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Sub-type Missing

Under sub-types there needs to be included "Psychotic Depression". With this, the onset of a depressive episode also manifests with hallucinations (any type ie. visual, auditory, tactile, etc.). An important note is that people suffering from a Psychotic Depressive episode are usually able to identify their hallucinations as being products of their mind or not real, whereas a schizophrenic is not. —Preceding unsigned comment added by 74.131.111.224 (talk) 17:43, 17 October 2008 (UTC)

Thanks. It was there but appears to have disappeared somewhere...Cheers, Casliber (talk · contribs) 17:59, 17 October 2008 (UTC)

Psychotherapy section

Since CBT is by far the most frequently used approach, perhaps the others could be dealt with in the sub-article. More iportantly, I have issues with the paragraph that starts, "For the treatment of adolescent depression..." It relies on primary sources, which is not good, and a search on Google Scholar shows that later secondary sources are available that don't draw the same conclusions, for example this. Looie496 (talk) 16:26, 25 September 2008 (UTC)

Well spotted. I didn't add that bit. I have FOnagy and Roth's book, and that is an interesting link too. I agree we need to address that. I stuck back in the one-liner linking to treatment-resistant depression as it is a common problem and a challenging one. Disagree about CBT being the most universal by far - not sure how it goes in the US with Managed Care but here in Oz many therapists end up being pragmatic and adopting measures from IPT, CBT and psychodynamic lore, not to mention what is now called Supposrtive Therapy in difficult periods. Furthermore, CBT is generally more often used with anxiety (and there is a more clear preponderance for its use than in depression). WRT cutting down, patients get alot more psychotherapy than they do vagal nerve stimulation, which is I guess the point we're trying to get to in the previous section above. There is a push in practice to relegate use of antidepressants to second choice behind psychotherapy, which is why I had that mentioned about "treatment of choice", and it has been a controversial issue here in Oz too, not sure about the US - agree your version is more succinct and am reading it a couple of times to see if the message is conserved (I think its ok :)) Cheers, Casliber (talk · contribs) 21:09, 25 September 2008 (UTC)

Update

Fonagy and Roth was a bit vague but there is alot of review material that suggests effectiveness, so I replaced. Cheers, Casliber (talk · contribs) 12:44, 12 October 2008 (UTC)

edits

• Cas, ECT is perfect now.
• I don't see why historical origin should affect the engvar issue now: it should be in the overall variety. Tony (talk) 13:25, 3 October 2008 (UTC)

Thanks - main issue now is how aggressively to reduce down to 50 kb ceiling of prose for FAC, and if so, what else to lose. There is some copyediting and some page numbers to get but otherwise...Cheers, Casliber (talk · contribs) 13:31, 3 October 2008 (UTC)

Is it a deal-breaker to get it down? I've seen FACs pass with as much info as this. I'd worry about that later. More important to address these micro-issues (well, not so micro). Tony (talk) 13:51, 3 October 2008 (UTC)

• Yes, older people are more likely to have those symptoms - should it be changed to "are more likely to..."? Cheers, Casliber (talk · contribs) 13:36, 3 October 2008 (UTC)

Yes, I think it's clear enough; too wordy to spell out "than .... RETHINK: no, I think it does need to be spelt out. See what you think of my attempt now. PS I meant to say that I'm delighted you're branching into this area; great use of your expertise. Because I'm in the know, it's easy to see the slight hospital bias, but I don't think it matters. Tony (talk) 13:51, 3 October 2008 (UTC)

(ec) To clarify, the term investigation refers to blood tests, ecgs, CT scans, ultrasounds etc. and is not used for a physical examination, hence the use of both terms. Cheers, Casliber (talk · contribs) 14:02, 3 October 2008 (UTC)

• I'm slightly concerned that it's very centred on the western world. I wonder whether you might cover yourselves by adding to the lead the cultural/historical/non-western context. I was particularly concerned in reading "Clinical assessment", where it seems to assume that the neat divisions between generalists, psychiatrists and psychologists are universal. Here, "in the developed world" might cover you (if indeed that is accurate (Japan?)), after the acknowledgement of the importance of cultural construction to the disorder and its professional treatment. I know this is hard, but it's necessary, don't you think? Tony (talk) 14:01, 3 October 2008 (UTC)

• I am pretty sure the profiles of the three clinicians are similar worldwide, though would imagine more general medial doctors in less developed areas (true in Oz as well). Agree regarding getting a sense of place/context in the worldwide milieu. Will have to think on how best to do it. Cheers, Casliber (talk · contribs) 14:05, 3 October 2008 (UTC)

• PS: Found some stuff , , , and . Interesting, will try and incorporate. Cheers, Casliber (talk · contribs) 20:52, 4 October 2008 (UTC)

Cas, some MoS notes: I see incorrect use of WP:ITALICS in lots of places, and left-aligned images under third-level section headings (review WP:ACCESS and WP:MOS#Images). Something wrong here: This tendency is characteristic of a "depressive attributional style," or "pessimistic explanatory style,". Incorrect use of logical punctuation, see WP:PUNC, sample: ... things leads to "neurotic anxiety," "self-alienation," ... Citation placement, why not put it after the "or", ... additional benefit or, ... Lots of WP:DASH problems in the citations; you can ask User:Brighterorange to run his script. Don't forget WP:ALLCAPS: WOULD HONEST ABE HAVE WRITTEN THE GETTYSBURG ADDRESS ON PROZAC?". Retrieved on October 3, 2008. I assume this formatting and quality of sourcing won't be staying: <http://webspace.ship.edu/cgboer/maslow.html> I also saw some punctuation issues and WP:OVERLINKing, so you might want to review for that. I'm unsure why you don't create a History of article (Colin and I have been intending to work on History of Tourette syndrome for a year.) That was just a scan; I didn't actually read anything, and don't want to engage much deeper so I won't have to recuse at FAC. SandyGeorgia (Talk) 07:26, 5 October 2008 (UTC)

Good pickups, have reduced overlinking now and fixed the caps and image issues, Will look at other style stuff. Cheers, Casliber (talk · contribs) 20:44, 5 October 2008 (UTC)

Working on incorporating a worldwide view

I have read the above articles which are fascinating - question is, how to incorporate in a succinct manner; clearly a few sentences on the paucity of resources will fit very well in the treatment top section, but how much should go above it under diagnosis? I was musing on removing the subheadings of Physical investigations and Clinical assessment, as what to add there would be relevant for both, or just a statement on this being a usual pracitce in developed countries (is enough?). Cheers, Casliber (talk · contribs) 21:27, 4 October 2008 (UTC)

Rumination

I came across an interesting bit of news about the relationship between depression (explicitly, both unipolar and bipolar--finally!) and creativity (i.e., an inclination to ruminate seems to be the common variable). I've already incorporated this into "Sociocultural aspects," but feel free to work with it further if it interests you. Cosmic Latte (talk) 08:39, 8 October 2008 (UTC)

Aaargh! just when we're trying to shorten the article, but seriously, it is interesting. One could argue that if it is general/inclusive, then it being placed on mood disorder may be more appropriate. I guess I am a little skeptical as many people with personality disorder somehow end up with the label of a mood disorder, from what I have seen, and just from looking at bookstores and popular literature, trauma and adverse events do prompt alot of soul-searching and what could be construed as rumination, but I digress. The connection of bipolar and depressive illnesses in highly creative people could be due to a large number of reasons (the whole chicken-or-egg conundrum comes to mind here). Anyway, the article is a bit of a hotchpotch, but seems to foucs more on bipolar more than depression, even though the latter is mentioned - would you mind if we moved it to mood disorder? That article is rather slim and there is ample room there for discussion. Cheers, Casliber (talk · contribs) 12:47, 8 October 2008 (UTC)

