prominence was given to a clustering of sadness, dejection, and despondency symptoms, but also often included fear, anger, delusions and obsessions.177 Medieval to Renaissance eras Influenced by Greek and Roman texts, physicians in the Persian and then the Muslim empire developed ideas about melancholia during the Islamic Golden Age. Ishaq ibn Imran d. 908, known as Isaac in the West, combined the concepts of melancholia and phrenitis.178 In The Canon of Medicine 1020s, Avicenna described melancholia as a depressive type of mood disorder in which the person may become suspicious and develop certain types of phobias.179 The Canon of Medicine became the standard of medical science in Europe for centuries, together with works of Hippocrates and Galen.180 Galen's ideas about medicine dominated Western medical thinking from the medieval era until the Renaissance, in part because the Catholic church supported them. In addition to viewing mental illness through the lens of Galen's four humors, medieval Europeans viewed mental illness as the entry of demons or evil spirits into the body181 and either a punishment for sin or a test of faith and character.182 The Franciscan monk Bartholomeus Anglicus ca. 1203-1272 described a condition which resembles depression in his encyclopedia, De Proprietatibis Rerum, and he suggested that music would help people with this condition. In Christian settings, a spiritual malaise called acedia sloth or absence of caring was described, involving low spirits and lethargy, especially related to isolation. It was viewed as a spiritual disease, vice, or undesirable trait of character.183182 17th to 19th centuries The seminal scholarly work of the 17th century was Robert Burton's The Anatomy of Melancholy, drawing on numerous theories and the author's own experiences. Burton suggested that melancholy could be combated with a healthy diet, sufficient sleep, music, and meaningful work, along with talking about the problem with a friend.184185 Shakespeare's plays, such as Hamlet and King Lear, described characters with deep melancholy. There was increasing medical dissatisfaction with the concept of melancholia. During the 18th century its connections to humoral theory were increasingly challenged by mechanical and electrical explanations; references to dark and gloomy states gave way to ideas of slowed circulation and depleted energy.186 The German physician Johann Christian Heinroth 1773-1843, however, argued that melancholia was a disturbance of the soul due to moral conflict within the patient. Eventually various authors proposed up to 30 different subtypes of melancholia, and alternative terms were suggested and discarded. Hypochondria came to be seen as a separate disorder. Melancholia and Melancholy had been used interchangeably until the 19th century, but the former came to refer to a pathological condition and the latter to a temperament.177 The term depression was derived from the Latin verb deprimere, to press down.187 From the 14th century, to depress meant to subjugate or to bring down in spirits. An early published instance of a psychological usage of the noun was in 1665 in Richard Baker's Chronicle, referring to someone having a great depression of spirit, and Samuel Johnson used the term in a similar sense in 1753.188 The term also came in to use in physiology and economics. One of the earliest uses to refer to a psychiatric symptom was by Louis Delasiauve in 1856; by the 1860s it was appearing in medical dictionaries to refer to a physiological and metaphorical lowering of emotional function.189 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 19th century, became more associated with women.177 Although melancholia remained the dominant diagnostic term, depression gained increasing currency in medical treatises and by the end of the century it had become a synonym of melancholia; the German psychiatrist Emil Kraepelin 1855-1926 may have been the first to use it as the overarching term, referring to different kinds of melancholia as depressive states.174 English psychiatrist Henry Maudsley proposed an overarching category of affective disorder.190 20th century to the present day Emil Kraepelin helped to distinguish mood disorders from psychoses. Emil Kraepelin helped to distinguish mood disorders from psychoses. The influential system put forward by Emil Kraepelin unified nearly all types of mood disorder into manic-depressive insanity, with a separate category of Dementia praecox Schizophrenia. Kraepelin worked from an assumption of underlying brain pathology, but also promoted a distinction between endogenous and exogenous types.174 Kurt Schneider honed the terms and coined endogenous depression, commonly associated with prominent psychomotor slowing and seen in inpatients, and reactive depression, more usually seen in outpatients, in 1920.44 The latter was so named for reactivity in mood and not reaction to outside events and was frequently misinterpreted. This view was challenged in 1926 by British psychiatrist Edward Mapother, who found a continuum of severity, and noted no clear differences