Natural Depression Treatment System

Destroy Depression

Destroy Depression is written by James Gordon, a former sufferer of depression from the United Kingdom who was unhappy with the treatment he was being given by medical personnell to fight his illness. Apparently, he stopped All of his medication one day and began to search for answers on how to cure himself of depression in a 100% natural way. He spent every waking hour researching all he could on the subject, making notes and changing things along the way until he had totally cured his depression. Three years later, he put all of his findings into an eBook and the Destroy Depression System was born. The Destroy Depression System is a comprehensive system that will guide you to overcome your depression and to prevent it from injuring you mentally and physically. Read more here...

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Postnatal Depressive Disorders

These disorders present in three forms. The first is a transient anxiety-depressive state known as postpartum blues that occurs a few days after delivery, peaks within 10 days and subsides usually within 3 weeks after delivery. About half of the mothers experience the blues in various degrees 4,10, 79 . The symptoms are mild, not necessitating medical attention. Characteristic symptoms include mild depressive mood, crying, fatigue. The second form occurs in almost 10-15 of mothers 80 , as a rule within the first month after delivery. The symptoms do not essentially differ from the moderate and severe non-psychotic DE MD. They have a disrupting and long-term effect on the personal and family life of the mother. The third, known as post-partum depression with psychotic features, occurs in about one out of 1000 mothers. In this form of postnatal depression, the first month after delivery is characterized, in addition to DE MD symptomatology, by psychotic features among which are...

Models of Classification of Depressive Disorders

Stefanis and Stefanis' description of depressive disorders according to the present state of knowledge raises, among other things, a basic issue the model or models best suited for their classification. As pointed out by Stefanis and Stefanis, two models exist, the categorical and the dimensional. The purpose of both is to condense the available information as accurately as possible. In the categorical model, mutually exclusive classes are defined by specific patterns of characteristics (usually symptoms). The attribution of each subject to a given class is based on the fact that the pattern presented is closer to the pattern defining that class than to any of the other patterns. The model condenses the information by substituting this attribution to a detailed description of the characteristics of the individual. Although many patterns have been constituted on a priori grounds, in a ''true'' class the co-occurrence of the elements constituting the pattern must have a higher frequency...

The Identification of Diagnostic Subtypes of Depressive Disorders

The clinical core of the modern diagnosis of depressive disorders (DD) is the ''depressive episode'' (DE) or ''major depression'' (MD), which can occur as a single episode or be recurrent. DE is presented descriptively in ICD-10, whereas MD is defined by operational criteria in DSM-IV. These diagnostic categories are comparable, and include depression with or without psychotic symptoms, with or without catatonic features, and with or without somatic (melancholic) symptoms. Other subtypes of depression include subsyn-dromal symptomatic depression 1 and specific conditions limited mostly by temporal frameworks recurrent brief depression, dysthymia, cyclothymia, seasonal depression, premenstrual dysphoric disorders, postpartum and menopausal depressions, and so on. An ambiguity of current classifications is the use of the term ''bereavement''. First, a situation of loss is often observed in major depressive episodes second, depressive symptoms when a loss has occurred are sometimes...

Negative and Depressive Symptoms Suicidality

Various methodological issues impede the interpretation of clinical trials in patients suffering from negative and or depressive symptoms in the course of schizophrenia. Differential diagnosis is one of them negative symptoms, depression and akinesia share many common features. This makes diagnosis difficult, especially in a cross-sectional evaluation. Negative symptoms can be of secondary nature, for instance as a result of EPS or as sequelae of positive symptoms or psychosocial deprivation 174 . Depressive syndromes in schizophrenia are commonly seen as an inherent feature of the illness they can also occur as a psychological reaction to the diagnosis 183-185 . Problems of clinical trials evaluating negative symptoms have been dealt with in the previous section.

Severity and Duration of Major Depressive Episode MDE

Severity of symptoms in an episode of major depression is a key dimension 23 . DSM-IV and ICD-10, as well as the HAM-D, use the term ''psychotic depression'' to mean the most severe degree of the depressive syndrome accompanied by either delusions or hallucinations. A major depressive episode (MDE), therefore, maybe with or without psychotic features. Furthermore, the psychotic features can be either mood-congruent (i.e. severe degree of such symptoms as guilt or hypochondriasis) or mood-incongruent (i.e. independent of the depression symptoms). A major depressive episode may be with or without melancholia. The terms ''melancholic'' as used in DSM-IV and ''somatic'' as used in ICD-10 Table 2.2 Imipramine-responsive symptoms, DSM-IV major depression symptoms, and the Hamilton depression symptoms DSM-IV syndrome profile of major depression Table 2.3 Relationship between the DSM-IV ICD-10 categories of major depression and the total severity score on HAM-D-17 Less than major depression...

Treatment Of An Episode Of Major Depression

Figure 2.1 shows the terminology of response, remission, relapse, and recovery as introduced by Frank et al 27 and Kupfer 28 . With reference to HAM-D, a response is defined as at least a 50 reduction of the pre-treatment score, and a full remission as a score of 7 or less. According to the European guidelines for antidepressants 29 , the treatment of an episode of major depression covers both a short- and a medium-term period. The short-term treatment Kupfer 28 calls the acute therapy of depression. The duration of the acute therapy is typically 6-8 weeks the response will typically occur after 4 weeks of therapy and full remission after 8 weeks. However, as shown by Stassen and Angst 30 , a 20-25 reduction of HAM-D will typically occur after 2 weeks of therapy (early improvement, Figure 2.1).

Evidence Of Clinical Effect Of Firstgeneration Antidepressants

Evidence-based medicine refers to the outcome of randomized clinical trials (RCTs). Evidence means empirical documentation. The use of placebo tablets when evaluating the effect of pharmacological treatment in randomized controlled trials was introduced in medicine at a time when the firstgeneration antidepressants had already been found to be effective in open trials. At that time, in the late 1950s or early 1960s, ECT was the only effective reference treatment. The first review that selectively included RCTs for measuring efficacy of first-generation antidepressants was published by Morris and Beck 31 . All RCTs were pertinent to short-term treatment. Morris and Beck noticed many intertrial differences, for example in the diagnostic assessment of depression, in definition of response, in the nature of control treatment, and in the statistical analysis. In the following, short-term trials have been classified according to the setting in which they were conducted inpatients vs....

Tricyclic Antidepressants

The cyclic antidepressants produce sedation, a-blocking, anticholinergic, and quinidinelike effects. In the central and peripheral nervous systems, norepinephrine, 5-hydrox-ytryptamine, and dopamine are blocked. Risk Factors Etiology. Ingestion of tricyclic antidepressants is a serious problem in the pediatric population because of the availability of these in the home when prescribed for depression and bed-wetting. Poisoning with tricyclic antidepressants is a leading cause of death.

Other Secondgeneration Antidepressants vs Fluoxetine in Major Depression

Available RCTs comparing other second-generation antidepressants with fluoxetine have usually found no difference in terms of efficacy. However, venlafaxine has been found to be superior to fluoxetine in two trials (Table 2.7). An inpatient trial by Clerc et al 145 compared 200 mg venlafaxine with 40 mg fluoxetine daily, and the difference between the two drugs was significant when measured on HAM-D after 4 weeks of treatment.

Profile Of Antidepressants And Dosage Recommendations

Most RCTs with antidepressants have focused on short-term treatment, although a substance is accepted as an antidepressant not only if it can be shown to be more effective than placebo in short-term trials, but also if it is effective in medium-term trials, corresponding to the total duration of a major depressive episode 29 , typically carried out in an outpatient setting (although more than 80 of the patients with major depression are treated in the GP setting). It is also a paradox that so few trials have been carried out in the elderly between 75 and 90 years of age, as the benign safety profile of the second-generation antidepressants has special clinical relevance for this group of patients 192 . The drug-placebo advantage in short-term trials is 15-20 when measured as a 50 reduction of the HAM-D score from pre-treatment (baseline) to endpoint, which equals a global assessment of very much and much improvement. In their review of the first-generation antidepressants, Smith et al...

Antidepressants Forty Years of Experience

Antidepressants of modern types have now been available for 40 years. They are well established in the pharmacopoeia, and have a longer history than many of the drugs used today elsewhere in medicine. They are products of the controlled trial era, and their efficacy has been tested in a very large number of randomized trials. The novelty has worn off. Now is a time to draw some conclusions. In this commentary I will discuss a few selected issues. Prof. Bech correctly points out that overall efficacy of the antidepressants is limited, with a 15-20 advantage over placebo. Part of this is due to the good outcome often seen in placebo groups, which probably reflects spontaneous remission and the benefits of non-specific therapeutic elements inherent in psychiatric care, rather than being due to the placebo. The drugs themselves also have limited effects in some patients. Incomplete remission with residual symptoms and later relapse is also common 1 . It is this limited overall advantage...

The Treatment of Major Depressive Episode

With the toxicity and side effects of tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) in mind, I think that most patients and psychiatrists would prefer to stop using these drugs. However, what is myth, what is reality and what is a matter of interpretation of data when it comes to evaluation of the efficacy of the new generation of antidepressants Per Bech, through a very comprehensive review of the literature, enables the reader to evaluate results from a large number of randomized clinical trials (RCTs) and against this background to try to answer the question put forward in the title of this commentary. One controversial point is whether it is meaningful to distinguish between efficacy in the treatment of inpatients and outpatients, when they are all classified as suffering from a major depressive episode (MDE). In other words, are the two groups clinically similar or are we dealing with two different groups although they fulfil the same inclusion...