Sure, it'd be fine to move it over to mood disorder--but to what section? Without a comparable section on sociocultural aspects, it might be a bit of a challenge to fit it in. Maybe a new section needs to be made on that article? Cosmic Latte (talk) 13:34, 8 October 2008 (UTC)

Absolutely, and this can be the first bit in it. Cheers, Casliber (talk · contribs) 13:40, 8 October 2008 (UTC)

Done! :-) Also moved the bit about female poets to mood disorder. After all, this finding--the Sylvia Plath effect--was named after a bipolar poet, so it's probably more appropriate there. Cosmic Latte (talk) 14:25, 8 October 2008 (UTC)

Was Sylvia Plath bipolar? I thought she was purely depressive. (Her poetry is purely depressing, for sure.) Looie496 (talk) 15:47, 8 October 2008 (UTC)

This is a tricky one, as is apparent on Plath's own talk page, but Barlow and Durand (2005, p. 223) cite a study in which they remark in a footnote, "Plath, although not treated for mania, was probably bipolar II"--so I figure mood disorder is probably a safe spot to allude to her. Cosmic Latte (talk) 16:46, 8 October 2008 (UTC)

I'd be careful, the label bipolar II is getting splashed around an awful lot these days. Issues such as personalty disorder and PTSD are often mistaken. Cheers, Casliber (talk · contribs) 21:08, 8 October 2008 (UTC)

Plea for page numbers of books used

can anyone who reffed a book who hasn't done so already please add page numbers if possible? There are a few left which I can list if we like. we are nearly ready to nominate methinks. Any last issues jot here too. Cheers, Casliber (talk · contribs) 22:59, 12 October 2008 (UTC)

• As far as article size, we are only just over the ceiling of 50k prose size . I thought of actually throwing this up at FAC and letting that be the forum for consensus on further pruning. What do we think, as I am stumped as to what to prune next. Cheers, Casliber (talk · contribs) 14:50, 13 October 2008 (UTC)

I'm doing one more round of copy-editing, and so far the article looks very good. The boldest thing I've felt a need to do was to remove the sentence about Gordon Parker from the item about the melancholic subtype, because it jumped out at me as glaringly out of place there. Could belong in a discussion of the validity of the DSM-IV criteria somewhere, but it doesn't belong where it was. Looie496 (talk) 16:45, 13 October 2008 (UTC)

Follow-up: I've swapped the first two paragraphs under "Medication". This might not be the ideal solution, but if you want to swap it back, the first paragraph needs something to introduce it. Looie496 (talk) 17:02, 13 October 2008 (UTC)

Okay, done with that. I do have one suggestion that I'm not quite bold enough to implement: that the "Sociocultural aspects" section be retitled "The experience of depression" and moved up near the top, below "Signs and Symptoms" and above "Diagnosis". This is material of broad interest, and really should be shown to the reader before the technical stuff. In any case, this article looks ready for FA to me. Looie496 (talk) 17:33, 13 October 2008 (UTC)

Hmm. I know what you're getting at, but I think calling it "The experience of depression" strikes me as somewhat vague and overencompassing. "Sociocultural" defines it as different from "clinical" in some ways and places it in a "bigger picture" scenario after discussion of the syndrome in a clinical (or some would say reductionistic) way. I am musing on it and will have a further look. Cheers, Casliber (talk · contribs) 20:35, 13 October 2008 (UTC)

I have a personal policy in editing that if it's in a book, it's really old (even if published this year). We can always find the proper source for anything in a book. The DSM-IV criteria probably needs a page number, but even then, it's not necessary. This is all IMHO, and if you choose to flog me, I'll cry. OrangeMarlin 21:17, 13 October 2008 (UTC)

Erm, yeah, but I think I can sort the wheat from the, er, chaff. Cheers, Casliber (talk · contribs) 22:33, 13 October 2008 (UTC)

Other methods of treatment

I think this section gives too much weight to either placebo effects, discredited methods, or other stuff. I think it should be digested into one paragraph, similar to what is done in either the treatment or prevention sections of Alzheimer's disease. Sadly, people come here for there medical information. I don't want anyone to get the impression that there's any chance of treating Major depressive disorder with acupuncture or some other off-the-wall treatment. For example, St. John's wort has no effect on MJD, and worse yet, the dosage required to actually have any effect is so large, that we should consider the safety vs. efficacy of the herb. So, should we cut this section down to one paragraph or so per WP:WEIGHT?? OrangeMarlin 21:21, 13 October 2008 (UTC)

Agree. Given it duplicates Treatment for depression, there's no reason to go into much detail in this article. --Ronz (talk) 21:41, 13 October 2008 (UTC)

Yeah, good point. we did a bit but should do some more. Cheers, Casliber (talk · contribs) 22:35, 13 October 2008 (UTC)

Let me take a pass. I need to work on a real article for awhile. OrangeMarlin 22:46, 13 October 2008 (UTC)

Go for it (sigh of relief) - bit busy off keyboard..Cheers, Casliber (talk · contribs) 23:05, 13 October 2008 (UTC)

I'm always suspicious of the CAM sections of any medical article. Most of us ignore it, so it just is filled with stuff. I reviewed each of the citations, and few, if any, supported the statement in the article. In fact, there is no evidence that Omega-3 or tryptophan have any effect on any type of depression. Light therapy has an effect on seasonal disorder, but not on depression, specifically because they couldn't do any trials long enough to determine if it could work. St John's wort may work for major depression, but the pharmaceutical quality of the herb in your local store is so variable, that it probably shouldn't be used. I deleted the stuff that obviously doesn't work. OrangeMarlin 23:32, 13 October 2008 (UTC)

(Back again for a sec)..where I am the connection is so damn slow, just what I need when trying to look at a )^*$&)#(#%( large article....Cheers, Casliber (talk · contribs) 23:51, 13 October 2008 (UTC)

What do you have down there for internet connection, a tin can and string? OrangeMarlin 00:00, 14 October 2008 (UTC)

Nice bit of pruning there; article now at 51 kb readable prose...any other problems?Cheers, Casliber (talk · contribs) 09:24, 14 October 2008 (UTC)

←I wasn't happy about the changes to the section. They were weasel-worded and often outside of what was written in the citations. I reverted. I'm doing some copy editing--I'm finding some redundant prose, that need some work. I think it will help out. OrangeMarlin 17:15, 14 October 2008 (UTC)

I certainly don't want an edit war, but I'm a bit puzzled at OrangeMarlin's changes. He is insisting on, "Other supplements such as omega-3 fatty acids, tryptophan, and 5-hydroxytryptophan (5-HTP), no effect beyond placebo." And yet reference states in the abstract, "Available evidence does suggest these substances are better than placebo at alleviating depression", referring to Trypt and 5-HTP. And again, he is insisting on, "Exercise has shown to have moderate, but not statistically significant, effects in reducing the symptoms of depression." Reference states in the abstract, "Exercise seems to improve depressive symptoms in people with a diagnosis of depression, but when only methodologically robust trials are included, the effect sizes are only moderate and not statistically significant." In short, the sources are drawing the conclusion that there probably are effects but that more studies are needed, whereas the current wording is drawing the conclusion that there probably are not effects. Looie496 (talk) 17:22, 14 October 2008 (UTC)

Dude, I have no patience for this type of discussion. Abstracts are useless. The conclusion states clearly that they have no effect beyond placebo. OrangeMarlin 17:35, 14 October 2008 (UTC)

What you're saying in effect is, the way that the authors summarized their findings is useless, I can summarize them better myself. Anyway, I'm going to leave it there until Casliber can express an opinion on this. Looie496 (talk) 17:51, 14 October 2008 (UTC)

The writer's conclusions are what I used. OrangeMarlin 17:53, 14 October 2008 (UTC)

