Topic Overview

 

What is depression?

Depression is a mood disorder that causes symptoms such as low energy, prolonged sadness or irritability, and lack of interest in daily activities.  It can be triggered by a chemical imbalance or stressful, emotional situations.  Depression is a medical condition, not a character flaw or weakness.  Many people with depression do not seek treatment because they are embarrassed or think they will get over it on their own.  If you feel you have depression or have been diagnose with depression, there are many successful treatments available to help you.  You do not have to live with depression.

 

What causes depression?

 

The cause of depression is not entirely clear.  It is thought to be caused by an imbalance of certain brain chemicals (neurotransmitters).  Depression seems to run in families and may be triggered by stressful life events and lack of social support, and it tends to recur.

 

Who gets depression?

 

Anyone can develop depression regardless of age, race, or social status.  Women experience depression twice as often as men, although men are more likely to commit suicide as a result of depression.  One out of every 10 people who visit a doctor has depression, but it goes unrecognized or under treated in about half of those with the disorder.  If left untreated, depression can lead to poor quality of life and increased risk of suicide.

 

Depression is a growing problem and is often under diagnosed in children and older adults.  In children and adolescents, depression might be mistaken for hormonal “moodiness.”  Older adults may think it is normal to experience feelings of depression along with aging.  Depression is not normal at any age, and treatment is important.

 

What are the symptoms of depression?

 

Depression is more than just the normal, temporary feelings of sadness and hopelessness associated with difficult life events.  Symptoms of depression include depressed mood and an inability to enjoy activities which persist for at least 2 weeks and are associated with 4 or more of the following:

 

• Problems concentrating
• Poor memory
• Difficulty making decisions
• Changes in eating habits
• Changes in sleeping habits
• A loss of interest in things you once enjoyed
• Difficulty going to work or taking care of your daily responsibilities
• Feelings of guilt and hopelessness.  It is common for depression to make you wonder if life is worth living.
• Slowed thoughts and speech, or no speech
• Preoccupation with thoughts of death or suicide

 

Atypical or uncommon symptoms of depression can also include:

 

• Complaints (such as headache and stomachache) with no physical cause.
• Weight gain instead of weight loss.
• Sleeping too much.

 

All of these symptoms can interfere with your ability to function in your day-to-day activities and create difficulty going to work or taking care of your daily responsibilities.

 

What is a depressive episode?

 

A depressive episode usually has a distinct beginning and ending and last at least 2 weeks.  You may have one or many episodes of depression throughout your life, and each episode increases the chances that you will have another.

 

Depressive episodes can be brief or last a long time, and symptoms can be mild to severe.  Sometimes episodes of depression are preceded or followed by periods of high energy (mania).  For more information, see the topic Bipolar Disorder.

 

How is depression treated?

 

Depression is often treated successfully with professional counseling and medications such as antidepressants.  Let your health professional know if you suspect you have depression, as it is often overlooked or under treated.  Once diagnosed, you and your health professional can decide how to best treat your depression.  The earlier you are treated the more quickly you will recover.

 

Are there different types of depression?

 

Depressive disorders are classified according to their severity and duration.  Depression may be mild, moderate, or severe.  It may start suddenly (acute) or be long-lasting (chronic).  Dysthymic disorder, for example, is chronic mild depression.

 

Can depression cause other health problems?

 

Research supports a relationship between depression and other diseases.  However, it is not yet clear whether depression is a cause or a result of other illnesses.

 

• Depression and risk of stroke
• Depression and risk of coronary artery disease

 

Health Tools

 

Health tools help you make wise health decisions or take action to improve your health.

 

Decision points focus on key medical care decisions that are important to many health problems.

 

Actionsets are designed to help people take an active role in managing a health condition.

 

Cause

 

The cause of depression is not well understood.  Depression has chemical, genetic, and environmental or emotional causes.

 

Chemical causes

 

An imbalance of certain neurotransmitters, such as serotonin, can cause depression.  serotonin is involved in the processing of thoughts and emotions.

 

Genetic causes

 

Depression may be passed down through genes.  Your risk of developing depression is up to 3 times greater than that of the general population if you have a father, mother, or sibling with depression.