Antidepressants in Broader Context

There is currently a trend to transform custodial psychiatric care toward more community-based service. This also necessitates developing drugs with higher compliance and safety. On the other hand, the need for treatment of pharmacoresistant depression has become more important in inpatient facilities. The change of one antidepressant for another, their combination or augmentation with lithium, with thyroid hormones (for review see 6 ), with pindolol 7 or with other drugs (e.g. buspirone 8 ) has been recommended to overcome resistance. In bipolar depression, calcium channel blockers have also been studied (for review, see 9 ). Verapamil has been superior to placebo in the treatment of mania in a double-blind study, but failed in the treatment of depressive episode 10 . Serious attempts to develop practically useful treatment guidelines have recently been made 11 . Besides antidepressants, anticonvulsants 12 , herbal remedies (Hypericum perforatum 13 ), acupuncture, exercise, sleep...

Antidepressants for Better Quality of Life

Antidepressant pharmacotherapy revolutionized treatment in both unipolar and bipolar depression. Whereas the first antidepressants were found by chance, their successful usage stimulated further basic research programs with the aim of finding more specifically acting antidepressants with a distinct mechanism of action. Together with non-pharmacological, biologically based antidepressant treatment modalities, such as electroconvulsive treatment, therapeutic sleep deprivation, light therapy and transcranial magnetic stimulation, a line of antidepressant treatment modalities emerged for the benefit of our patients (see 1 for a review). Whereas first generation antidepressants (tricyclics and MAO inhibitors) were associated with burdensome side effects, the class of selective serotonin reuptake inhibitors (SSRIs) first exhibited a favourable side-effect profile, which opened the way for effective pharmacotherapy for the necessary long-term treatment in depression (see 2 for a review)....

Compliance Issues and the Efficacy of Antidepressants

The depressive condition, with its cognitive deficit, helplessness, poor motivation and withdrawal, leads to forgetfulness and passive non-compliance. Disturbing beliefs about antidepressants often result in active non-compliance you only take antidepressants when you feel depressed and not when you feel better you need to give your body some rest from antidepressants once in a while or otherwise you become dependent on the medication you feel you are being controlled by these drugs, and so on 1 . Such passive and active non-compliance makes 50 of depressed patients prematurely discontinue treatment within 10 weeks 2 . The clinical importance of compliance and non-compliance is obvious. Taking longer drug holidays can result in discontinuation symptoms, particularly with antidepressants with a shorter half-life 7-9 . Taking extra doses of antidepressants can result in an increased incidence of adverse events again threatening compliance. The most important clinical aspect of...

Interpersonal Therapy Ipt Major Depressive Disorder

In prospective comparative outcome trials, Jarrett and Rush 70 found IPT to be superior to nonscheduled treatment 64 , and no different from antidepressant medication 64, 65 , CT 65 , or PLA plus clinical management (CM) 65 . The Depression Guideline Panel 46 found IPT to provide a 52.3 response rate based on Elkin et al 65 .

Cognitive Therapy Ct Major Depressive Disorder MDD

A recent meta-analysis of 65 studies of CT for depression tried to control for potential investigator bias 92 . Even with researcher allegiance taken into account, Dobson's 87 meta-analytic results (i.e. CT was at least as effective as pharmacotherapy for depression with some evidence for its superiority taking all studies together) were upheld. Conversely, Gelder 93 noted that Dobson 87 found eight studies in which CT was at least as effective as antidepressant medication, but criticized them for lacking a PLA control noting that CT was less effective than IMI-CM 65, 75 . He concluded that medication with CM was as effective as CT but was easier to administer. Elkin et al 65 compared CT, IPT, PLA, and IMI. This three-site study entered 239 moderately-severely depressed outpatients, of which 40 had been depressed < 6 months. CT was no different than other treatments, including IMI-CM (ITT sample). Based on recovery (defined as a HAM-D score < 6 or a BDI score < 9), CT was no...

Behavioral Therapy Bt Major Depressive Disorder MDD

The first step in BT is usually a functional analysis by which clinicians determine the functional relationship between behaviors and the environment. They identify antecedents and consequences that surround and presumably control specific depressive behaviors. Detailed descriptions of BT approaches include activity scheduling 165 , self-control techniques 166 , social skills training 167 , behavioral marital therapy 168 , and stress management 165 . Some variations of BT also include problem-solving 42 in this grouping. Lewinsohn et al 165 have developed a treatment manual entitled The Coping with Depression Course, which outlines strategies often used in BT for depressed patients. BT has been used to treat MDD and DD in adults and MDD in adolescents 123 . The Depression Guideline Panel 46 meta-analysis of BT alone revealed a 55.3 response rate (ITT sample) in 10 studies. Jarrett and Rush 70 detailed the individual studies. BT exceeded WL in 7 of 8 trials 40,42,169-173 . Only Usaf...

Major Depressive Disorder MDD

Study limitations include the fact that an unknown number of subjects, initially taking antidepressant medication and who refused to discontinue, were excluded. Response rates included only completers (i.e. ITT analyses not conducted). Treatment consisted of 20 sessions of BMT or CT, but only 20 reported total sessions for COMB (i.e. 10 for CT and 10 for BMT), so COMB was half dose of each treatment. O'Leary and Beach 199 also evaluated married couples complaining of both depression in the wife and marital discord. Random assignment to BMT, CT, or WL revealed both active treatments to be equally effective in alleviating depression. Only BMT was successful in enhancing marital satisfaction. This study suggests that BMT is effective in improving marriages, but efficacy appears related to the couples' distress levels 199 .

Does Psychotherapy Add To The Benefits Obtained With Antidepressant Medication

While the combination of medication and psychotherapy is often recommended on clinical grounds for MDD 239 , RCT evidence is not yet convincing 12, 46, 239-241 . An extensive review 89 found no advantage of the combination contrasted with either psychotherapy alone or medication alone, as did the Depression Guideline Panel 46 , Wexler and Cicchetti 242 and Manning et al 243 . Thase 240 conducted a meta-analysis that included 595 depressed outpatients treated with either CBT or IPT alone, or IPT in combination with antidepressants. Among the less severe, single episode patients, the combination strategy had only a modest advantage ( 10 ) over the psychotherapies alone. By contrast, among the patients with more severe, recurrent depression, combined treatment produced a large and clinically Another clinically logical role for therapy is with patients who have responded but not remitted with medication only 46 . Fava and associates have recently conducted such studies 245-248 . In the...

Clinical Picture And Differential Diagnosis Diagnosis of Depressive Disorder

Depressive Disorders, Second Edition. Edited by Mario Majand Norman Sartorius. 2002 John Wiley & Sons Ltd. ISBN tf)-470-84965-7 problematic to establish the limits of depressive disorder in young people, because of the cognitive and physical changes that take place during this time. Adolescents tend to feel things particularly deeply, and marked mood swings are common during the teens 4 . It can be difficult to distinguish these intense emotional reactions from depressive disorders. By contrast, young children do not find it easy to describe how they are feeling, and often confuse emotions such as anger and sadness 5 . They have particular difficulty in describing certain of the key cognitive symptoms of depression, such as hopelessness and self-denigration. Indeed, there are developmental changes in many of the cognitive abilities that may underlie these depressive cognitions. Thus, for instance, during middle childhood (ages 7-9) the self is conceived in outward, physical terms....

Other Antidepressants

A recent report suggests that the selective serotonin reuptake inhibitor (SSRI) fluoxetine may be of benefit to children and adolescents with major depression 93 . It is too early to say whether this finding is robust a small previous trial with fluoxetine produced a negative result 128 . Nevertheless, it clearly raises the possibility that young people may be more responsive to antidepressants than previously thought. The study by Emslie et al 93 did not find that children responded differently from adolescents. Negative results have been reported in a trial with venlafaxine 129 .

Depressive Disorders in Childhood and Adolescence State of the

Not to exist or to manifest itself by non-depressive symptoms such as somatic complaints, behavioral difficulties, or academic failure 1, 2 . Subsequent work 3-9 revealed that depressive disorders can and do occur during childhood adolescence. The results of recent studies indicate that depression is more prevalent during childhood adolescence than had previously been thought 10-12 , and the lifetime prevalence during adolescence has been estimated as high as 20 13 .

Increasing Awareness of Depressive Disorders in Childhood Implications for World Child and Adolescent Mental Health

The increasing awareness that depressive disorders in childhood can be recognized more frequently than was previously thought has important implications both for prevention and for the provision of services. This explosion of interest parallels attempts to destigmatize depression in adults. involved newspaper and magazine articles, radio and television programmes and other media activities. The survey was repeated in March 1995 and June 1997 and showed significant positive changes regarding attitudes to depression, reported experience of it, attitudes to antidepressants and, less consistently, to help from general practitioners. Changes were of the order of 5-10 and throughout attitudes to depression and to treatment by counselling were very favourable, whereas antidepressants were regarded as addictive and less effective. Much of the research on depression in young people has been reported from academic centres in Europe and America, and now that methods have been established for...

Research Trends in Depressive Disorders of Youth

After decades of separation between child and adult psychiatry, with respect to nosology and treatment approach, there has been a recent rapprochement between the two fields. Focus has been on the continuity of psychopathology across the age span, with the adoption of the same diagnostic criteria for youth as in adults. This approach is well grounded in the fact that most psychiatric disorders that affect adults have their inception in youth and continue into adulthood 1 . Valid diagnoses can be obtained utilizing similar criteria across age. In both the 10th edition of the International Classification of Diseases (ICD-10) 2 and the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) 3 , the criteria for depressive disorders in youth are basically the same as in adults. In DSM-IV, the only differences are that in youth mood can be ''irritable'' as well as ''depressed,'' and the minimum duration of mood disturbance for a diagnosis of dysthymic disorder is...