Just to further waste my valuable time, here's what the authors say about Omega 3 in their conclusions: "The evidence available provides little support for the use of n-3 PUFAs to improve depressed mood." I believe that summarizes it perfectly. Using non-weasel wording, with clear writing, as I have done, Omega 3 is useless for MDD. OrangeMarlin 17:56, 14 October 2008 (UTC)

OM has a point - we always forget abot effects like placebo effect and regression to the mean etc. so caution is advised. I will have a look myself a bit later but need to hop off again - brekfast/coffee/dog walk beckon...Cheers, Casliber (talk · contribs) 20:26, 14 October 2008 (UTC)

Looie, stuff like The presence of funnel plot asymmetry suggested that publication bias was the likely source of heterogeneity. doesn't look good (i.e. the studies which showed no benefit weren't published)....still looking. Cheers, Casliber (talk · contribs) 13:43, 15 October 2008 (UTC)

I think have shown no effect beyond placebo is best solution as it states exactly that. The omega 3 does say they are of little use and then leaves the door open a little (tantalizingly or annoyingly I guess, depending on how you look at it) WRT more data required yada yada yada. FWIW - the whole shebang can be read from a link here. Cheers, Casliber (talk · contribs) 14:07, 15 October 2008 (UTC)

Diagnosis section

I'm having some issues with this section. First of all, the title of the section, "Physical investigations" is kind of weird. Sounds like a UFO investigation. :D Also, what's a medical practitioner? A nurse practitioner? A physician's assistant? A registered nurse? A physician? In the US, in a managed care environment (about 95% of health care), a "primary care" physician usually makes the first diagnosis of depression. In children, that's a pediatrician, in adults, an internist. Can't we just write physician, who is the only person that can prescribe medications? OrangeMarlin 17:20, 14 October 2008 (UTC)

Physician in Oz means someone who is an internal medicine specialist (eg neurologist, gastroenterologsit etc.) i.e. not GP or family doctor really, medical practitioner is standard word for doctor here, hmmm...how about (gasp) "doctor"? Cheers, Casliber (talk · contribs) 20:18, 15 October 2008 (UTC)

How about Primary Care Physician? Doctor might work, but it's fairly generalized. OrangeMarlin 18:33, 17 October 2008 (UTC)

I guess if that is the only common mutually understandable term, then so be it..(?) you guys don't say GP or family doctor (although the later is a bit informal)? Cheers, Casliber (talk · contribs) 18:36, 17 October 2008 (UTC)

GP is hardly used anymore. Mostly, in US managed care, the Primary Care Physician (PCP) is the gatekeeper to healthcare, including prescriptions, diagnostic testing, hospital admission, and referrals to specialists (including headshrinkers). The PCP is almost always Internist (Internal Medicine), Ob-Gyn, or Pediatrician. Again, taking a US perspective, a medical practitioner is so generic and nonspecific, that when I read it, I was a bit confused. Maybe medical doctor is the best term. OrangeMarlin 18:47, 17 October 2008 (UTC)

MEDMOS

I'm kind of anal-retentive (I wonder if that's in DSM IV?), so I'm rearranging to meet WP:MEDMOS, especially if this article is going to be FAC'ed, there are many editors (myself included) who think that all medical articles should meet that standard. I tried to read over some of the comments to see if this was discussed, and I didn't see it anywhere. So, if this has been discussed, and there was some reason to not use MEDMOS, then I'm all right with it, and I'll find some drug to treat my retentiveness. Is there a drug? OrangeMarlin 17:33, 14 October 2008 (UTC)

Alcohol works pretty well. But seriously, I had intended to make it comply with MEDMOS (oh where did I go wrong...)...Cheers, Casliber (talk · contribs) 20:19, 14 October 2008 (UTC)

At first I didn't like MEDMOS, but I like the consistency. And it walks us through the story in a logical manner. OK, now I've got to go turn on the fireplace...it's cold here this morning. OrangeMarlin 14:29, 15 October 2008 (UTC)

Kierkegaard

Is everyone okay with the Kierkegaard image in the causes section? I added this picture, of an existential philosopher, after delldot pointed out that the earlier picture, of existential psychologist Rollo May, was unsourced. But if this seems like too much of a stretch (which I tried to compensate for in the caption), I could replace this image with a picture of a more famously psychological/psychiatric figure, such as Freud. Cosmic Latte (talk) 23:00, 17 October 2008 (UTC)

I do think it is a bit tangential, and a photo of someone more directly involved so to speak would be preferable - this is a hard article to illustrate...Cheers, Casliber (talk · contribs) 12:10, 18 October 2008 (UTC)

I went ahead and added a picture of Freud instead. Will this be all right? It's too bad that there don't seem to be any PD images of Beck or Bandura out there. Cosmic Latte (talk) 04:08, 19 October 2008 (UTC)

Yeah, images are tough. Good as any. Cheers, Casliber (talk · contribs) 08:46, 19 October 2008 (UTC)

Lonelyness is not mentioned

But the word "guilt" is used 5 times. 11:45, 27 October 2008 (UTC) —Preceding unsigned comment added by 68.187.233.197 (talk)

In response to this, I've come up with the following passage:

Depression and loneliness have enough features in common that loneliness may be viewed as a differential diagnosis. In general, depression is likely to coexist with loneliness if the loneliness is chronic rather than transient. If the patient has global concerns that do not focus strictly on interpersonal relationships, if the patient feels a high degree of guilt, or if the patient is particularly vegetative, then he or she is likely to be depressed; if these conditions are not met, he or she may be lonely instead.

Should it be added to the article? If so, where?

As for guilt being mentioned more often, note that my source states that "guilt appears to be more typical of depression than loneliness." Cosmic Latte (talk) 03:10, 28 October 2008 (UTC)

I've gone ahead and added it to Major_depressive_disorder#Differential_diagnoses, but feel free to remove it if it's misplaced or too much text. Cosmic Latte (talk) 15:55, 28 October 2008 (UTC)

Religious faith

From FAC:

This statement noted by Tony as being from a questionable source is still in the article. I am concerned also that many of the sources in this article similarly are very old and/or reference a single study. I am trying to correct some of them, where the sources are accessible, to clarify the meaning in the article in the context of the reference. —Mattisse (Talk) 14:51, 30 October 2008 (UTC)

I don't see why a loss of religious faith would be any less depressing now than it was 36 years ago, at least in individuals for whom faith had been their primary source of meaning. I do wonder which is more often the cause and which more often the effect (e.g., I can picture something like, X --> MDD --> blame/doubt God --> lose religious faith), but if "lose religious faith --> MDD" is sourced, then it at least jives with what I'd call common sense or intuition. Cosmic Latte (talk) 15:07, 30 October 2008 (UTC)

The point is not what you or I think now, but rather that the reference to a statement given prominence in the section is from one questionable source, the Journal of Religion and Health, and is 36 years old. —Mattisse (Talk) 15:18, 30 October 2008 (UTC)

It looks like the journal is still taken reasonably seriously, e.g., , , . In any event, my point was that there is no reason to assume that the veracity of the referenced finding has changed in the past 36 years. Questioning the finding on account of its age raises the question, "why?"--and I, for one, don't see a reason why the finding would be dated. And as it's worded now, "A depressive episode may also be related to a loss of religious faith," without implying cause or effect, and placed after other components of MDD and directly before a statement that cause and effect are unclear, I certainly don't think it's being given any undue prominence. Cosmic Latte (talk) 15:34, 30 October 2008 (UTC)