 

Environmental causes

 

Certain medications, such as blood pressure medicines, can trigger depressive episodes.  Once the medication is stopped, the depressive symptoms usually disappear.

 

Certain medical conditions, such as hypothyroidism or coronary artery disease, can cause depression.

 

Significant stress or changes in your life can also trigger depression.  Social stressors (such as the death of a loved one) and chronic stressors (such as poverty, family difficulties, or long-term illnesses) can significantly contribute to depression.  Older adults who move from an independent lifestyle to one that is more dependant upon other often experience depression.

 

Social and peer pressures can cause depression in children and adolescents.

 

Other events that can trigger depression include:

 

• Drinking alcohol, using illegal drugs, or having a substance abuse problem.
• Having serious medical problems or living with someone who does.
• Grieving the death of a loved one.
• Recently giving birth (postpartum depression).

 

Symptoms

 

If you are depressed, you may feel hopeless and sad or stop experiencing pleasure in almost everything you do.  You may feel “down in the dump,” tearful, or discouraged.  You may also feel irritable, anxious, and apathetic.

 

In order to be accurately diagnosed with depression, you will have symptoms of either.

 

• Sadness or hopelessness.
• Loss of interest or pleasure in most of your daily activities.

 

Along with sadness or loss of interest that lasts for more than 2 weeks, you will also have at least four of the following symptoms:

 

• A change in appetite that causes either weight gain or weight loss
• Sleeping too much or not enough
• Feeling restless and unable to sit still, or feeling that moving takes a great effort
• Feeling tired all the time
• Feeling unworthy or guilty without and obvious reason
• Having problems concentrating, remembering, or making decisions
• Thinking often about death or suicide

 

Many family doctors, internists, or general practitioners see people with general symptoms that are difficult to attribute to depression.  Other symptoms that commonly occur with depression include:

 

• Headaches and other body aches and pains.
• Digestive problems, including constipation or diarrhea.
• Loss of interest in sex or inability to perform sexually.
• Feeling anxious or worried without and obvious reason.
• Blaming yourself or others for you depression.
• Not moving or talking for hours.

 

Certain atypical symptoms of depression occur more often in women, such as:

 

• Overeating and weight gain (instead of loss of appetite).
• Oversleeping (instead of insomnia). Increased tearfulness, anger, and generally not feeling well, along with anxiety and tension.
• Sometimes, a feeling of heaviness in the arms and legs.
• Sensitivity to rejection.

 

Some people may experience a episode of depression together with dysthymic disorder (double depression).

 

Depression in older adults can include symptoms such as mild confusion or forgetfulness.  However, these symptoms can also be caused by medications, so be sure to let your health professional know what medications you are taking.  Depression has recently been identified as a significant risk factor for death in older adults with heart problems.  If you are an older adult and think you might be depressed, seek treatment right away.  Depression is not normal at any age.

 

Symptoms of depression in children and teens are sometimes different from adult symptoms, which can make it more difficult to diagnose and treat.  See the topic Depression in Childhood and Adolescence for more information.

 

What Happens

 

The course of depression varies from one person to another.  You might have mild or severe symptoms of depression for a long time, or you may have them for a brief time.  A small number of people feel depressed for most of their lives and require long-term treatment.  Most people with depression can be treated successfully with medication and professional counseling.

 

Depression may first being with symptoms of anxiety (such as excessive worrying) and mild symptoms such as sadness or lack of energy that last for days or months before the onset of full depression.

 

You may have trouble concentrating or remembering.  You probably will experience a loss of pleasure in things you used to enjoy.  Feelings of hopelessness usually occur along with low energy and changes in sleeping and eating patterns.  Women may gain weight during this time due to cravings of carbohydrates and sugar, while men may gain or lose weight.  Children with depression may not make expected weight gains.

 

You may have difficulty going to sleep and then awaken during the night and have trouble getting back to sleep.  You may withdraw socially from others and also experience a loss in sexual desire.  A depressive episode that is left untreated may last from 6 to 9 months.

 

If you have short episodes of mild, you may be able to continue to work and take care of your daily activities.  However, if you do not seek some from of treatment for your depression, you run the risk of getting more depressed or becoming physically ill.