Nonmajor Depression

Psychosocial interventions, which have similar efficacy in non-major depression as compared with major depression 198 , are usually preferred as the Progressive resistance training was found to significantly reduce depressive symptoms and improve quality of life measures as compared with an attention-control group in a 10-week programme involving 32 elderly subjects with mild to moderate depressions 211 . Intensity of training was a significant independent predictor of decrease in depression scores. In contrast, aerobic exercise in a walking group was not found to have a significantly different effect than a social contact group in the treatment of moderate depression in old age 212 . Music therapy, provided either in an 8-week home-based programme or a self-administered programme, was found to reduce depressive symptoms and distress and to improve self-esteem compared with waiting list controls in 30 older patients with major and minor depression 213 . Improvements were maintained...

Depressive Disorders in the Elderly A Fresh Perspective

The thorny issue of the depression-dementia continuum is also explored. Despite the efforts of researchers, the picture remains muddled. It is clear that some depressed patients go on to develop a dementia, but ''the who and the how'' as yet defy definition. Although treatments such as electroconvulsive therapy (ECT) have been known to worsen a pre-existing dementia, evidence shows that affective symptoms can improve and individuals should not automatically be deprived of a potentially life-saving therapy on the basis of abnormal neuroradiology. Possibly of more concern to the busy clinician are the bio-psycho-social correlates of depression in old age. A strong association exists between physical ill-health and depression, but the patients' view of their own physical health may be adversely affected by their prevailing mood. More objective measures of ill-health, such as cancer, Parkinson's disease and stroke, all produce a consistent excess of depressive illness in sufferers of...

Suggested Priorities for Research into Depressive Disorders in the Elderly

One of the major basic problems which has long hindered our research efforts into the aetiology and management of depression in all age groups has been the absence of an adequate classification. There is general agreement that depressive illness is a heterogeneous condition, but our knowledge of the components of that heterogeneity remains pathetically inadequate, despite major attention to the subject throughout much of this century. This heterogeneity includes DSM-IV major depressive disorder and dysthymic disorder. As the review has pointed out, the syndromically defined diagnoses which have occupied nosology in the last two decades, while enhancing research vigor and reliability, unfortunately also have created an environment of ''international suppression of variability'' by which confounding factors (medical illnesses, heterogeneous symptom clusters) have been ''defined out'' of studies. This has driven research in a direction which increasingly is unrelated to the reality of...

Tricyclic Antidepressants vs Selective Serotonin Reuptake Inhibitors

Meta-analyses 113,122-124 have generally argued that, since clinical trial efficacy and overall dropout rates are similar between the different classes, there is no difference in effectiveness either and therefore no greater cost-effectiveness of the newer agents over the TCAs. Some have extended this argument to claim that the higher drug acquisition expenditures of the newer antidepressants (e.g. the SSRIs) are not justified 122,124 . Unfortunately, this view does not acknowledge that antidepressant use patterns, and therefore clinical outcomes and expenditures, may differ between specific antidepres-sants in actual clinical practice. As the authors of one recent meta-analysis 124 concluded regarding the use of data from controlled clinical trials to make inferences about cost-effectiveness, ''the most obvious conclusion is that research performed to date cannot provide an answer to this problem.'' Thus, conclusions from RCTs or meta-analyses of clinical trial data may not be...

Costs of Treating Depression Policy Should Be Evidencebased

Rosenbaum and Hylan's review focuses inevitably on treatment with antidepressants. However, despite an extensive literature, consensus on cost-effectiveness remains elusive. There are fewer data on other treatments. Findings for psychotherapy are mixed outcomes improve, but direct medical costs increase, with no conclusive comparative data with antidepressants. Data for electroconvulsive therapy are very limited, relating only to the length of hospital admission. Methods of conducting health economics research, especially with antide-pressants, continue to develop. Studies relying on data from controlled clinical trials meta-analyses and decision-analytic models are largely unreliable 6-9 . Naturalistic studies consistently find that tricyclic antidepressants (TCAs) are used suboptimally 4,5 such use is unlikely to be cost-effective. Other naturalistic studies have found that, in comparison, selective serotonin reuptake inhibitors (SSRIs) are associated with lower total health care...

Limitations to Cost Assessments of Depressive Disorders

The extensive review of the costs of depressive disorders by Rosenbaum and Hylan provides an excellent point of reference on the economics of these illnesses. The burden of depression is becoming increasingly recognized in the industrialized world because of the high costs of health care and the negative impact that the disorder has on productivity. This is all the more important when one considers that the World Health Organization projects an increase in the incidence of depression as our societies evolve 1 . Historically, the assessment of costs has generally focused on the costs of direct intervention, be it by medication or by health care professionals, with or without additional institutional costs. Recently, a broadening of the cost base has occurred to include indirect costs which are, for all intents and purposes, astronomical. An analysis of the indirect costs of depressive disorders is necessary to bring them into perspective. Unfortunately, these ''soft'' costs are...

Combinations Between Antidepressants

The synergistic benefits of serotonin and noradrenaline reuptake inhibitors in the acute treatment of major depression were first noticed by Nelson et al in 1991 178 , in an open trial in which fluoxetine and desipramine were combined. In this trial fluoxetine raised the blood levels of desipramine. The combination of pindolol, a serotonin autoreceptor antagonist, with SSRIs has induced a rapid onset of action in some trials, but not in others 184 . Augmentation with mianserin in fluoxetine-resistant patients with major depression is superior to continuation with fluoxetine alone 185 , which is in agreement with the study by Dam et al 186 . Augmentation with buspirone, a partial 5HT-1A agonist, in therapy-resistant depressed patients has also been suggested 187, 188 . In mild degrees but not severe forms of depression buspirone might itself have an antidepressive effect 189 . One double-blind placebo-controlled trial with buspirone has been carried out in patients resistant to SSRIs...

Depressive Disorders In Children

Depressive Disorders in Children and Adolescents A Review 233 4.3 Depressive Disorders in Childhood and 4.4 ''At least in the form seen in adults.'' A Commentary on Major Depressive Disorder 4.8 Taking Stock and Moving on Current Issues and Challenges Concerning Child and Adolescent Depressive Disorders 283 4.9 Increasing Awareness of Depressive Disorders in Childhood Implications for World Child and Adolescent Mental Health 286 4.12 Research Trends in Depressive Disorders 4.13 The Nature of First Episode Major Depression in Childhood and Adolescence 297 CHAPTER 5 DEPRESSIVE DISORDERS IN THE ELDERLY 313 Depressive Disorders in the Elderly A Review 313 5.4 Depressive Disorders in the Elderly A Fresh Perspective 371 5.11 Suggested Priorities for Research into Depressive Disorders in the Elderly 386

Subsyndromal Depressive Symptoms SSD

Neither ICD-10 nor DSM-IV make any reference to SSD as a separate subtype of depressive disorder. Whereas there are no established criteria for their syndromal definition, recent studies have shown that they are a clinical entity, Although falling short of full-fledged depression, SSD are very close to the mild depressive episode of ICD-10 and to many other conditions which in the past were known as ''neurotic'' or ''characterological''. It has been reported 64 that subthreshold depression does not significantly differ in terms of sleep parameters, family history and follow-up course from threshold depressive conditions, with the exception of the major (severe) depressive episode with psychotic features 66 . On the basis of these observations, it has been postulated that SSD and the minor depression disorders appear on a symptomatic continuum, with the other subtypes of syndromal depressive illness representing an alternative form or different symptomatic phase of the same parent...

Depressive Disorders

Rush and Thase have discussed the very limited evidence suggesting a beneficial effect of the combination of medication and psychotherapy in depression. This is probably due to the fact that the two types of treatment are generally provided at the same time. Administration of treatment in sequential order has been mainly limited to instances of treatment resistance. Cognitive-behavioral strategies have been successful in the management of drug-resistant major depressive disorders 1 , to the same extent that imipramine was found to be effective after unsuccessful cognitive therapy of depression 2 . This literature suggests that a trial of a different modality of treatment should be performed before labeling an episode of major depression as ''refractory'' or treatment-resistant. Only when both psychotherapeutic and pharmacological approaches have been used in a sequential order, is it justified to define depression as refractory. depression by pharmacological means is likely to leave a...

Antidepressants

Antidepressants play a major role in the treatment of major depression. Per Bech has described the developments in antidepressant therapy in a lucid and comprehensive way. The clinician will find this chapter a useful update of differences between older and second generation antidepressants in terms of clinical efficacy, side-effect profile and safety. It is interesting to see that the pendulum swings from broad-spectrum pharmacological profiles to high degrees of selectivity and recently, with the introduction of dual action antide-pressants, back to a broader pharmacological profile with a reduced propensity for disabling side effects such as impotence and toxicity at higher dosages. There is, mainly due to the publication of recent meta-analyses, an ongoing debate concerning the differential efficacy of dual action versus selective monoamine reuptake inhibitors. The recently introduced dual action antide-pressants venlafaxine and mirtazapine in particular have been compared to...