in cause, prognosis or treatment response.191 The unitarian view became more popular in the United Kingdom, while the binary view held sway in the United States, influenced by the work of Adolf Meyer and before him Sigmund Freud.192 Freud had emphasized early life experiences and conflicting psychological drives; he associated melancholia with psychological loss and self-criticism.177 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.190 The DSM-I 1952 contained depressive reaction and the DSM-II 1968 depressive neurosis, defined as an excessive reaction to internal conflict or an identifiable event, as well as including a depressive type of manic-depressive psychosis within Major affective disorders.193 The depressive reaction of the 1950s was distinguished from endogenous depression, purportedly a rare biological condition, which borrowed as a synonym the longstanding term, melancholic.194 In the mid-20th century, researchers theorized that depression was caused by a 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.195 During the 1960s and 70s, manic-depression came to refer to just one type of mood disorder now most commonly known as bipolar disorder which was distinguished from unipolar depression. The terms unipolar and bipolar had been coined by Karl Kleist.174 The term Major depressive disorder was introduced by a group of US psychiatrists in the mid-1970s as part of proposals for diagnostic criteria based on patterns of symptoms called the Research Diagnostic Criteria, building on earlier Feighner Criteria, and was incorporated in to the DSM-III in 1980.196 In order to maintain consistency the ICD-10 used the same criteria, with only minor alterations, but using the DSM diagnostic threshold to mark a mild depressive episode, adding higher threshold categories for moderate and severe episodes.196197 The ancient idea of melancholia still survives in the notion of a melancholic subtype. The new criterion definitions of depression received widespread acceptance, although there have been conflicting findings and views on the validity of imposing such categorical cut-offs on a continuum198 and of not incorporating any evaluation of the personal and social context except for grief in which it occurs.199200 Debate has also continued about whether a categorical distinction between unipolar and bipolar distinction best reflects the evidence.201 There are also some continuing empirical arguments for a return to the diagnosis of melancholia.202203 Many causes for depression have been proposed.204 Biological psychiatrists, for example, explored the biological substrates of depression; psychiatrist David Healy wrote about the growth of the diagnosis, along with perspectives on the development and promotion of antidepressants and the biological model since the late 1950s.205 Sociocultural aspects Because of the lack of scientific certainty, 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.206 There are cultural differences in the extent to which serious depression is considered an illness requiring personal professional treatment, or an indicator of the need to address social problems, structural determinants of powerlessness, and emotional struggle.207208 The diagnosis is less common in some countries, such as China. It has been argued that the Chinese traditionally deny or somatize emotional depression, or alternatively that Western cultures reframe and elevate some expressions of human distress to disorder status.209 Australian psychiatrist Gordon Parker and others have argued that the Western concept of depression medicalizes sadness or misery.210194 The influential psychologist William James was nearly driven to suicide during his depression. His choice to believe in free will was instrumental in helping him to overcome this condition. The influential psychologist William James was nearly driven to suicide during his depression. His choice to believe in free will was instrumental in helping him to overcome this condition.211 Evolutionary theorists view depression as an adaptation to regulate relationships or resources, although it may be unwanted or disordered in modern environments.212 From this perspective, depression can be seen as a species-wide evolved suite of emotional programmes that are mostly activated by a perception, almost always over-negative, of a major decline in personal usefulness, that can sometimes be linked to guilt, shame or perceived rejection.71 Like an ageing hunter in our foraging past, an alienated member of today's society may feel and act in ways that prompt support from friends and kin. Additionally, in a manner analogous to that in which physical pain has evolved to hinder actions that may cause further injury, psychic misery may have evolved to prevent hasty and maladaptive reactions to distressing situations.67 These insights may be helpful in counselling therapy.213214 There is ongoing debate about the extent to which depression and mental illness in general may be linked to creativity in arts.215 The relationship between depression and creativity appears to be especially strong among female poets.216217 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 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.218 English essayist and wit Samuel Johnson used the term the black dog in 1780s to describe his own depression.219 Subsequently popularised by depression sufferer former British Prime Minister Sir Winston Churchill,219 the term lives on in the Black Dog Institute, an Australian facility for research and education into mood disorders such as major depression and bipolar disorder.220 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. 