 

For serious depression, you may need to be admitted to a hospital for a short time, especially if you are having thoughts of suicide.  Depression puts you at a risk for attempting suicide.  Seek immediate treatment if you have thoughts of suicide.

 

Depression often recurs.  If you have on episode of depression, you are more likely to become depressed again at some point in your life.  The risk of having another episode of depression increases with each additional episode.

 

Depression can be a contributing factor in the development of certain diseases such as coronary artery disease.

 

If you experience depression only during certain seasons of the year, such as the fall and winter months, you may have seasonal pattern depression.  For more information, see the topic Seasonal Affective Disorder (SAD).

 

If you have depression along with mania, you may be suffering from another condition called bipolar disorder.  For more information, see the topic Bipolar Disorder.

 

What Increases Your Risk

 

Several factors increase your risk for depression.  General risk factors for depression include:

 

• A previous depressive episode.
• A family history of depression.
• A history of heart problems, such as coronary artery disease.
• A serious chronic illness, such as diabetes, cancer, or chronic pain.
• Problems in your marriage.
• Use of drugs or alcohol. (For more information, see the topic Alcohol Abuse and Dependence.)
• Use of certain medications that are known to trigger depression, such as those used to treat high blood pressure or seizures.
• A stressful life event, such as losing a job or a loved one.  This is especially true for older persons who experience many social stressors, such as becoming dependant upon others for care.
• Certain medical conditions, such as anemia and thyroid disease, may trigger depression. 
• Recent serious illness or surgery, or living with chronic pain.
• A childhood history of physical or sexual abuse.
• Being a worrier or overly anxious (neuroticism).
• Having an eating disorder or anxiety disorder.

 

Other risk factors associated with depression that occur in women include:

 

• Experiencing postpartum depression after giving birth.
• Use of oral contraceptives.
• A family history of mood disorders in the reproductive years.
• A history of premenstrual dysphoric disorder (severe PMS).

 

When to Call a Doctor

 

Call other emergency services if:

 

• You think you cannot keep from harming yourself.
• You hear voices.
• Someone you know makes threats or shows warning signs of suicide or attempts suicide.

 

Watchful Waiting

 

Watchful waiting may be appropriate if you are experiencing feelings of grief, sadness, or melancholy.  However, if symptoms do not improve after 2 weeks, talk with a health professional.

 

Who to See

 

Treatment for depression usually involves both medication and some form of professional counseling.  It is important that you establish a long-term and comfortable relationship with your care providers for treatment of depression.

 

Diagnosis and medication management for depression can be provided by a:

 

• General practitioner.
• Family doctor.
• Psychiatrist.
• Physician’s assistant.
• Nurse practitioner.

 

Professional counseling can by provided by a:

 

• Psychiatrist.
• Psychologist.
• Social worker.
• Licensed professional counselor.

 

Exams and Tests

 

There are currently no laboratory tests available to diagnose depression.  If you think you have depression, your health professional will diagnose the disorder by taking your medical history and performing a physical exam to rule out other causes of your symptoms.  You may also take a mental health assessment.  Other tests that can detect depression may be given.  Your health professional may ask whether you are having any suicidal thoughts.

 

It is important to point out your symptoms of depression to your health professional.  Approximately half of those with depression go undiagnosed or undertreated.  Health professionals are now being encouraged to ask routine questions about depression at all office visits.

 

Treatment Overview

 

Treatment of depression usually includes professional counseling (such as cognitive-behavioral therapy) and sometimes use of medications (usually antidepressants).  Less than one-third of people suffering from depression seek professional treatment.  Even when treatment is sought, doctors sometimes attribute the vague symptoms of depression with other illnesses.  You may not realize you are depressed, or you may be embarrassed to seek treatment.  However, it is important to seek treatment as soon as you suspect you or someone you love is experiencing depression.  The sooner you seek treatment, the better your chance for a quick and full recovery.

 

The goals of treatment are to improve your mood and your ability to function both at work and in society, and to improve the overall quality of your life.  Preventing recurrence of depression is also important.