Pharmacological Treatment Of

DEPRESSIVE DISORDERS 89 Pharmacological Treatment of Depressive Disorders A Review 89 2.1 Antidepressants Forty Years of Experience 129 2.6 Increasing Our Understanding of the Working Mechanism of Antidepressants 140 2.7 Are the First Generation Monoamine Reuptake Inhibitors Still Needed in the Treatment of Major Depressive Episode 142 2.8 Antidepressants in Broader Context 144 2.9 Antidepressants for Better Quality of Life 146 2.11 Compliance Issues and the Efficacy of Antidepressants 150 2.13 What is a Lot of Antidepressants for so Few

Comparison of ICD10 with DSMIV

As shown in Table 1.1, ICD-10 and DSM-IV are basically similar in their orientation, and despite their differences, mainly in terminology, may be used interchangeably in clinical practice. They converge on the following major features (a) the previously dispersed depressive disorders are grouped together under a common name signifying a unified syndromal entity (b) the term ''affective disorders'' is replaced by the term ''mood disorders'', thus narrowing the depression's boundaries by not subsuming anxiety disorders under the same roof (c) while the clear intraclass distinction between bipolar and depressive disorders is retained, the term ''unipolar'' is abandoned (d) the diagnostic criteria are symptom-based, descriptive and not explanatory (e) symptom severity and recurrence are used as subtyping and specifying criteria (f) diagnostic threshold is determined by a constellation of core and supplementary symptoms, which have to fulfill the number and duration criteria in order to...

Melancholia Depression with Somatic Symptoms

This subtype is listed as melancholia in DSM-IV and as severe depressive episode with somatic symptoms in ICD-10. Melancholia is the oldest diagnostic term used in psychiatry and is characterized by vegetative disturbances and other clinical features that indicate a profound dysfunction of neurobiological mechanisms 7, 8, 10, 43 . The main features of its clinical identity include psychomotor retardation or agitation, late insomnia, loss of weight and appetite, anhedonia (lack of reactivity to pleasurable stimuli), diurnal variation of mood and libido disturbances. The question is still raised, however, whether this cluster of symptoms identifies a separate clinical entity discrete from the other subtypes of MD or if it should be considered as a variant of MD different only on severity measures, as inferred in the ICD-10 classification 27, 44 . Support for the distinction of this subtype may derive from reports in the literature indicating its stronger association with neurobiological...

Depression with Psychotic Symptoms

This subtype of depression is listed as severe episode with psychotic symptoms in ICD-10 and major depression with psychotic features (mood-congruent and mood-incongruent) in DSM-IV. It is also commonly cited in the literature as psychotic or delusional depression. On the basis of its presenting symptoms, it was found in the ECA study to cover 14 of all major depressions, representing their most severe form 49 . It has long been a controversial issue and is still debated whether delusions and other psychotic features in depression denote a qualitatively distinct psychopathological entity or merely manifest a greater severity of the depressive disorder continuum 50 . Demographic and clinical characteristics (phenomenology, course and prognosis), family history, treatment response and neurobiological markers have been used as variables to validate the diagnostic autonomy of delusional from non-delusional depression 3,10,49-51 . Findings derived from the community survey of the ECA study...

Adjustment Disorder AD

One of the subtypes of AD is the one with depressed mood. The main features of AD, that is the development of significant emotional or behavioral response to an identified psychological stress, are presented in association with predominant depressive symptoms (crying spells, hopelessness and distress). To qualify as AD the symptoms should appear in less than 3 months following the psychosocial stressor. This subtype, like AD in general, has to be distinguished from post-traumatic stress disorder (PTSD), which, however, is a response to an exceptionally severe and threatening traumatic event that results in several long-lasting adverse effects on the patient's mental health and social functioning.

Association With And Differential Diagnosis From Medical Illnesses

Prevalence rates of depressive disorders among patients suffering from a medical illness are considerable, from 22 to 33 95 , while it has been estimated that in the primary health setting the median prevalence rate for depressive disorders is more than 10 40 . It may be difficult to distinguish a primary from a secondary depression occurring during or as a consequence of a physical disease or as a side effect of various prescribed drugs. The mode of onset (acute), the symptomatology (atypical for depression), the resistance to previous antidepressant treatment and the positive laboratory findings for a non-depressive disorder should always be considered in order not to miss a physical illness underlying or occurring with depression 4, 8, 9,34 .

Drug abusedependence and Depression

Symptoms of anxiety and depression frequently appear during the intoxication and withdrawal phases of drug dependence and in that case they are considered as part of the ''substance abuse induced disorder'' (with predominant anxiety or depression symptoms). Symptoms meeting the full criteria of depressive disorder, however, are encountered in drug dependants while they are free from both the direct drug effect and withdrawal symptoms. According to a number of recent studies in which structured interviews were used and operational diagnostic criteria were applied, cooccurrence of depression and drug abuse is much higher than expected in the general population. The rates vary somewhat across studies in different sites, but the overall figures of lifetime and recent prevalence of the two conditions confirm their close association 117-120 . The subthreshold depressive symptomatology was shown to have an equal or even higher impact than

Specific Instruments for Measuring the Severity of Depression

The MADRS (Montgomery-Asberg Depression Rating Scale) is one of the most user-friendly observer-rating scales. It includes a selected small number of items, considered to be the core and most commonly encountered depressive symptoms in clinical practice. It scores less high than HAM-D on somatic

Much Diversity Many Categories No Entities

Their prevalence and chronicity, and the extensive suffering and disability they produce, make depressive disorders one of the most important of all human illnesses. Clinical depression is indeed, as Stefanis and Stefanis observe in their opening paragraph, ''a medically significant condition'', but it is far more than that. The Global Burden of Disease Study (conducted by the Harvard School of Public Health for the World Health Organization WHO and the World Bank) has shown that the burden it imposes on individuals and societies throughout the world greatly exceeds that of most other illnesses. Using ''disability adjusted life years'' (DALYs) as the index of burden, unipolar major depression was, worldwide, the fourth most important of all causes of disability and premature death, ahead of ischaemic heart disease, cardiovascular disease, tuberculosis and AIDS. And in the industrial world it ranked second only to ischaemic heart disease, even though, in accordance with ICD-9...

Categorical and Dimensional Perspectives of Depression

Stefanis and Stefanis' paper on the diagnoses of depressive disorders stimulates some thoughts on the current development of diagnostic classification in general, and diagnoses of depression in particular. The development of psychiatric classification over the past 20 years has been very fruitful, as a consequence of the introduction by DSM-III of a more descriptive oper-ationalized approach with specified diagnostic criteria. Nonetheless, some redundant survivals of a problematic etiological classification of depressive syndromes have remained, which is precisely what modern classification sought to avoid. A first example is ''adjustment disorders in response to psychosocial stressors'' with depressed mood and with mixed anxiety and depressed mood under the diagnostic threshold of an Axis I mood disorder. In a multiaxial perspective, a psychosocial stressor would clearly belong to Axis IV, and depressive symptoms as subdiagnostic depression to Axis I. A second example is bereavement...

Depression the Complexity of its Interface with Soft Bipolarity

Progress made, especially the attempt to subtype the illness with respect to differential treatment options, there is still a great deal of uncertainty about how different subtypes of mood disorder are related to one another. My commentary to Stefanis and Stefanis' masterful review will focus on recent provocative developments about the bipolar border of major depressive disorder. Of all the classificatory schemas for affective disorders, the unipolarbipolar distinction is the one that has the broadest consensus among both researchers and clinicians. Stefanis and Stefanis wisely avoid the term ''unipolar.'' This caution is justified in as much as an increasing body of research data has indicated the existence of a prevalent group of soft bipolar disorders that occupy an intermediary position between the two poles. Bipolar II, which is the prototype of soft bipolarity, has affinity to classic manic depressive illness from a familial standpoint, but in some respects resembles unipolar...

Contextualizing the Diagnosis of Depression

This commentary responds to Stefanis and Stefanis' plea for attention to the particularities and complexity of the depressive patient by briefly discussing ways to contextualize the diagnosis of depression. We do this by outlining critical aspects and levels of a comprehensive diagnostic model that succinctly describes the clinical condition of the person experiencing depressive disorders and that articulates the evaluational perspectives required to accomplish the diagnostic task validly and competently. First to be recognized is the nosological complexity of depression. This makes it compelling to attend to the variety of forms to be depressed specified in the Tenth Revision of the International Classification of Diseases and Health Related Problems (ICD-10) 1 and its local versions or annotations such as DSM-IV 2 , the Chinese Classification of Mental Disorders, 2nd edition, revised (CCMD-2-R) 3 , and the Third Cuban Glossary of Psychiatry (GC-3) 4 . The nosological map covers...

Age Loss and the Diagnostic Boundaries of Depression

Stefanis and Stefanis' comprehensive review covers all the major areas and many of the key controversies regarding the diagnoses of depressive disorders. In this commentary, I will expand or highlight additional diagnostic issues in two areas life cycle considerations and bereavement. The ICD-10 and DSM-IV operationalize diagnostic criteria for major depression that are particularly pertinent to young and mid-life adults, but may be less helpful for the diagnosis of individuals at the extremes of age. In older children and adolescents, for example, depression may not present with the classical symptoms of dysphoria or anhedonia. Instead, irritability, behavioral changes, social withdrawal, a change in school performance, an excursion into alcohol or other drugs, and vague somatic complaints may be the predominant manifestations 1 . Furthermore, when dysthymia or major depression occurs for the first time in adolescence, it often is the forerunner of a chronic or recurring illness that...