I refer you to Tony's comment that the source is not mainstream in the field. The links you give are not reliable sources as to the mainstream importance of the journal. Further, the text in one of your links says: "The Journal of Religion and Health explores the most contemporary modes of religious thought with particular emphasis on their relevance to current medical and psychological research." Current medical and psychological research is not 36 years ago. In medically-related field, recency counts. References to such statements should be to recent review articles (within the last few years). Further discussion of this should move to the talk page. —Mattisse (Talk) 15:56, 30 October 2008 (UTC)

--

The source may not be mainstream, but it is an independent publication expressing, in this case, the argument of a MD/PhD psychiatrist, namely Nancy Coover Andreasen, who is extremely well-renowned. Barring the discovery of some source that refutes the thesis that depression and a loss of religious faith may be related, I really think it's appropriate to let this be. Cosmic Latte (talk) 16:40, 30 October 2008 (UTC)

Reading the beginning of Andreasen's article, she does not say that a depressive episode may be related to a loss of religious faith. She says depression may be expressed in the form of exaggerated guilt experienced by people who worry that they have committed sins or who have feelings of estrangement from God, or in the form of feelings of torment from punishment by an angry God. She is suggesting that if the symptoms of depression are expressed in the form of religious concerns, the best way for a sensitive therapist to proceed is to be flexible and attempt to separate genuine religious concerns from the symptoms of depression. It appears that the article is not research but an opinion piece and makes sense in that context. But Tony's point was also that a great many things may impact depression, as the Major depression article indicates, and is loss of religious faith one of the most frequent and foremost causes? Where is the evidence that it is? —Mattisse (Talk) 17:58, 30 October 2008 (UTC)

My access is limited to the first page of the article, so I assumed that whoever added the reference had read the entire piece. The closest thing I saw to "loss of religious faith" was "estranged from God and from all the wellsprings of meaning, hope, and love." I'd have no problem with changing "loss of religious faith" to "a feeling of estrangement from God" or "estrangement from the divine" or "religious alienation" or something along those lines, but I don't think that it needs to be demonstrably "one of the most frequent and foremost causes," largely because we're not necessarily talking about causes in the first place--the article is explicit about cause and effect being difficult to discern. My thinking here is that, regardless of the stats, this is qualitatively justified for inclusion (albeit perhaps in a reworded form), because 1) given that so many people are religious, of all the things that could be associated with depression, surely religious alienation is among the most appreciable; and 2) the author is clearly a respectable source of information, even opinion. But again, I have no objections to altering the phrasing so that our article is undoubtedly consistent with hers. Cosmic Latte (talk) 18:22, 30 October 2008 (UTC)

I have a "take it or leave it" feeling about the ref, oftentimes in mental health people used to talk about religion being a protective factor (so intuitively I can confirm it is something on folks' radar so to speak), and Andreasen is a well-recognised name in psychiatry (though more in schizophrenia). I figure one sentence in 50 kb of prose isn't undue weight but wouldn't fuss if it was removed either. Cheers, Casliber (talk · contribs) 23:32, 30 October 2008 (UTC)

I see that Mattisse has removed it, but I came across essentially the same finding--just not stated as eloquently as in Andreasen's piece--in the abstract to a 2000 Journal of Clinical Psychology article. Can we settle for this? Cosmic Latte (talk) 04:07, 31 October 2008 (UTC)

Some FAC notes: crit 2c of WP:WIAFA requires consistently formatted citations. Introducing a raw URL is going the wrong direction. And, the URL was to an abstract on a personal website rather than a PMID abstract. I corrected the citation to point at PubMed, but the edit also added text sourced to a primary study. The article should be sourced to high quality secondary sources or reviews. To find reviews in PubMed, please take note of the Review tab, next to the All tab, under the display button when searching in PubMed. Misplaced Pages:Misplaced Pages Signpost/2008-06-30/Dispatches explains how to search for reviews in PubMed. We can't just string together conclusions from primary studies: that's original research. For example, compare PMID 11132565 (not a review) with PMID 11077021 (is a review). To find recent reviews on MDD in PubMed, search on Major depressive disorder, and then click on the "review" tab instead of the "all" tab. There are 2800 reviews on MDD in PubMed; text that can't be sourced to secondary reviews might not belong in the article. A Pubmed search on "Major depressive disorder religion" yields seven review articles: those are secondary sources. SandyGeorgia (Talk) 05:08, 31 October 2008 (UTC)

1: Lassnig RM, Hofmann P. Wien Med Wochenschr. 2007;157(17-18):435-44. Review. German. PMID 17928946

2: Pilkington K, Kirkwood G, Rampes H, Richardson J. Yoga for depression: the research evidence. J Affect Disord. 2005 Dec;89(1-3):13-24. Epub 2005 Sep 26. Review. PMID 16185770

3: Shannahoff-Khalsa DS. An introduction to Kundalini yoga meditation techniques that are specific for the treatment of psychiatric disorders. J Altern Complement Med. 2004 Feb;10(1):91-101. Review. PMID 15025884

4: Sullivan MD. Hope and hopelessness at the end of life. Am J Geriatr Psychiatry. 2003 Jul-Aug;11(4):393-405. Review. PMID 12837668

5: Storck M, Csordas TJ, Strauss M. Depressive illness and Navajo healing. Med Anthropol Q. 2000 Dec;14(4):571-97. Review. PMID 11224981

6: Bilu Y, Witztum E. Culturally sensitive therapy with ultra-orthodox patients: the strategic employment of religious idioms of distress. Isr J Psychiatry Relat Sci. 1994;31(3):170-82; discussion 189-99. Review. PMID 7532632

7: Wells VE, Deykin EY, Klerman GL. Risk factors for depression in adolescence. Psychiatr Dev. 1985 Spring;3(1):83-108. Review. PMID 3889900

And I assume text isn't being cited to abstracts only, rather the entire journal article has been read. To find review articles with free full-text, click on "Limits" in PubMed, check the reviews box and check the Free full-text box. SandyGeorgia (Talk) 05:22, 31 October 2008 (UTC)

I found PMID 16924349 by searching with limits on reviews and free full text for "depression religion"; you can access the free full text from the link in the PMID. SandyGeorgia (Talk) 05:34, 31 October 2008 (UTC)

Romantic artist

Since Aristotle, melancholia had been associated with men of learning and intellectual brilliance, a hazard of contemplation and creativity. The newer concept abandoned these associations and, through the 19th century, became more associated with women - While it is true that diseases of the "nerves" became associated with women during the 19th century, I'm wondering just how disassociated depression became from "men of learning and brilliance". Part of the myth of the Romantic artist is that he is a tortured soul - see, for example, John Keats and his "Ode on Melancholy". It is, of course, ironic that the article begins with an image by Vincent Van Gogh, who perfectly illustrates this type. If you need sources that describe this phenomenon, I'm sure I can dig some up. Awadewit (talk) 18:11, 2 November 2008 (UTC)

Interesting issue and more sources would be good. The timing/causation is a bit unclear; the current source is focused on the adoption of the actual term "depression" and says:

Second, for hundreds of years, influenced by Aristotle and almost every subsequent thinker until the eighteenth century, melancholia also carried glamorous associations of intellectual brilliance and later even genius, associations absent from today's conception of depression (Klibansky, Panofsky, and Saxl 1964). It was the disease of the man of learning, the disposition and occupational hazard of the intellectual and of any man of reflective and contemplative tendencies. Such desirable associations are absent from today's conception of depression.

Next, melancholia was the disorder of the man (of genius, of sensitivity, intellect, and creativity), whereas today's depression is both apparently linked with women in epidemiological fact and associated with the feminine in cultural ideas. Depression's gender link is the reverse of the masculine and male associations of melancholia.

These last two are, of course, connected. Because genius, creativity, and intellectual prowess were themselves "gendered" traits associated with men and the masculine, the perceived link between women and depression, a product of the nineteenth century, inevitably expunged these more glamorous associations (Enterline 1995; Lunbeck 1994; Radden 1987, 2000a; Schiesari 1992).