 

Initial treatment

 

The first step is an evaluation of your symptoms by a health professional.  Initial treatment options generally include professional counseling, medications, or a combination of the two.  Professional counseling may be all that is needed for mild to moderate depression, but counseling alone may take longer to be effective.

 

If your early symptoms are severe, your initial treatment most likely will include both medications, such as antidepressants, and professional counseling.  You may also need hospitalization, especially if you show any warning signs of suicide.

 

Electroconvulsive therapy (ECT) may also be an initial treatment choice for people with severe symptoms of depression, such as psychosis or refusing to eat.

 

Eating a balanced diet, avoiding alcohol, and getting enough exercise and sleep are important in treating your depression.  It may also be helpful for you to obtain social support from family and friends while you are recovering from depression.

 

If you have recently given birth, learning how to manage postpartum depression may help you recover more quickly than taking medications.

Ongoing treatment

 

Depression can usually be successfully treated with medication and professional counseling.  However, it sometimes takes several attempts at treatment to find the medication and type of counseling that work best for you.  It can take 4 to 6 weeks for medications to take effect, although they often work much more quickly.  You and your health professional will work together to find the right treatment.

 

At least half of those who experience one depressive episode will experience a relapse of symptoms.  Continuing to take medications for at least 4 to 6 months after recovery reduces your risk for relapse.

 

Regular exercise, a nutritious diet, and adequate sleep are important parts of ongoing treatment.

 

Treatment if the condition gets worse

 

If your condition worsens while you are receiving professional counseling alone, medications can be added to your treatment.  Evidence shows that adding medications to counseling for severe depression works better than counseling alone.

 

If your condition worsens while you are already taking medications and receiving professional counseling, additional treatment may be needed.  Electroconvulsive therapy (ECT) has been shown to be an effective treatment for severe depression or depression that has not been helped by other treatment.  However, ECT will need to be followed with medications and counseling, because relapse of symptoms is common.  If you have recurrent depression, you may need to take medications for the rest of your life.

 

If you have another illness along with your depression, you need to continue receiving treatment for your other illness.  Tell all health professionals you see which medications you are taking and the treatment you are receiving.  It is possible for other mood disorders such as anxiety and anxiety disorders, psychosis, or mania to accompany depression.  For more information, see the topics Anxiety and Bipolar Disorder.

Major depression can be a risk factor for developing heart problems such as coronary artery disease or heart attack.  However, the greatest danger from depression is suicide.  Up to 15% of people with depression die by suicide.

 

What to Think About

 

Early treatment of depression in older adults can delay nursing home placement.  The risk of death associated with depression increases significantly during the first year an older adult enters a nursing home.

 

If you have recently given birth, learning how to manage postpartum depression early on may help you recover more quickly and prevent a prolonged or serious problem with postpartum depression.

 

Family involvement and support in the treatment of depression can be very important, especially for children, teens, and older persons.  Sometimes parents of depressed children and teens may also become depressed and need treatment.

 

Usually, the sooner treatment for depression is started, the quicker you will get better.  Waiting to seek treatment for depression may result in a difficult and lengthy recovery.

 

The best treatment for mild depression may be professional counseling alone, although adding medications may help you feel better faster.  For moderate to severe depression, a combination of medications and counseling may work best.

 

Prevention

 

There is no known way to prevent the biological mood disorder depression.  However, you may be able to prevent or reduce relapse of depression by:

 

• Continuing to take medications for at least 16 to 20 weeks months after your symptoms subside.  There is some evidence that continuing to take your medications for 6 to 12 months after recovery significantly reduces your risk for relapse.
• Continuing with cognitive-behavioral therapy even after medications have been stopped.  Research shows those who continued this type of counseling for 2 years after medications were stopped had lower rates of relapse.
• Eating a balanced diet.
• Getting enough regular exercise.
• Seeking treatment immediately when you first notice symptoms of depression.

 

It is difficult to prevent all episodes of depression.  However, you may be able to prevent or reduce the severity of future episodes.  If you are on a maintenance does of medication to treat ongoing depression, be sure to take all of your medications as directed by your health professional.  Keep your counseling appointments.  Seek help when you notice the first symptoms of depression, especially if your depressive episodes are moderate to severe.