Depression Among Elderly and Postpartum Women

Suicide risk is high among depressed people 1 . Stefanis and Stefanis have highlighted the problems of non-recognition or misdiagnosis of depression at the primary care setting. This is particularly common in the presence of a comorbid physical illness or if the physician has a tendency to overlook depressive symptoms. The situation is particularly applicable to the Chinese

Selfrating Depression Scales Some Methodological Issues

An important but much neglected issue of self-rating scales is their reduced validity after repeated use. Self-rating scales are often used to measure the temporal change of the condition. Kitamura et al 1 administered Zung's Self-Rating Depression Scale (SDS) 2 to the same women twice during pregnancy and twice after childbirth. The SDS validity was measured in terms of sensitivity and specificity using operationalized diagnoses made by psychiatrists. The SDS sufficiently identified cases of depressive disorders on the first occasion (the first trimester) but subsequently lost its validity. In the same sample, the scores of the General Health Questionnaire (GHQ) 3 lost significant differences between those women with and those without minor psychiatric morbidity 4 . This was due to the fact that the GHQ score decreased among the suffering women while the score of the non-suffering women did not change. In the literature, we have found ample reports of ''improvement'' of questionnaire...

Limited Options on Diagnosing Depression

The lack of knowledge about the specific etiological factors has complicated the issue of diagnosis and treatment. Till now, the diagnosis has been based on counting the number of symptoms, and the treatment has been symptomatic. The diagnosis also takes into account the duration of symptoms. Since one has to wait for the minimum period of 2 weeks to arrive at a diagnosis of major depression, and for a period of 2 years for a diagnosis of dysthymia, the person has to suffer during this period, and there is no scope for early intervention. If one noticed features of depression for a day or two and intervened successfully to relieve depression, the skepticism and doubt about the diagnosis would linger. What is so special about 14 days On day 13 it is not depression, on day 15 it can be diagnosed as depression In most physical diseases, the treatment begins the moment the first symptoms are noticed. Somatic symptoms add to further confusion. The International Classification of Diseases...

The Clinical Target Syndrome

With the release of the evidence-based classification system DSM-III 16 , the diagnosis of major depression became the target syndrome for antidepressants. Clinical research with symptom rating scales such as the HAM-D from 1960 to 1980 had shown that around ten symptoms are often sufficient to reflect the syndrome of acute depressive states 17 . The clinical syndrome of depression described by Kuhn included the same depression-specific symptoms as the HAM-D, as well as the nine symptoms of depression to be considered for the diagnosis of major depression in DSM-III (Table 2.2). Both DSM-IV 18 and ICD-10 19 are in accordance with the DSM-III diagnosis of major depression (Table 2.2). It has been argued that the current editions of DSM and ICD are essentially attempts to standardize the Kraepelin categories 20 , which also applies to Kuhn's and Hamilton's syndromes of depression. Table 2.3 shows the concordance between Kuhn, Hamilton and DSM-IV ICD-10 for the clinical target syndrome...

Treatment Of Dysthymia And Minor Depression

158 and sertraline 159 were similar to imipramine and superior to placebo. However, more reliable and valid trials are needed. Furthermore, very few trials have evaluated the long-term outcome of antidepressants in dysthymia 160,161 . There have been very few RCTs to evaluate the various antidepressants in minor depression or probable major depression. The most important trials have been carried out by Paykel et al 51 showing in the setting of general practice that amitriptyline was superior to placebo. In recent trials it has been shown that paroxetine equals maprotiline 162 and that citalopram equals imipramine 122 .

Adverse Drug Reactions

While the antidepressive efficacy of the first- and second-generation antide-pressants is assessable in terms of response and remission on the HAM-D, no internationally accepted scale for measuring the adverse reaction profile of the different antidepressants has been developed. By adverse drug reactions in this context we mean pharmacological, dose-related reactions, not the idiosyncratic or allergic types. Table 2.7 Randomized controlled trials of second-generation antidepressants vs. fluoxetine in major depression

Targeting Antidepressant Treatment The Evidence is Weak

In any therapeutic area the choice of treatment depends on three factors. First is the scientific evidence that one drug is superior to another in its efficacy or tolerability. The combination of this evidence with the current pricing regimes determines the cost-effectiveness of the different drugs. Second is the degree to which your patients are similar to the patients in the clinical trials. This will determine how much you can extrapolate from the scientific evidence to your practice. Most studies of antidepressants have been carried out on selected patients in secondary care, which creates problems for primary care workers, or those who treat a wide range of comorbid conditions alongside the depression. Third, and most important in the choice of an antidepressant for an individual patient, are the attitudes and beliefs of the patient. Most would prefer counselling, for which there is no evidence of effectiveness, and 74 think antidepressants are addictive 1 . Since depression is...

The Selection of the Antidepressant in Clinical Practice

There are over 25 different antidepressants marketed worldwide. These agents can be grouped into eight classes as defined by their putative mechanism of action 1 . They range from agents with an apparently single mechanism of action mediating their antidepressant efficacy, such as serotonin selective reuptake inhibitors (SSRIs) (e.g. citalopram and sertraline) and norepinephrine selective reuptake inhibitors (e.g. desipramine and reboxetine) to agents with multiple mechanisms of action (e.g. amitriptyline). For this reason, one of the most pressing needs in clinical psycho-pharmacology relative to antidepressants is what to do when the first antidepressant selected has failed to treat the patient adequately. A survey done in clinical practice found that the majority of primary care and psychiatric physicians choose one of the SSRIs as their antidepressant of first choice, presumably because of their safety and good tolerability along with adequate antidepressant efficacy. While this...

Gender and Antidepressant Response

The past decade has witnessed the rapid growth of antidepressant therapy, with a host of new antidepressants available for treating patients with depressive disorders. Prof. Bech's review highlights several of these advances and concludes that the major advantages of the newer antidepressants for acute therapy lie more with their better side-effect profiles than with enhanced efficacy. This argument has been made by a number of others. Although it seems reasonable on the surface, it is at some variance with the marked public acceptance and success enjoyed by the newer agents, particularly the selective serotonin reuptake inhibitors (SSRI). These agents have been heralded by so many patients and treaters that it is hard to believe the many studies that do not support superior efficacy over the tricyclic antidepressants (TCAs). Recent data suggest the situation is far more complex and that efficacy between older and newer agents may indeed not be equivalent in both men and women...

Would Rational Polypharmacy Improve Quality of Life

A number of the antidepressants reviewed by Prof. Bech, especially the newer ones, are not available in India, and possibly many other countries. This in effect means that the majority of depressed patients in the world are treated using traditional tricyclic antidepressants (TCAs) and perhaps a couple of selective serotonin reuptake inhibitors (SSRIs). Treatment of depressed patients in India is usually accomplished using TCAs such as imipramine or amitriptyline in general, dothiepin or doxepin for those with cardiac or physical problems, and SSRIs such as fluoxetine and sertra-line. Other antidepressants used sometimes include amoxapine, mianserin, trazodone, amineptine and tianeptine. The review is silent on these latter drugs. A number of antidepressants currently popular in the West, such as nefazodone, bupropion, venlafaxine, moclobemide, maprotiline, citalo-pram, fluvoxamine, lofepramine and paroxetine, are not yet available for Indian psychiatrists to treat their depressed...

The Parallel Need for Medicinebased Evidence

Trials (RCTs) identified by systematic literature review (whenever possible coupled with meta-analysis of the findings) and concludes by applying this knowledge to the clinical conundrum that caused the question to be asked. But is this process in itself sufficient to produce meaningful decisions when treating individual depressed patients 1 Prof. Bech provides a characteristically clear and comprehensive review of the pharmacological treatment of depression, derived mainly from the findings of RCTs. I believe there are many other sources of evidence that are required to guide practice when treating depressed patients. Of course, RCTs are essential for establishing the relative efficacy and tolerability of antidepressants. However, it seems to me that the patients recruited into RCTs are a highly selective sample, unrepresentative of the total population of depressed patients seen by psychiatrists, and certainly dissimilar from the patients seen by general practitioners. Typically,...

Antidepressant Drugs The Indian Experience

The Indian experience with antidepressants, in terms of indications, effectiveness, duration of treatment, long-term outcome, is very limited. Currently, only a limited number of tricyclic antidepressants are available (imipramine, amitriptyline, clomipramine, doxepin, nortriptyline, trimipramine and dothiepin) 1 . The other drugs that are available are trazodone, mianserin, tianepine, amineptine, and among selective serotonin reuptake inhibitors (SSRIs), fluoxetine. In addition, lithium is available. Other drugs mentioned in the table in Prof. Bech's review are not available. In view of this, our experience, until about 5 years ago, was largely with the tricyclic antidepressants. In terms of evidence for the clinical effect of the antidepressants, all the studies done in India have been limited to short-term efficacy. These studies have been mostly for purposes of registration and have not covered periods longer than 4-6 weeks. Though professionals have suggested that trials should...

Introduction The Therapies

Psychotherapy has different objectives, including improved adherence to medication (or other disease management procedures), symptom reduction or attainment of symptom remission, reduction of disability (e.g. improved marital occupational functioning), prevention of relapses recurrences, or prevention or delay of the onset progression of depressive conditions 1 . This review evaluates the evidence for efficacy and indications of psychoed-ucational problem-solving, interpersonal, cognitive, behavioral, marital, and psychodynamic therapies for depressive disorders in attaining these goals. Formal psychotherapies may also be used to reduce symptoms or restore function. Therapies designed to reduce symptoms acutely include interpersonal (IPT), cognitive (CT), behavioral (BT), marital (MT), and brief psychodynamic (BPD) psychotherapies. These therapies address intermediate variables (e.g. disrupted interpersonal relationships, negative automatic thinking) that theoretically account for the...