It does seem an exaggeration to say they were "expunged" even today (cf Sylvia Plath as mentioned below); perhaps in formal medical usage. EverSince (talk) 21:27, 2 November 2008 (UTC)

I don't think Sylvia Plath is a typical example. Rather, the romanticizing of her story, perhaps because of its timing during the rise of feminism, is the exception that proves the rule. Remember, Ted Hughes was the bad guy they said then. I do think that depression has lost its glamor, as the section on British literary figures shows. William Styron did not try to glamorize depression when he wrote about it, and we have no quotes from him in this article. Statistics are uniform in showing that women are more afflicted by depression then men today. And the articles you reference below appear to address this issue. —Mattisse (Talk) 21:43, 2 November 2008 (UTC)

I find that there is some vagueness in the source's language. The sources seems to want to link depression to women and femininity without distinguishing much between the two. (Sex and gender are different and I as a woman, for example, can adopt masculine traits, but I cannot be a man.) Did you want me to find sources that discuss the Romantic artist and depression/melancholia? Awadewit (talk) 19:54, 4 November 2008 (UTC)

Gender bias?

How come the article only lists famous men with depression in the "Sociocultural aspects" section, especially considering the disease statistically affects more women? If you are looking for a depressed female artist, try Mary Wollstonecraft or Mary Shelley. There are more. Those I happen to know I could get sources for. :) Awadewit (talk) 18:23, 2 November 2008 (UTC)

Good point! I also note that neither of those are listed in List of people with depression. /skagedal 18:39, 2 November 2008 (UTC)

Also, the mention of hormone replacement for men is mentioned but nothing about all the research being done in the field for hormone replacement for for women, now that giving estrogen for depression and other symptoms is no longer considered safe. The editor dismissed the mention of this by a commenter, saying he had not encountered it. But there are all sorts of substitutions for estrogen being researched, including nasal sprays that affect dopamine receptors in the brain. —Mattisse (Talk) 18:42, 2 November 2008 (UTC)

Regarding adding more British literary figures, although I would agree with that females should be included, there is already a huge British bias to the article, including a section on British literary figures, while literary figures from other countries are ignored, for the most part. —Mattisse (Talk) 18:50, 2 November 2008 (UTC)

Virginia Woolf would probably be a good example, since she suffered very severely from it. Looie496 (talk) 19:02, 2 November 2008 (UTC)

And as a non-British figure, William Styron is probably worth mentioning, since he actually wrote about depression in "Darkness Visible". Looie496 (talk) 19:04, 2 November 2008 (UTC)

What about Emily Dickinson? Kate Chopin? Awadewit (talk) 19:14, 2 November 2008 (UTC)

Sylvia Plath? Fainites 19:51, 2 November 2008 (UTC)

• Misplaced Pages:MEDMOS#Notable cases: "One restriction that some editors favour is to include only those individuals who have lastingly affected the popular perception of a condition." SandyGeorgia (Talk) 19:53, 2 November 2008 (UTC)

• I would favor including substitutions for estrogen being researched for women rather than just mentioning men and testosterone, for example (as mentioned above) studies on estrogen research, including nasal sprays that affect dopamine receptors This is an example of bias in the article that another commenter brought up on the FAC page. —Mattisse (Talk) 20:12, 2 November 2008 (UTC)

One issue I have with historical people, or in reported media etc. with a psychiatric condition is that I get a sense that some reported mood disorders (whether depression or bipolar) actually sound like other conditions (eg personality disorder) when symptoms are listed, but it is hard to diagnose when the person has been dead for hundreds of years. I would be more than happy to include some women (and should have noticed this before), but it goes without saying that the source needs to be peer-reviewed/academic etc. A psychiatric historian would be great. Woolf and Plath come to mind as highly notable for their connection with psychiatric conditions, and there are likely to be others. If someone can find a scholarly source that would be great. I'd love the help :)

WRT hormone therapy, some form of review paper would be good. I will ask and look around. Cheers, Casliber (talk · contribs) 13:25, 3 November 2008 (UTC)

PS: I had not been aware of Mary Shelley or Wollestonecraft being linked with depression (but then again, I have not read much about either), Awadewit, if there is a detailed analysis that may be interesting. Cheers, Casliber (talk · contribs) 13:28, 3 November 2008 (UTC)

First, let me say that the MEDMOS guideline is terrible! Put that on my list to change. The "popular perception" of a disease is often horribly misinformed. Moreover, the list of people who have "lastingly" affected any historical narrative of a disease is a result of the way historians tell that narrative. Considering that until the 1970s, historians were loathe to consider women important in history, women are often not a part of that narrative. Should we therefore be perpetuating that here? I really hope not. (Now that's off my chest....) Second, the information I have on Wollstonecraft and Shelley does not come from psychiatric historians, I'm afraid, nor have I read any in-depth analyses of their states of mind. As you say, it is difficult to diagnose someone two hundred years after their death, particularly of a psychiatric disorder. However, Wollstonecraft did attempt suicide. Twice. Her letters are horrifying to read. Anyway, the sources I have are modern biographies written by historians and literary scholars. If you don't want to use those, I would understand. Awadewit (talk) 20:27, 4 November 2008 (UTC)

Well, given the depth of it, and the fact that there is a 3rd party commentary and discussion on the topic, go for it. The points you raise are valid.:) or should that be :( (depressed emoticon) Cheers, Casliber (talk · contribs) 20:50, 4 November 2008 (UTC)

Biopsychosocial developmental perspective

There's a couple of recent reviews on the emergence of major depression in adolescence, giving an integrative perspective that I think could be represented more in the causes section here. I'm suggesting first here 'cos of the word count constraints.

"The emergence of depression in adolescence: Development of the prefrontal cortex and the representation of reward" summarizes 3 recent models put forward - the social information processing network model, The triadic model, and the dysregulated positive affect model. The review extends these into a more specific explanatory model that "integrates findings from epidemiology, adolescent ethnography, phenomenology, descriptive psychopathology and the developmental, cognitive and affective neurosciences", and addresses the links between "substantial remodeling and maturation of the dopaminergic reward system and the prefrontal cortex during adolescence" and "the adolescent entering the complex world of adult peer and romantic relationships" described as "a period of particularly high interpersonal stress, associated especially with the establishment and maintenance of the kind of social reputation that will enhance social acceptance and reduce the likelihood of rejection and ostracism. Adolescent relationships as a whole are marked by an increase in depth and complexity. Compared to childhood relationships, they take more effort, and are nested in more complicated social structures that make them less stable and necessitate the development of important new skills to navigate them."

"Stress, sensitive periods and maturational events in adolescent depression" intro's with "The overriding issue of this review is to understand why depression emerges with such force and frequency in adolescence, particularly in young women. Conceivably, a host of psychosocial factors can render adolescents especially vulnerable, but our focus will be on neurobiological factors. In particular, we will examine the interplay of genetic, maturational and experiential factors affecting mood using a translational perspective that melds clinical and basic laboratory findings."