 

Home Treatment

 

Home treatment is very important in treating depression.  There are many steps you can take to help yourself during a depressive episode and to prevent episodes in the future.  Some of these steps include:

 

• Not making any major life decisions (like changing jobs, moving, or getting married or divorced) when you are depressed.
• Not drinking alcohol or using illegal drugs or medications that have not been prescribed to you because they may interfere with your medications.
• Getting enough sleep.  If you have problems sleeping, try:
  • Going to bed at the same time every night and, more importantly, getting up at the same time every morning.
  • Keeping your bedroom dark and free of noise.
  • Not exercising after 5:00 p.m.
  • Avoiding the consumption of caffeine containing beverages after 5:00 p.m.
  • Avoiding the use of nonprescription sleeping pills or alcohol because they can make your sleep restless and may interact with your depression medications.

• Eating a balanced diet.  If you lack an appetite, eat small snacks rather than large meals.
• Trying to keep up hope that you will improve, even if gradually.
• Getting regular exercise.
• Obtaining social support from friends and family.

 

If you know someone who is depressed, it can be beneficial to spend some quiet time with him or her.  Avoid offering advice, but encourage the person to seek treatment.  You do not need to take responsibility for the person’s depression.  However, if you notice any warning signs of suicide, you should seek professional help immediately by calling either the person’s health professional or if you feel the person is in immediate danger.

 

Medications

 

Depression is often underdiagnosed and undertreated.  Most depressed people need antidepressant medications.  Antidepressants can improve or completely relieve the symptoms of depression.  Several medication options are available, depending on your age and tolerance of the medications.  There is no evidence that one medication works better than another; however, the side effects of the medications differ.  You and your health professional can choose the medication that is right for you based on your tolerance of the side effects and how you respond to the medication.

 

Medication Choices

 

Antidepressant medications include:

 

• Selective serotonin reuptake inhibitors (SSRIs).
• Tricyclic (TCAs) and heterocyclic antidepressants.
• Atypical antidepressants.
• Monoamine oxidase inhibitors (MAOIs)

 

What to Think About

 

If you and your health professional decide that you need medication, there are several considerations in choosing the right medication:

 

• Understand the side effects of the medication.
• Tell your doctor about all of your current medical conditions and all medications you are taking, including nonprescription drugs, herbs, and supplements, so the doctor can determine whether there are potential drug interactions.
• If you are an older person, you may need less medication, and it may take longer to be effective.
• Your health professional will need to monitor your progress until it can be determined whether a particular medication is working for you.
• Often the first medication you take will effectively treat your depression.  If not, there are other choices that will usually work well.  You may need to try several different medications before you find the one that works best for you.
• Once you have begun to feel better, you will need to continue taking your medication for 6 to 12 months or longer to help reduce the likelihood of another depressive episode.
• Some people need to remain on maintenance medication therapy for several months to years, while some need medication for the remainder of their lives, especially those who have experienced several episodes of major depression.

 

When deciding which medication to prescribe, your doctor will consider:

 

• Your response to medications in previous depressive episodes.
• Whether you have other illnesses, so you are not given a depression medication that will interact poorly with other medicine you may be taking.
• Whether the medication used to treat your depression will make any other illness you have worse or more difficult to treat.
• Your age and overall physical health.  Older adults may need to take lower doses of medications for depression.
• How much the side effects of the medication are likely to bother you.

 

Some people with depression do not continue taking their medications for depression or take them sporadically.  It is important to continue taking medications for depression as prescribed, even after symptoms go away, to prevent recurrence of depression.

 

Antidepressant medications often need to be taken for as long as 4 to 8 weeks before they start to relieve the symptoms of depression.  During this time, you may experience side effects of the medication.  Many of the side effects are temporary and go away with continued use of the medications, although some (such as dry mouth, constipation, and sexual effects) may continue.  Do not stop taking the medication on your own unless you are having chest pain, hives, shortness of breath, trouble swallowing, or swelling of your lips.  Contact your doctor immediately if you do experience any of these serious side effects.  If your side effects are less serious but bothersome, talk with your doctor to see if you should continue the medication or try another.  There are many things you can do to reduce bothersome side effects of medications.