Clinical Managementpsychoeducation Medication Adherence

BBT provides psychoeducation in a practical, time-efficient manner. Both clinically and statistically significantly more improvements in symptom severity were found with cognitive BBT than with WL. These gains were maintained at 3-month follow-up 30 . Treatment involved reading the book Feeling Good 31 , and emphasized a self-help approach to treating depression with minimal staff involvement. The effect was large in that the Hamilton Rating Scale for Depression (HAM-D) 32, 33 score decreased from 20.2 to 9.6 for BBT as compared to 19.6 to 19.0 for controls. Two previous trials of BBT also report significant benefits 34,35 . Individuals in these studies, however, were recruited by media announcements, suffered milder (i.e. 21-item HAM-D score > 10) forms of depression, were not formally evaluated for either Axis I or Axis II disorders, and could be taking medication during the trial. While this evidence does not recommend BBT alone for self-identified, more severely ill patients, it...

Inpatients Severe Depression

CT has been adapted to inpatients 111,112 . Roth et al 12 recently reviewed results of several trials with severely depressed patients. In an open trial of 16 unmedicated inpatients with MDD using CT alone 5 times a week for up to 4 weeks (patients averaged 13 sessions), Thase et al 113 found that 81 responded (defined as a 50 reduction in HAM-D score and a final HAM-D score < 10). Bowers 117 compared NT alone, relaxation in combination with NT, or CBT and NT in 30 inpatients (combined with usual hospital milieu therapy consisted of 12 group sessions) to find, in this moderately-severely depressed group, that all groups improved, but patients receiving CBT or relaxation had significantly fewer depressive symptoms and negative cognitions than those on medication alone. Patients receiving CT were less likely to be judged depressed at discharge than any other treatment conditions. When recovery was defined (HAM-D score < 6), 8 of 10 patients in CT compared to 1 of 10 or 2 of 10 in...

Latest Developments in Psychotherapy for Depression

This volume sponsored by the World Psychiatric Association, including the excellent review by Rush and Thase, is timely. Epidemiologic studies, conducted across diverse cultures, show clearly the variation in rates for major depression, but consistency of age of onset, symptom patterns, risk factors and comorbidity worldwide, suggesting that standardized treatments with established efficacy also have worldwide applicability 1 . Psychotherapy, while of increasing interest globally, is declining as a treatment in the United States. A recent study of visits to psychiatrists over the last decade (1985-1995), showed a significant decrease in psychotherapy and an increase in psychotropic medication 2 . The mean duration of visits has gone down and the number of visits which were 10 minutes or less has increased. Shortening of visits was most evident in the patients previously identified as users of psychotherapy. The decline in psychotherapy in the United States is primarily motivated by...

Depression The Evidence for What Works and What Doesnt

The review is not in itself a guideline for treatment. As the authors point out, ''several features distinguish research studies and routine care application.'' One of the major distinguishing and confounding realities is the issue of comorbidities. Consistent with Kessler's survey 1 , a report from the American Psychiatric Association's Practice Research Network (PRN) noted that 57 of the patients studied had at least two Axis I diagnoses and 39 had an Axis II diagnosis 2 . In many of the RCTs, patients with comorbidities are excluded or not considered. There is clear evidence that these comorbidities influence the efficacy results. For example, as noted by Rush and Thase, Shea et al 3 and Hardy et al 4 reported that personality pathology was associated with poorer responses of depressed patients to some therapies but not to others. Hence, the generalizability of the results of the RCTs to the patient population at large must be done cautiously. The evidence seems clear that ITP, CT,...

Psychotherapy of Depression Research and Practice

Rush and Thase conclude that in research settings some psychotherapies are effective in reducing symptoms in the acute phase treatment of mild to moderate major depression disorder. They alert us that the evidence is less clear if we consider other depressive disorders, broader measures, longer term outcomes, prophylaxis, or factors Most depressed patients never receive appropriate treatment. They are not recognized, if recognized not correctly diagnosed, and if diagnosed not appropriately treated. They often have comorbid problems medical conditions, personality disorders, or substance abuse and the treatment of depression, particularly mild, subsyndromal or dysthymic depression, is only one component of the treatment of the patient. The clinician's question is not ''Is psychotherapy A an effective treatment for disorder B '' but rather ''What is the best way to treat this patient who is depressed along with a number of other problems Does the research literature help '' The answer...

Recovery from the Index Episode

Although the risk of recurrence of juvenile depression is high, it is important to know that the prognosis for the index episode is quite good. The available data suggest that the majority of children with major depression will recover within 2 years. For example, Kovacs et al 31 reported that the cumulative probability of recovery from major depression by 1 year after onset was 74 and by 2 years was 92 . This study was based on subjects who in most cases had a previous history of treatment for emotional-behavioural problems. However, Keller et al 32 reported very similar findings in a retrospective study of time to recovery from first episode of major depression in young people who had mostly not received treatment. The probability of recovery for adolescent inpatients with major depression also appears to be about 90 by 2 years 33 , though those with long-standing depressions recover less quickly than those whose presentation is acute. It seems, then, that most young people with...

Principles Of Treatment

The second question is whether the depression is complicated by other disorders such as behavioural problems. If it is, then as a general rule it is best to sort out these complications before embarking on treatment for the depression. For example, if a child has a major behavioural disorder, then it will be necessary to ensure that appropriate psychosocial measures are being taken to deal with this. Similarly, the depression-like states that are common in adolescents with anorexia nervosa usually respond much better to weight gain than they do to antidepressants. The third question concerns the management of the stresses that are found in many cases of major depression. It is sometimes possible to alleviate some of these stresses, such as bullying. However, in the majority of cases, acute stressors are just one of a number of causes of the depression. Moreover, such stressors commonly arise out of chronic difficulties such as family discord, and may therefore be very hard to remedy....

Individual and Group Cognitivebehavioural Therapies

There have been trials of cognitive-behaviour therapy in samples of children with (a) depressive symptoms, recruited from schools, and (b) depressive disorder. There have been at least nine controlled studies of CBT in samples of children with depressive symptoms recruited through schools 42-50 . The design has usually been to screen all children with a depression questionnaire and then to invite those with a high score to participate in a group intervention. For example, in one of the first randomized controlled trials to suggest that CBT is effective in childhood depression, Reynolds and Coats 42 involved an entire school in a multiple stage screening procedure. They invited those who were screen positive (a high score on a depression questionnaire on two occasions) to take part in the study. Cognitive-behaviour therapy consisted of 10 group sessions that emphasized the training of self-control skills such as self-monitoring, problem-solving and self-reinforcement. Although these...

Psychosocial Prevention Of Childhood Depression

Targeted programmes aim to prevent depression in a population known to be at risk. The best established risk factors for depressive disorder in childhood are depressive symptoms and a family history of depression 81 . Interventions for children with depressive symptoms are similar to those described earlier. Family interventions typically involve an educational Table 4.3 Randomized comparative studies of family interventions in samples diagnosed with depressive disorder Table 4.3 Randomized comparative studies of family interventions in samples diagnosed with depressive disorder

Pharmacological Treatments Theoretical Basis

Three types of investigations have provided information on possible neuro-biological abnormalities in depressed young people. The first is the study of cortisol secretion, measured by investigationssuchasthe DST. Several studies have shown that, in comparison with non-depressed patients, depressed young people are less likely to show suppression of cortisol secretion when the exogenous corticosteroid dexamethasone is administered 11 . The specificity of the DST for depressive disorder is, however, less for young people than it is for adults 89 . The second investigation is the study of sleep. Polysomnographic (PSG) studies of depressed adults have found that they tend to show abnormalities of sleep, including shortened rapid eye movement (REM) latency (time from the start of sleep to the first period of REM sleep) and reduced slow wave sleep 90 . Many PSG studies with depressed adolescents have shown sleep abnormalities, mainly of REM sleep 91-96 . These generally positive results...

Developing A Treatment Strategy

Table 4.6 shows the steps in the management of moderately severe depressive disorder in adolescents which are discussed below. Adolescents with severe depression, which we define as a Global Assessment Scale 130 score of 30 or less (which means that the adolescent is unable to function in most activities of daily life) seldom respond to CBT alone 61 . Step 1. In clinical samples, mild and moderately severe depressive disorders in adolescents remit rapidly in around a third of cases 81,131 . Step 2. This suggests that a sensible initial approach should consist of a thorough assessment, sympathetic discussions with the adolescent and the family, and encouraging support. These simple interventions, especially if combined with measures to alleviate stress, are often followed by improvement in mood. Step 3. However, about two thirds of depressed adolescents will not remit within a month, and these cases should be offered further treatment. Step 4. The best treatment for major depression in...

Towards an Understanding of Early Onset Depression

Recent studies of adult depression and the criteria used to guide diagnostic decisions have found little empirical support for most of the thresholds used in the DSM-IV criteria for major depression 1 . Most of the relevant characteristics appeared to be continuous traits, suggesting that major depression as specified by DSM-IV may best be seen as a diagnostic convention imposed on a continuum of depressive symptoms of varying severity and duration. While comparable studies have not been completed in child and adolescent populations, there would appear to be little doubt that similar results would pertain. One could also credibly argue that clinically relevant dimensions would extend, in most cases, beyond depressed mood and would include other troubling affects, particularly anxiety. Indeed, twin studies have suggested that both an individual's vulnerability to develop anxiety and his depression are governed in part by the same set of genes 2 . illnesses. In one example,...