I think a sense of the above could be given in the initial causes bit before the subsections; the first article itself suggests links to the evolutionary perspective that's already mentioned there. In the process the article's current tendency to dualism (incl. in the lead) could be tempered. EverSince (talk) 20:57, 2 November 2008 (UTC)

Unfortunately, I cannot access the complete articles, but PMID 18329735 does mention "gender differences" and you quote "The overriding issue of this review is to understand why depression emerges with such force and frequency in adolescence, particularly in young women." As I mention in the section above (concerned with gender bias in the article), substitutions for estrogen replacement in women are being researched, including nasal sprays that affect dopamine receptors in the brain. I think the issue of gender differences needs to be addressed more forcibly than it is in the article. PMID 17570526 says: "Adolescent development is accompanied by the emergence of a population-wide increase in vulnerability to depression that is maintained through adulthood." These sound like two very interesting articles that, as you say, could allow this article to present a more integrated perspective than scattered statements that are not hooked together meaningfully - dualism, as you say. —Mattisse (Talk) 21:27, 2 November 2008 (UTC)

I have always found the literature on depression (especially review/overview articles) light on analysis of depression in women - which has been frustrating for this article as there are lots of bits and pieces of research, but not much is taken into big overviews. One of course could speculate this may have something to do with the gender of the researchers (top end that is), and political issues - e.g. I was always mindful of the anecdotal incidence of dysphoria in women taking OCP and whether in a large number (say, 50% of the popualtion of reporductive age, as I think was quoted at one point taking it), how many vulnerable were tipped from subclinical to clinical mood disorder. OTOH, states like menopause and childbirth have huge psychological and social implications for many women (even leaving out biology). Anyway, I did work with Christohper Davey briefly a few years ago so I can get complete versions of these. Cheers, Casliber (talk · contribs) 23:15, 2 November 2008 (UTC)

Yes, it is interesting reading through the talk page archives. The issue of sex differences never appears to have been discussed. Many of the articles abstracts linked there do not even break down subjects by sex. —Mattisse (Talk) 03:12, 3 November 2008 (UTC)

Well that may have something to do with the gender of the editors editing the article. :) Cheers, Casliber (talk · contribs) 04:16, 3 November 2008 (UTC)

I notice now that a point I added about childhood disadvantage potentially affecting women more was deleted on 26th Oct, and needs to be reinstated. Reminds me also to put the gender stats on completed suicide in the context of the different picture from suicide attempts and self-harm (e.g. PMID 18341543 Case survey, PMID 18470773 Psych impairmnet). Re. the reviews above, the second refers to onset coinciding with menarche suggesting hormonal mechanisms, a subtype associated with anxiety, sleep/appetite disturbances and fatigue, and "they can also experience more body image dissatisfaction, feelings of failure, concentration problems and work difficulties." and "adolescence is associated with sexually dimorphic pruning of synapses and signaling mechanisms in brain regions implicated in depression. The emergence of depression during adolescence might result, in part, from either insufficient overproduction or enhanced pruning of these brain regions. Estrogenic effects might further exacerbate these processes." The first review refers to "consistent with the proposal by Cyranowski et al. (2000) that this difference emerges because of the heightened “affiliative need” of women that is driven by social and hormonal influences that operate from puberty. The suggestion is that affiliative rewards have more salience for women, who are subsequently more likely to be disappointed by the frustration of these needs (Allen and Badcock, 2003; Allen et al., 2006). Interestingly, there is evidence that the prefrontal gray matter changes that occur in adolescence begin earlier for females, which may account for some of the difference in vulnerability between the genders." This is all quite far removed from the wider cultural contexts and power dynamics of course; tried to cover that a bit in history & link on women refugees in sociocultural aspects, but needs more there as mentioned. EverSince (talk) 15:20, 3 November 2008 (UTC)

p.s. Toward a Comprehensive Developmental Model for Major Depression in Women (2002) -- Toward a Comprehensive Developmental Model for Major Depression in Men (2006) EverSince (talk) 11:41, 4 November 2008 (UTC)

Interesting two studies nice big ones, notable authors, funny I haven't seen them before - but they don't really say too much not covered thus far, and there is little gender-specific apart from a link with early-onset anxiety disorder with women (which I have not seen recorded elsewhere (?), makes me wonder why not) Cheers, Casliber (talk · contribs) 12:58, 4 November 2008 (UTC)

Overdiagnosis

A recent edit in the lead changed the wording from "However, authorities such as Australian psychiatrist Gordon Parker have argued that it is overdiagnosed, and that current diagnostic standards have the effect of medicalizing sadness" to "However, recent trends have overdiagnosed depression with the effect of medicalizing sadness." I do agree with the editor that it might be unnecessary to mention a specific clinician in the introduction, this view is held by more than him. But the new version seems to be saying that overdiagnosing is an objective fact. This is not supported by sources in the article. Is it ok to use weasly wording in the intro, like "Some writers have argued...", when it is clarified later in the article who these critics are? Or how could this be resolved? /skagedal 13:56, 3 November 2008 (UTC)

I was responsible for the first edit and naming Parker, to avoid weasel words, and flag it as it is an important point with some support. He is an authority on mood disorders and has published many papers and books on the subject. His view of medicalisation is supported by many and I have seen concerns of overdiagnosis in psychiatry scattered about the literature. Snowman has changed it to the second. I agree that it is better not to state it as fact as it would still be contested by many in psychiatry. My default option is naming Parker as I doubt we can come up with a non-weasly way of wording it, but I am open to suggestions if one can be found. I need to sleep now as it is v. late here in Australia. Cheers, Casliber (talk · contribs) 14:06, 3 November 2008 (UTC)

PS: I have just moved it out as I reorganized the lead for flow and wasn't sure where to put it at first glance. I really need to sleep now. Cheers, Casliber (talk · contribs) 14:23, 3 November 2008 (UTC)

Might I suggest that somebody add some information to Gordon Parker to support using him here? As it is, the information on that page barely suffices to show notability, much less authority in the field. Looie496 (talk) 17:08, 3 November 2008 (UTC)

This has been a problem with many FACs, as side articles sprout all over the place and you can see what else needs to be added where, just getting the time to add it. He is pretty preeminent, just have to add more material and tehre are only so many hours in the day. Cheers, Casliber (talk · contribs) 22:35, 3 November 2008 (UTC)

The current version reads, "However, depression may be overdiagnosed, and current diagnostic trends arguably have the effect of medicalizing sadness." I think this could work, and doesn't sound weaselly, although I favour mentioning Parker because this statement might be surprising to many, and so it seems to beg for early attribution. It's the sort of statement that, without early attribution, might be dismissed as counterintuitive, or be accepted albeit as in conflict with intuition, or--worst of all--be blindly acknowledged by those who aren't really paying attention. IMO it's an important and divergent viewpoint that the reader should take seriously, and I suspect that it'll be most seriously presented if it's properly attributed early on. Parker is obviously notable, so I don't think it's inappropriate at all to mention him by name in the introduction. Cosmic Latte (talk) 00:16, 4 November 2008 (UTC)

I am sure that Parker is important. There are lots of other important psychiatrists and psychologists and they do not get a mention in the introduction. Even Jung and Freud are not mentioned in the introduction. I think that it would be a mistake to single out one psychiatrist to me mentioned by name in the introduction, just to make a point about "medicalizing sadness". He is mentioned and wikilinked in the main text. The same thing is said in the UK, and I have not heard Parker's name here. It would be better to use inline refs in the introduction to indicate the sources. Snowman (talk) 10:16, 4 November 2008 (UTC)

I think the issue could be framed as a "debate", as there is also a view through the literature that much depression is underdiagnosed - that sufferers aren't being reached or are reluctant to talk about it; that allegedly it can be "masked" by other things like somatic complaints, substance use or behavioral problems esp. in men; that whether or not there are as obvious functional problems, quality of life may still be markedly reduced. The opinion piece Parker is contrasted with makes some points, I note they both have pharma links. Going the other way, I also think the issue of medicalization shouldn't be reduced to equivocations over the cut-off point for diagnosis - it also involves more radical foundational critiques of the entire diagnostic and treatment system as currently formulated and employed within societies (some of which are mentioned in sociocultural aspects) EverSince (talk) 12:41, 4 November 2008 (UTC)

Aargh! So much of this is like the tip of the iceberg, as one needs further and further elaboration to explain how, what and why experts come to conclusions. The trick is where to draw the line I guess. Parker has also argued the whole classification has problems too. Cheers, Casliber (talk · contribs) 12:49, 4 November 2008 (UTC)