 

Most antidepressant medications need to be started at low doses and increased gradually, especially in older adults.  Medications should also be stopped gradually by decreasing the dose.  If certain antidepressant medications are stopped abruptly, you may suffer negative effects or the symptoms of depression may return.

 

Older adults or others who are depressed and taking several medications for other health conditions (not related to depression) need careful monitoring of their medications.  People are more likely to develop harmful side effects from taking many different medications.

 

FDA Advisory.  The US Food and Drug Administration (FDA) has issued an advisory to patients, families, and health care providers to closely monitor adults and children taking antidepressants for signs of suicide.  This is especially important at the beginning of treatment or when doses are changed.

 

The FDA also advises that patients be observed for increases in anxiety, panic attacks, agitation, irritability, insomnia, impulsivity, hostility, and mania.  It is most important to watch for these behaviors in children who may be less able to control their impulsivity as much as adults and therefore may be at greater risk for suicidal impulses.  The FDA has no recommended that people stop using antidepressants, but simply to monitor those taking the medications and, if concerns arise, to contact a health professional.

 

Surgery

 

There is no surgical treatment for depression at this time.

 

Other Treatment

 

Professional counseling is an important part of treatment for depression.  Other therapies, such as the use of herbs or relaxation techniques, may also help you recover more quickly and improve your quality of life.  Family therapy may be helpful for you and those who care about you in dealing with depression.

 

Electroconvulsive therapy (ECT) may be used for those who either have not responded to other treatments or whose depression is severe and includes symptoms of psychosis.

 

Other Treatment Choices

 

Counseling is an important part of the treatment for depression.  The types of counseling most often used for effective treatment of depression include:

 

• Cognitive-behavioral therapy.
• Interpersonal therapy.
• Problem-solving therapy.
• Family therapy.

 

Electroconvulsive therapy (ECT) may be used to treat severe depression or depression that has not responded well to medications and counseling.  ECT also may be a treatment choice for someone who cannot tolerate the side effects of antidepressant medications.  In the past, ECT was portrayed as a gruesome form of treatment.  However, this is not accurate.  ECT consists of very mild electrical shocks while you are under sedation and is quite a successful form of treatment for depression.  Side effects of ECT include some temporary memory loss and confusion.

 

Complementary therapy

 

The herb St. John’s wort is being tested in the United States to determine its safety and efficacy.  So far, the results have been mixed.  High-quality St. John’s wort has been shown by some studies to be effective in the treatment of mild to moderate depression.  However, some negative and dangerous interactions between St. John’s wort and certain medications have been discovered, especially between St. John’s wort and medications used to treat AIDS.  Let your doctor know if you are using St. John’s wort, especially if you are taking other medications.  It is also important to avoid taking St. John’s wort along with other antidepressants because you could overmedicate yourself and have serious side effects.

 

SAM-e is sometimes used to treat depression.  However, currently there is no convincing clinical evidence that SAM-e is either safe or effective for treating depression.

 

What to Think About

 

Deciding whether to undergo electroconvulsive therapy (ECT) can be difficult.  For more information, see electroconvulsive therapy (ECT).

 

Other Places to Get Help

 

Book

 

The Feeling Good Handbook

Author/Editor:                                    D.D. Burns

Publisher:                                Plume

Publication Date:                    1999

 

This is a consumer’s guide to reshaping negative thoughts and reponses to help avoid stress and depression.

 

Organizations

 

National Institute of Mental Health (NIMH), Public Inquiries

6001 Executive Boulevard

Suite 8184, MSC 9663

Bethesda, MD 20892-9663

Phone:                         (301) 443-4513

Fax:                             (301) 443-4279

E-mail:                         nimhinfo@nih.gov

Web Address:             http://www.nimh.nih.gov

 

NIMH provides information to help people better understand mental health and mental disorders.  NIMH does not provide referrals to mental health professionals or treatment for mental health problems.

 

 

National Mental Health Association (NMHA)

1021 Prince Street

Alexandria, VA 22314-0297

Phone:                         (703) 684-7722

1-800-969-NMHA (1-800-969-6642).  This also is a hot line for help with depression.