How the Study of Early Onset Depression Challenges Us to Produce a New Paradigm for Understanding Mood Disorders

Early onset depressive disorder is an area of increasing investigation across a variety of domains. Yet its current, and by extension, future elucidation is hampered by a conceptual paradigm that may be confusing at best and distracting at worse. Indeed, much of our activity directed towards understanding early onset depressive disorder can be likened to the response of the person who, when asked why he was searching for his hat in front of a shop window instead of in an adjacent park where it had blown away, replied ''because the light is much better here''. by a homogeneous pattern of constricted variability. For example, low-grade but persistent unhappiness can now be diagnosed as dysthymia, and even brief dysphoric experiences of low intensity can be somehow construed as minor depression. Thus, clinical depression (as a medical term) may be conceptually and actively confused with distress and unhappiness. The wish to sanitize the human condition, even if it arises primarily from...

Adult and Childhood Depressions May in Fact be Different Illnesses

Classifying a child's misery correctly becomes a semantic exercise unless that categorization contributes to a superior understanding and or better potential or actual interventions. Like many hypotheses in child psychiatry, the current childhood depression paradigm derived in large part from an advance in general psychiatry adults with unipolar depressions were being treated very successfully with tricyclic antidepressants. For them, tricyclic medications have been shown to be highly effective 1 . Might these medications also relieve children's suffering After all, in contemporary practice, clinicians certainly see some children from organized, supportive families perhaps with a genetic loading for depression who suffer from major depressions that look remarkably like the adult condition. Today, While the hypothesis that childhood depression is like adult depression and therefore highly treatable with antidepressants was worth testing, as Prof. Harrington writes, ''with the exception...

Childhood Depression Some Unresolved Research Questions

Depression in children and adolescents has received increasing attention over the last 20 years. The number of published research and clinical articles has grown exponentially and nothing indicates that this trend is abating. As pointed out by Richard Harrington, much of this trend reflects changes in psychiatric research in general, with an increased emphasis on direct interviewing of subjects (including children) with standardized procedures, and on the use of symptom-oriented approaches to child psychiatric diagnoses. However, there is also the possibility that the growing focus on affective disorders amongst youth reflected a genuine increase in the incidence of these conditions. Careful reviews of the adult epidemiological literature have concluded that lifetime rates of depressive disorders have increased for birth cohorts born in the post-Second World War era 1 . Furthermore, a decreasing age of onset was simultaneously reported, meaning that depression now appears not only...

Is Depression in Old Age Different from Depression in Younger Adults

Depressive Disorders, Second Edition. Edited by Mario Majand Norman Sartorius. 2002 John Wiley & Sons Ltd. ISBN tf)-470-84965-7 compared with depression in younger adults. Studies comparing depression in older vs. younger adults have produced inconsistent results. Brown et al 3 reflected on the essential similarity between younger and older patients and between patients with early or late onset. The similarity in the core phenomenological picture is supported by Baldwin 4 , Blazer et al 5 , Burvill et al 6 , Greenwald and Kramer-Ginsberg 7 and Brodaty et al 8 . On the other hand, Georgotas 9 observed that elderly people with depressive disorders complained less of subjective lowering of mood than younger persons. Hypochondriasis (overconcern with the fear of bodily illness) was found more often in older compared with younger patients 10 . De Alarcon 11 and Good et al 12 reported the preponderance of somatic complaints. Gurland 10 reported greater agitation, which was also noted by...

Is Depression in the Older Person Necessarily Associated with Cognitive Impairment and Structural Abnormalities

Alexopoulos et al 29 followed up 57 depressed patients annually over an average period of 3 years. Their survival analysis revealed an almost fivefold increase in the risk of developing dementia over those 3 years for those presenting originally with what was considered to be ''reversible dementia''. They were unable to identify clinical predictors of eventual dementia as neuropsychological and imaging data were not systematically recorded at baseline. The study of Reding et al 30 , however, identified that the presence of cerebrovascular, extrapyramidal or spinocerebellar disorder, together with development of confusion on low doses of tricyclic drugs, were good baseline predictors of future development of dementia.

Subtypes of Depression in the Elderly

The fact that the current diagnostic categories do not adequately describe older individuals with depression 32 raises the necessity for additional diagnostic categories to be examined to adequately classify depressive disorders experienced by the elderly. In particular, the addition has been suggested of minor depression 33, 34 or subsyndromal depression, being In non-Western cultural environments, the diagnosis of ''major depression'' may not apply to some patients who present with ''depressive disorder equivalents'' 35 . Many Asian patients have somatic, psychomotor and vegetative symptoms without dysphoria or depressed mood and prefer the culturally more acceptable diagnosis of ''neurasthenia'' 36, 37 . Caine 38 was cogent in his argument that the syndromatically defined diagnoses which have occupied nosology in the last two decades, while enhancing research vigour and reliability, leading the movement of psychiatric research from the anecdotal to the scientific, unfortunately...

Epidemiology Of Depression In Old

There is conflicting evidence concerning the prevalence of depression in old age. There have been several large surveys of adult populations that purported to show a lower rate of depressive disorders among elderly than among younger adults 55-57 . The latest of these studies found that 1.7 of persons aged 65 years or more manifested affective disorders, in contrast to rates of 5.0 in the 55-64 age group and 6.4 or more in age groups of 18-54 years 57 . One sixth of the affective disorders were labelled as dysthymia while five sixths had ''depression''. The two large North American surveys provided data concerning major depressive episode, dysthymia and manic episode in the Epidemiologic Catchment Area study ECA 55 , the 1-month prevalence rate of major depressive episode in those aged 65 years or more was 0.7 , while the rate for dysthymia was 1.8 . In the Canadian study 56 , the 6-month prevalence rate of major depressive episode was 1.2 and the lifetime prevalence of dysthymia was...

Correlates Of Depression In Old Age Health and Disability

Both cross-sectional and longitudinal studies have provided evidence of a close relationship between physical health and depression 84 . Blazer et al 33 found that chronic illness and disability, analysed as separate variables, were both significantly associated with depression rating scores. In a study of depression in a large community sample of older adults, Kennedy et al 85 reported that poor health and disability explained 35 of the total variance, and outranked demographic, social support and life event characteristics in their association with depressive symptoms. In a longitudinal study, they found that increasing disability and declining health preceded the emergence of depression in many subjects, and changes in health provided ''a major if incomplete'' explanation of the remission or persistence of depressive symptoms. It is well recognized that the prevalence of depression is considerably increased among people with serious medical problems, such as cancer, Parkinson's...

Treatment Of Depression In Old

Numerous factors affect the quality of available evidence. There are doubts about whether the data obtained from most existing randomized controlled trials (RCTs) of antidepressants can be generalized, due to the use of samples not typical of routine clinical practice. For example, only 4.2 of depressed elderly patients referred for inclusion in a phase III antidepressant study could be recruited 126 . Application of stringent exclusion criteria regarding concomitant medication, physical and psychiatric comorbidity was the main reason. The ''old'', physically ill and institutionalized elderly are underrepresented in RCTs, despite the latter two having the highest rates of depression. Further, the presence of comorbid acute or serious physical illness reduces the chance of recovery 127,128 . Yet, it is information regarding the safety, acceptability and effectiveness of treatments in such patients that is of the greatest benefit to the clinician. In addition, RCTs of antidepressants...

Pharmacological Treatment

Since 1964, more than 70 RCTs of the use of antidepressants in old age have been published. Most subjects have been physically well, independently living, ''young'' old outpatients with non-psychotic major depression and without comorbid psychiatric disorders (''uncomplicated major depression''). Reviews and meta-analyses have concluded that antidepressants are efficacious, with around 50-60 of patients improving as compared to about 30 with placebo 133, 148, 149 . Age alone does not appear to significantly affect the general efficacy of antidepressants in the acute treatment of uncomplicated major depression. Acute treatment response is influenced by a number of factors. Older patients whose first episode of major depression occurred before the age of 60 have been found to take 5-6 weeks longer to achieve remission than late-onset depressives 153 . Delayed response has also been found to occur in patients with high baseline anxiety and with outpatient treatment 154 . Poor acute...

Depression Associated with Dementia

The evidence for the efficacy of antidepressants is limited, as noted by the five RCTs listed in Table 5.2. The placebo-controlled studies recorded a large placebo response. Only one study of moclobemide with a large sample size of 511 demonstrated a significantly higher response rate with the antidepressant 187 , although two studies showed significantly fewer depressive symptoms with citalo-pram 184 and maprotiline 186 . A comparison of trazodone and folic acid found no significant differences between the agents and while there was a

Depression in Residential Care

The only placebo-controlled trial of antidepressant treatment of major depression in elderly nursing home residents found that nortriptyline was effective in significantly improving depressed mood and reducing suicidality. However, 34 of subjects had adverse events that required termination of treatment, demonstrating the vulnerability of these patients and the need for careful monitoring 175 . In an open-label trial of SSRIs in ''old'' old depressed nursing home residents, good responses were obtained in those with major depressive disorder (93 ), but not in depression associated with dementia (7 ) 193 .

Electroconvulsive Therapy ECT

A meta-analysis of the efficacy of ECT in severe depression has demonstrated its superiority over other treatments 224 . Yet, only one study of real vs. simulated ECT has provided separate analyses to show efficacy in older patients 225 . There have also been few comparisons of ECT with antide-pressant medication in the elderly and there are methodological limitations. Yet in each study ECT was found to be superior in antidepressant-resistant depression 226 , psychotic depression 222 and major depression 128, 227 . Relapse rates range around 30-60 over 6 months, but are reduced by two thirds by maintenance antidepressants, mood stabilizers and occasionally ECT 244 . The timing of the introduction of the maintenance agent, choice of agent and dosage are issues that have not been addressed in the elderly. ECT is generally safe in the elderly. There is evidence that complications, particularly cardio-respiratory problems, falls and confusion, are more likely in patients over 75 and with...