True... Regarding Parker yes but at the same time he's ultimately defending medicalized categorical diagnosis, in a retrograde melancholia sense even, and he elsewhere chooses to compare different states of depression with different types of breast lump EverSince (talk) 14:38, 4 November 2008 (UTC)

Examples of truer alternatives that actually address the structural issues - Depression, antidepressants and an examination of epidemiological changes - "The interests of modern industry lead to creation of a docile population that seeks socially sanctioned cures for their ills: in this way, the market economy has molded people’s understanding of their own experience ... If we are to develop a more humane society we must begin to address these problems in their complexity." - and The social problem of depression - "Clients who learn to deconstruct the social roots of their depression or other psychosocial problems may be more likely to become involved in their communities to enact change. ... Further, while we are not arguing that the medical profession is intentionally medicating dissidents or those with alternative political agendas, we may be tranquilizing those who might be more politically active or radicalized if they did find a social explanation for their depression." Time for change in other words. EverSince (talk) 20:05, 5 November 2008 (UTC)

Excellent findings. I'd be all in favour of citing both. Cosmic Latte (talk) 16:27, 6 November 2008 (UTC)

Laboured (?) section

I am musing on first para of Efficacy of medication and psychotherapy section, which has been cited as a little hard to follow and on re-reading comes across to me as possibly a little overdetailed, and could be summarised as follows:

Antidepressants have been shown to be effective in severe depression. However minimal gains over placebo in moderate depression have been interpreted as showing no effect over placebo by some, and as of minor benefit by others.

Need to check and slot in references. Cheers, Casliber (talk · contribs) 13:20, 4 November 2008 (UTC)

I need to go to bed now, was debating whther a sentence on publication bias was essential. Cheers, Casliber (talk · contribs) 13:32, 4 November 2008 (UTC)

Is it "no effect over placebo" or "no clinically significant effect over placebo" with NICE specifying what short of improvement they regard as clinically useful? Colin° 18:44, 4 November 2008 (UTC)

I agree this section spends too much time discussing the debate rather than just giving the reader the facts, if they can be summarised. But let's rewind to the start of the treatment section. What I'd like to know as a reader is what the aims of treatment are, how the treatment is judged against it, and whether it is judged to be effective and worthwhile. Possible aims are:

• To make the person no longer depressed.
• To reduce the level of depressed feelings (measurable on some scale).
• To stop the depression getting worse.
• To reduce the risk of suicide.
• To shorten the period of depression.
• To allow some other therapy to work well (combination treatment).

I'm guessing that unlike many medicines, the first and most obvious aim isn't actually directly achievable. There isn't a magic bullet. All these things can be regarded as an "improvement" but the text doesn't say what it means by improved. In fact the psychotherapy section compares that therapy with medication or with "usual care" whatever that is. But the reader hasn't read about medication yet, nor does he know the natural history. Perhaps the treatment section should begin with a short sentence or so on the typical duration and re-occurrence patterns. Should the medication and psychotherapy sections be reversed? Could the efficacy of each be discussed within each section rather than an add-on section? Should we mention briefly the cut-off used by folk like NICE when working out whether a medicine is useful, to give the reader an idea of what is achievable.

Both treatment sections suffer somewhat from overuse of primary sources. There's really no excuse for multiple citations other than the editor is trying to strengthen the case by citing more examples. The text could also be improved by mentioning studies/reviews less and just presenting the facts. One particular problematic sentence is "Overall, systematic review reveals CBT to be an ". A systematic review is just a form of article. The review presented the results of a meta-analysis, which was the instrument that "revealed" CBT's attributes. But unless we are writing about history or how research is conducted, I think we should just confidently state "CBT is an effective treatment in depressed adolescents" and cite the best source we have.

Sorry this is a bit rushed. Got to go. Colin° 18:44, 4 November 2008 (UTC)

I agree with Casliber about summarizing the efficacy section, as done above, and about adding a bit on publication bias. I also agree with Colin about stating the aims of treatment. (I wish Paul were around to comment, too.) But I think that all of these things--along with any aspects of the efficacy section that we'd like to save--should be integrated into the psychotherapy and/or medication sections, rather than left in an efficacy section that begs for far more elaboration than we can give it in this article (e.g., actual efficacy vs. placebo, spontaneous remission, regression toward the mean, etc.). I think that the appropriate place to keep and expand this section is in Treatment for depression, into which that section was already merged a while back. Cosmic Latte (talk) 09:56, 5 November 2008 (UTC)

As it stands, though, there's sure a lot of text devoted to the sheer fact that both medication and psychotherapy leave something to be desired. As Colin put it on FAC, "The spat between the two 'authors' seems like 'A: Drugs are a bit rubbish. B: Depends what you mean by rubbish. Oh and psychotherapy isn't any better.'" Cosmic Latte (talk) 09:59, 5 November 2008 (UTC)

Good to see we all agree on a change and what needs to be done, I had intended getting stuck into it but got diverted by Vassyana's comments, among which were some very good suggestions. Anyway, access has been slow (all the election hits???) and it is 12:30 am here...I need to sleep. Sorry guys. Cheers, Casliber (talk · contribs) 13:40, 5 November 2008 (UTC)

I've tried to tighten the section a bit, but I still think it needs to be replaced or integrated or just completely reserved for Treatment for depression, where it can be given adequate treatment. Cosmic Latte (talk) 16:09, 6 November 2008 (UTC)

How about trimming that section down to the following...

Antidepressants in general are as effective as psychotherapy for both severe and mild forms of major depression. The subgroup of SSRIs may be slightly more efficacious than psychotherapy. On the other hand, significantly more patients drop off from the antidepressant treatment than from psychotherapy, likely because of the side effects of antidepressants. Successful psychotherapy appears to prevent the recurrence of depression even after it has been terminated or replaced by occasional booster sessions. The same degree of prevention can be achieved by continuing antidepressant treatment.

...and merging that with the main "medication" section, perhaps tacking it onto the end? Cosmic Latte (talk) 17:47, 6 November 2008 (UTC)

Image question

I have been searching through commons and this image of Freud could be useful: ]. I dont think it has any problems since the author and date of death are stated, but could somebody confirm it?--Garrondo (talk) 17:14, 5 November 2008 (UTC)

Yep, that's PD-US. Good work! Cosmic Latte (talk) 17:39, 5 November 2008 (UTC)

I think if there is an image of Freud there should also be an image of C.J. Jung for balance. Snowman (talk) 18:01, 5 November 2008 (UTC)

To Garrondo, It is easy to forget to do an edit summary, but I have noticed that several of your recent edit summaries are short or nil. It would be easier to follow the changes, if you wrote adequate edit summaries, as per wikiguidelines. Snowman (talk) 18:16, 5 November 2008 (UTC)

It's so easy I forget many times; also because I am not to used at working at an article with som much traffic. I'll try--Garrondo (talk) 18:39, 5 November 2008 (UTC)

An image of Jung might be appropriate if Jung were even mentioned in the article... Cosmic Latte (talk) 18:22, 5 November 2008 (UTC)

My intention is only to give "color" to the article. I do not really think that Jung should have its image in the article; specially since it is really not so easy to find copyright-suitable pictures...--Garrondo (talk) 18:37, 5 November 2008 (UTC)

I'd go ahead and add the Freud image to the "Psychological causes" section, perhaps with a caption similar to the one we had before. (Indeed, there was a different Freud image there previously, but it was removed due to PD concerns.) Cosmic Latte (talk) 18:46, 5 November 2008 (UTC)

I think that the image showing a group of several famous people important in psychoanalysis is better. It does include Jung and others, and it has an appropriate copyright apparently. Snowman (talk) 20:23, 5 November 2008 (UTC)

I can go with either..gawd, we've proably got space for both XD. I am sure the Freud image will get well worked on more articles across WP :) Cheers, Casliber (talk · contribs) 21:01, 5 November 2008 (UTC)

PS: Agree with note about edit summaries above - I have been trying to elaborate as much as possible in them (unless really tired!) due to the delicate stage things are at currently. Cheers, Casliber (talk · contribs) 21:01, 5 November 2008 (UTC)

Why do we need a picture of any psychiatrist or "famous people important in psychoanalysis". Are we to litter every topic in psychiatry/psychology with his portrait? It's not as though any of these people discovered depression. Colin° 21:13, 5 November 2008 (UTC)

Well, I was only suggesting a group, because someone suggested Freud, on his own. The group photo might provide easy to find links to other pages of people. Having no images of people would be ok with me too. I am not sure that the photo of Samuel Johnson, does anything for the page. It might be interesting to have a photo of an ECT box.