Fax:                             (703) 684-5968

Web Address:             http://depression-screening.org

 

The NMHA has launched a Web site with a confidential depression screening exam available to anyone who would like to take the test.  The short test may help you decide whether or not your symptoms are related to depression.

 

Related Information

 

• Anorexia Nervosa
• Bipolar Disorder
• Coronary Artery Disease
• Depression in Childhood and Adolescence
• Family Life Cycle
• High Blood Pressure (Hypertension)
• Obsessive-Compulsive Disorder(OCD).
• Post-Traumatic Stress Disorder.
• Premenstrual Syndrome (PMS).
• Stroke.

 

References

 

Citations

 

1.      Whooley MA, Simon GE (2000).  Managing depression in medical outpatients.  New England Journal of Medicine, 343(26): 1942-1950.

2.      American Psychiatric Association (2000).  Depressive disorders.  In Diagnostic and Statistical Manual of Mental Disorders,  4^th ed., text rev., pp. 349-381.  Washington, DC: American Psychiatric Association.

3.      Schulberg HC, et al. (1999).  Best clinical practice: Guidelines for managing major depression in primary medical care.  Journal of Clinical Psychiatry, 60(7): 19-28.

4.      Kornstein SG (2001).  The evaluation and management of depression in women across the life span.  Journal of Clinical Psychiatry, 62 (suppl 24): 11-17.

5.      Schulz R, et al.  (2000).  Association between depression and mortality in older adults:  The cardiovascular health study.  Archives of Internal Medicine, 160: 1761-1768.

6.      Penninx BWJH, et al. (2001).  Depression and cardiac mortality.  Archives of General Psychiatry, 58: 221-227.

7.      Januzzi JL, et al. (2000).  The influence of anxiety and depression on outcomes of patients with coronary artery disease.  Archives of Internal Medicine, 160: 1913-1921.

8.      Davidson JRT, et al. (1999).  The underrecognition and undertreatment of depression:  What is the breadth and depth of the problem?  Journal of Clinical Psychiatry, 60(suppl 7): 4-11.

9.      Chilvers C, et al. (2001).  Antidepressant drugs and generic counseling for treatment of major depression in primary care: Randomized trial with patient preference arms.  BMJ, 322: 1-5.

10.  American Psychiatric Association (2000).  Practice guidelines for the treatment of patients with major depressive disorder (revision).  American Journal of Psychiatry, 157(4, suppl): 1-45.

11.  Geddes J, Butler R (2002).  Depressive disorders.  Clinical Evidence, (7): 867-882.

12.  Sackheim HA, et al. (2001).  Continuation pharmacotherapy in the prevention of relapse following electroconvulsive therapy.  JAMA, 285: 1299-1307.

13.  Snow V, et al.  (2000). Pharmacologic treatment of acute major depression and dysthymia (ACP-ASIM clinical guideline, part 1).  Annals of Internal Medicine, 132(9):738-742.

 

Other Works Consulted

 

• Canadian Psychiatric Association and the CANMAT Depression Work Group (2001).  Clinical practice guidelines for the treatment of depressive disorders.  Canadian Journal of Psychiatry, 46 (Suppl 1): 13S-89S.
• Hypericum Depression Trial Study Group, American Medical Association (2002).  Effect of hypericum perforatum (St. John’s wort) in major depressive disorder.  JAMA, 387(14): 1807-1814.
• Roose SP, et al. (2001).  Relationship between depression and other medical illnesses.  JAMA, 286(14): 1687-1690.
• Schatzberg AF, et al. (2002).  Clinical use of nefazodone in major depression: A 6-year perspective.  Journal of Clinical Psychiatry, 63 (Suppl 1): 18-31.
• Williams JW (2002).  Is this patient clinically depressed?  JAMA, 287:1160-1170.
• Yager J, Gitlin, MJ (2000).  Depression section of clinical manifestations of psychiatric disorders.  In BJ Sadock, VA Sadock, eds., Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 7^th ed., vol. 1, pp. 813-814.  Philadelphia: Lippincoot Williams and Wilkins.

 

Author: Dana L. Rowett

Medical Review:  Terry Golden, DO – Family Practice

Lisa S. Weinstock, MD - Psychiatry