Treatmentresistant Depression

Although guidelines for treatment approaches have been devised, there have been few studies in the elderly 252 . Subsequent courses of antidepressants may need to be longer, a minimum of 6 weeks 131 . Lithium augmentation may not be as effective in older patients due to intolerance 130 . ECT may be the most effective treatment. A randomized study of 39 subjects with antidepressant-resistant depression demonstrated the superiority of ECT over paroxetine, with 71 of the ECT group fulfilling response criteria and the ECT response being faster 226 . Non-pharmacological treatments should also be considered, but data are lacking 254 .

Prognosis Of Depression In Old

The landmark study of Roth 255 overturned a long-standing belief that the outcome of late-life depression was uniformly malign. However, the comforting dictum that depression in the elderly usually has a good outcome was called into question by Murphy 237 28 years later, and for the last decade and a half a series of studies has added fuel to the fire of controversy about the fate of old people with depressive disorders. Factors which will affect the outcome of cohorts of elderly depressed patients include the definitions of depression, recovery and relapse employed by researchers, the instruments used and the source of the cohort followed. It is unethical to conduct naturalistic long-term studies on untreated patients who present for clinical assessment and care, but epidemiological studies of community-resident elderly often include many depressed subjects who are not receiving treatment.

Criteria for Study Validity

Have a huge effect, as the majority of depressed subjects identified in community surveys never reach specialist services. Even studies based in primary care would be subject to some bias, as not all individuals with depression present to or are recognized by general practitioners. Only community-based studies with random selection of subjects can overcome this form of bias. However, the challenges inherent in undertaking such research with meaningful numbers of subjects are huge. Some surveys of elderly people yield a prevalence of major depressive disorder below 1 66 . 4. Development of objective outcome criteria. Outcomes need to be rated in explicit categories which are objective and can be related to normal clinical practice. This is harder than it sounds. While it may not be too difficult to agree on which patients have remained continuously well since recovery from the index episode and which have died, the threshold for dementia may be hard to operationalize and the...

Psychiatric Hospital and Outpatient Studies

The Old Age Depression Interest Group 274 study compared the efficacy of dothiepin and placebo in 69 elderly patients who had recovered from major depression. Drug treatment reduced the risk of relapse by a factor of 2.5, whereas a prolonged index depressive episode trebled the chance of relapse. Although this study did not use structured interviews, it does report on the long-term impact of a prophylactic treatment for depression in the elderly and thus actually has some applicability in practice. Stoudemire et al 275 focused on cognitive outcome in 55 elderly patients treated for depression with antidepressants or ECT and followed for 4 years. After 4 years, 83.7 exhibited ''clinically meaningful improvements'', though 50 experienced a rehospitalization. Lee and Lawlor 278 for a mean period of 19 months followed, 51 elderly patients presenting to a Dublin old age service with major depression and 49 with other depressive diagnoses. Good outcomes were reported in 57 of those with...

Studies of Residential Populations

In both these cohorts, depression score and an expressed wish to die when screened were associated with mortality 300 . In a nursing home study of 454 new admissions, conducted in the USA by Rovner et al 190 , major depressive disorder was positively associated with mortality at 1 year.

Depression in the Elderly Issues in Diagnosis and Management

Depression in the elderly is of clinical significance because of the increasing numbers of elderly in the population, the prevalence of depression in this age group, and difficulty with relative tolerability of antidepressant agents amongst the elderly. Depression in the elderly can be a new or first episode, usually of unipolar major depressive disorder, a recurrence of prior episodes of unipolar or bipolar disorder, or an exacerbation or continuation of either chronic major depression or dysthymic disorder 1, 2 . In addition, bereavement is a more frequent experience in the elderly than in younger individuals, and bereavement itself may be experienced as a longstanding depression. According to DSM-IV, if significant symptoms of bereavement persist for 2 months or longer, the disorder is characterized as a major depressive disorder 3 . Depression in the elderly may be easy to recognize if it is a continuation of a condition that began earlier in life and persisted, such as chronic...

Depression in the Elderly Areas Open to Research

Far less information available regarding patients in primary care and the community. In addition, very few studies focus upon the older old, who are likely to have the most complex needs. Perhaps more worrying, however, are the limited data pertaining to certain aspects of treatment outcome. Although there are more than 70 double-blind placebo-controlled trials of antidepressants in the elderly, only 9 of these 1 incorporate samples with a mean age over 75. These patients are the most likely to have concurrent physical illness, are more likely to be taking additional pharmaceutical agents and have the poorest drug tolerability. Other specific areas where our knowledge regarding treatment outcome in the elderly is inadequate include treatment resistance and chronic depression, patients with physical illness and patients with depression and dementia. Dementia affects 1 in 5 people over the age of 80, 20 of whom will be experiencing a depressive illness at any one time 2 . Five...

Filling in the Gaps about Depression in the Elderly

Our understanding of etiological factors is disappointing, because we have learned little about the etiology of late life depression in recent years. The one area where we have made significant gains is in the focus upon vascular depression, a concept that goes back at least to Felix Post. Nonreversible changes in the brain with aging not only manifest themselves via the dementing disorders they also are the basis of depressive disorders often free of comorbid cognitive decline among the elderly. Many questions remain to be answered about vascular depression, not the least of which relate to the potential for preventing these changes through control of blood pressure and even more aggressive approaches, as we currently are witnessing in studies of the treatment and prevention of cardiovascular disease. The past decade has witnessed both successes and disappointments in the treatment of late life depression. The success is documented in the literature which substantiates the value of...

Clinical Point of View about Depression in the Elderly

Depression in the elderly is ubiquitous, present in the community, in hospitals, both somatic and psychiatric, in long-stay settings. It can be at the foreground or less evidently present, intermingled with physical diseases or and dementia. Symptoms can be emotional, cognitive and somatic. Emotional disorders include sadness, anxiety, reduction of interest. Sadness is not always evident. It can be minimized or hidden behind an apparently smiling facial expression. A diminished facial mobility, caused by Parkinson's or a multi-infarct cerebral disease, could falsely suggest the presence of sad feelings. Anxiety is often conveyed by somatic complaints, for instance ''pressure'' on the heart or the solar plexus region, an impression of tightening in the throat. Obviously, such symptoms call for investigation for possible physical comorbidities that can coexist with the depressive disorder. A diminished interest is not a symptom restricted to depression and is also a feature observed in...

Geriatric Depression A Look to the Future

The comprehensive review by Chiu et al underscores both recent advances and limitations in our understanding of depressive illnesses in later life. The World Health Organization (WHO) 1 has specified unipolar depression and In answer to the authors' question, we have recently completed a randomized, placebo-controlled study of maintenance therapies in late-life depression, which demonstrated the value of maintenance nortriptyline (NT, steady-state blood levels of 80-120 ng ml) and of monthly interpersonal psychotherapy (IPT) in preventing or delaying recurrence of major depressive episodes in elderly patients with histories of recurrent, non-psychotic, unipolar major depression (15 of whom also had histories of suicide attempts) 2 . The study showed that maintenance NT and monthly IPT, both singly and in combination, worked better than placebo in preventing or delaying recurrences of depression over a 3-year period, and that treatment combining NT and IPT was better than either...

Treatment of Depression in the Old Old

As pointed out by Chiu et al, only 4-30 of the elderly with clinical depression in primary care receive a trial of an antidepressant. That is likely in part due to the fact that physicians have few systematic data upon which to base treatment decisions. The clinical trials done to support the registration of antidepressants are usually conducted in physically healthy patients aged 20 -55. The databases used to support registration typically include 2500-3000 individuals of whom 300 or fewer are over the age of 65. Most of these are 65-70 (i.e. the young-old). Virtually no data come from the old-old (i.e. individuals over the age of 85). In addition, the young-old in these studies have to meet rigorous inclusion criteria no unstable medical illnesses, no other psychiatric medications, and limited concomitant medications. These requirements severely limit the generalizability of the results to actual clinical practice, especially with regard to the old-old. Yet, the old-old are a...

Comorbidity of Depression in Older People

As is apparent from the review by Chiu et al, there have been several epidemiological studies examining the prevalence of depressive disorders in older people, as well as many descriptions of symptom pattern in both clinical and epidemiological samples of patients with these disorders. It is perhaps surprising that few of these studies have examined the frequency with which depression coexists with other psychiatric disorders in old age, particularly since comorbidity with depression has been studied extensively in younger subjects 1 . These data indicate that older people who are depressed very commonly also have comorbid psychopathology particularly phobic disorder and generalized anxiety and or physical symptoms. Generalized anxiety indeed is almost exclusively found comorbidly with depression, suggesting that depressive symptoms should always be looked for in older people presenting with an apparent anxiety disorder. Sleep disturbance, somatic symptoms and complaints of memory...

Myth or Reality of Old Age Depression The Example of Taiwan Studies

Previous work in Taiwan reported low rates of depressive illness in the elderly community population (0.5-0.8 ) 1 , like many studies mentioned in Chiu et al's review. This low risk of depression has been explained by the positive effect of the family supporting system in Taiwanese society, which traditionally gives high respect to the elderly. However, recent epidemio-logical studies of community subjects in Taiwan showed that elderly people had a higher risk of minor psychiatric morbidity 2, 3 . Moreover, available statistics in Taiwan have shown that elderly people presented a consistently increased risk of suicide 4 and many of those who committed suicide were found retrospectively to have suffered from depressive disorders 5 . In view of the drastic change of social and population structure in contemporary Taiwan, an epidemiological study of old age depression in 1500 randomized community subjects was conducted from mid-1996 to the end of 1998 6 . Trained senior psychiatrists...

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