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R. 2005, An Introduction to the History of Psychology 5th ion ed., Belmont, CA, USA: Thomson Wadsworth Parker, Gordon 1996, Melancholia: A disorder of movement and mood : a phenomenological and neurobiological review, Cambridge: Cambridge University Press, ISBN 052147275X Sadock, Benjamin J. 2002, Kaplan and Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry 9th ed., Lippincott Williams Wilkins, ISBN 0781731836 External links DSM-IV Diagnostic Criteria for Major Depressive Disorder - DSM-IV-TR text from mindsite.com Depression at Epocrates Online Black Dog Institute - Depression and Bipolar Disorder Information Australia Depression at the Open Directory Project National Alliance on Mental Illness - Depression support, advocacy, and education National Depressive and Manic Depressive Association - National Depressive and Manic Depressive Association v d e WHO ICD-10 mental and behavioral disorders F · 290-319 Neurological/symptomatic Dementia Alzheimer's disease, multi-infarct dementia, Pick's disease, Creutzfeldt-Jakob disease, Huntington's disease, Parkinson's disease, AIDS dementia complex, Frontotemporal dementia, Elopement, Sundowning, Wandering · Delirium · Post-concussion syndrome · Organic brain syndrome Psychoactive substance alcohol drunkenness, alcohol dependence, alcoholic hallucinosis, Alcohol withdrawal, delirium tremens, Korsakoff's syndrome, alcohol abuse · opioids opioid dependency · sedative/hypnotic benzodiazepine withdrawal · cocaine cocaine dependence · general Intoxication, Drug abuse, Physical dependence, Withdrawal Psychotic disorder Schizophrenia disorganized schizophrenia · Schizophreniform disorder · Schizotypal personality disorder · Delusional disorder · Folie à deux · Schizoaffective disorder Mood affective Mania · Bipolar disorder · Clinical depression · Cyclothymia · Dysthymia Neurotic, stress-related and somatoform Anxiety disorder Agoraphobia, Panic disorder, Panic attack, Generalized anxiety disorder, Social anxiety, Social phobia · OCD · Acute stress reaction · PTSD · Adjustment disorder · Conversion disorder Ganser syndrome · Somatoform disorder Somatization disorder, Body dysmorphic disorder, Hypochondriasis, Nosophobia, Da Costa's syndrome, Psychalgia · Neurasthenia Physiological/physical behavioral Eating disorder: Anorexia nervosa · Bulimia nervosa Sleep disorder: Dyssomnia Hypersomnia, Insomnia · Parasomnia REM behavior disorder, Night terror · Nightmare Sexual dysfunction: Erectile dysfunction · Premature ejaculation · Vaginismus · Dyspareunia · Hypersexuality · Female sexual arousal disorder Postpartum depression · Postnatal psychosis Adult personality and behavior Personality disorder · Passive-aggressive behavior · Kleptomania · Trichotillomania · Voyeurism · Factitious disorder · Munchausen syndrome · Ego-dystonic sexual orientation · Fetishism Mental retardation Mental retardation Psychological development developmental disorder Specific: speech and language expressive language disorder, aphasia, expressive aphasia, receptive aphasia, Landau-Kleffner syndrome, lisp · Scholastic skills dyslexia, dysgraphia, Gerstmann syndrome · Motor function developmental dyspraxia Pervasive: Autism · Rett syndrome · Asperger syndrome Behavioral and emotional, childhood and adolescence onset ADHD · Conduct disorder · Oppositional defiant disorder · Separation anxiety disorder · Selective mutism · Reactive attachment disorder · Tic disorder · Tourette syndrome · Speech stuttering · cluttering Retrieved from http://en..org/wiki/Major_depressive_disorder Categories: Medical emergencies | Mood disorders | Abnormal psychology Views Article Discussion this page History Personal tools Log in / create account Navigation Main page Contents Featured content Current events Random article Search Go Search Interaction Community portal Recent changes Contact Donate to Help Toolbox What links here Related changes Upload file Special pages Printable version Permanent link Cite this page Languages Afrikaans العربية Bosanski Català Česky Dansk Deutsch Eesti Ελληνικά Español Esperanto Français 한국어 Hrvatski Bahasa Indonesia Italiano עברית Kurdî / كوردی Latina Lietuvių Lingála Magyar Bahasa Melayu Nederlands Nedersaksisch 日本語 ‪Norsk bokmål‬ ‪Norsk nynorsk‬ Occitan O'zbek Polski Português Română Ру�?�?кий Simple English Sloven�?ina Срп�?ки / Srpski Suomi Svenska Tiếng Việt Türkçe Україн�?ька ייִדיש 中文 This page was last modified on 29 August 2008, at 15:02

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