I protest the use of Samuel Johnson's photo. He is already mentioned in two separate sections of the article, and I was not aware that he was important to our understanding of depression or had an impact on the history of the diagnosis. There is already an over emphasis (from my point of view) on British literary figures that seems strange to me, leaving out the issue of representing a world wide view. —Mattisse (Talk) 21:48, 5 November 2008 (UTC)

I think the Samual Johnson image should be removed too, and it is largely irrelevant, and he had a movement disorder, which may be complicating the appearance or the impression the artist formed. There is a "list of people with depression" linked, from which one can find dozens of more links to notable peoples articles. Snowman (talk) 23:10, 5 November 2008 (UTC)

I have no problem if the Johnson image goes - the main reason for some more tangnetially related people is the lack of Public Domain or permission-given images to use...and how do you take a photo of therapy anyway? Or getting permission from a patient etc. I am quite happy to avoid pix of ECT material as I think as it is a rare treatment its role does not need to be emphasised any more than it is already. I think one of Spitzer would be important as he led the group which came up with term in 1980. Cheers, Casliber (talk · contribs) 23:28, 5 November 2008 (UTC)

I support using the image of Freud for the sheer reason that Freud is mentioned in the article (same goes for Johnson). The article doesn't present the opinion of everyone involved in the formation of psychoanalysis, nor does it present the views of everyone in the group photo, one of whom was not even a psychoanalyst. G. Stanley Hall simply invited Freud to give a lecture, as far as I am aware. In any case, this is a long article with a lot of text. Even the most technical of textbooks is often decorated with an illustration or photo on every other page or so. Cosmic Latte (talk) 04:38, 6 November 2008 (UTC)

I'm a huge fan of Jung, by the way, but just how tangential do we want to get? Cosmic Latte (talk) 04:41, 6 November 2008 (UTC)

Per same reasons as Cosmic Latte: I prefer to have a bit tangential images than non having any, and I feel the Freud image is a good one, and the Samuel Jonshon does no bad; however if anybody finds any other interesting images I would be greatly please to change them. The truth is that there is no need really for ANY of the images of the article, and the same could be said for the 99% of images in wikipedia and any other encyplodia. The reason to include them is not a need, but an interest to make the article easier to read, and therefore most images are as valuable as any other. Regarding the debate between the group picture and the Freud picture: the only psychoanalitic author named in the article is Freud, not all others, so I feel is a better ilustration. Apart from that there could be some aesthethic reasons since the quality of the Freud picture is much higher (have any of you tried to zoom the group picture?). Regarding sociocultural aspects how about changing Samuel Jonshon by Stuart Mill? He is more commented in the sociocultural aspects section?--Garrondo (talk) 08:46, 6 November 2008 (UTC)

For me, it is not a show stopper either way. Anyway, perhaps the caption of SJ could be expanded tangentially, like the one of a person on the Schizophrenia page, to make it more tangentially interesting. Snowman (talk) 09:31, 6 November 2008 (UTC)

I have been thinking, maybe there is some sort of therapy picture, I have been looking on commons but nothing interesting has come up yet. Cheers, Casliber (talk · contribs) 10:50, 6 November 2008 (UTC)

I tried to do a similar search a few days ago but I wasnt able to find anything interesting.--Garrondo (talk) 11:03, 6 November 2008 (UTC)

I'd be in favour of adding a picture of Mill--maybe in addition to the Johnson one--but I'm not sure if this picture of him is sourced properly enough. "Someone during 19th century" isn't really much of an attribution, although the rest of the sourcing leaves little doubt that it's PD-US. Cosmic Latte (talk) 14:40, 6 November 2008 (UTC)

Why the insistence on more images of British persons who did not have a significant impact on the history or understanding of depression but are merely decorative? Johnson is already mentioned in two different sections of the article gratuitously, as he has no particular relevance to Major depressive disorder, and where is the evidence that was his diagnosis? Does he meet the DSM criteria? He has already been retrospectively diagnosed with Tourette's syndrome. How many retrospective diagnoses are we going to give him? Considering the over emphasis on British literary persons in this article, this would increase the WP:UNDUE, and increase the British/Australian bias of the article. To me, this is another problem of using the DSM term "Major depressive disorder" to mean depression in general, and therefore a rationale for throwing in tangentially related material. —Mattisse (Talk) 15:11, 6 November 2008 (UTC)

I think that, in the sociocultural aspects section, we're allowing "depression" to be defined a bit more liberally than in the earlier, more technical and clinically-oriented sections of the article. This section follows a history section in which the modern origins of the term "major depressive disorder" are made clear, and which it is set against the backdrop of "melancholia" and of "depression" more generally. The reader will naturally understand that Johnson, Mill, and anyone else who lived before 1980 may have suffered from a condition comparable to the one named in 1980. Basically we've transitioned from science mode to history mode, and if we don't go into history mode regarding depression in this article, I don't see where else we're going to do it. As for the pictures being merely "decorative"...well, yes, that's the point. This is a long article with a lot of text--some visual aids can't hurt. Cosmic Latte (talk) 18:22, 6 November 2008 (UTC)

Differential diagnosis

Casliber, thanks for asking me to have another look. I really can't see any problems with the article as it stands now, except I'm not sure about "loneliness" in the differential diagnosis, for the following reasons (1) it seems wise to limit yourself to the differential diagnosis as described in DSM, and limit the list to other DSM disorders, (2) including loneliness here seems to elevate it to quasi-clinical status, makes it look like a "disorder" (the world has enough disorders already, thank you), (3) the supporting reference is not very strong and (4) the supporting reference refers to loneliness as a "condition" comparable to depression, but I suggest the condition of loneliness (like anomie) is a concept from sociological or existential, not clinical, discourse. Good luck with the FA nomination. Anonymaus (talk) 17:42, 5 November 2008 (UTC)

I agree that the differential diagnosis section might be an awkward spot to talk about loneliness, so I moved it to a relatively less "clinical" area. Feel free to modify it further, or to remove it altogether if it's too problematic. Cosmic Latte (talk) 18:37, 5 November 2008 (UTC)

After some tweaking, the loneliness passage reads, "Loneliness and depression have some features in common, and are likely to coexist if the loneliness is chronic rather than transient. If the individual has global concerns that do not focus strictly on interpersonal relationships, feels a high degree of guilt, or is particularly vegetative, then the person is likely to be depressed; if these conditions are not met, he or she may be lonely instead. It is unclear as to which factors are causes or effects of depression..." Now I'm wondering, would it be better to eliminate the "If the individual has global concerns...may be lonely instead" sentence, so that it simply reads, "Loneliness and depression have some features in common, and are likely to coexist if the loneliness is chronic rather than transient. It is unclear as to which factors are causes or effects of depression..."? Is that sentence too much detail, too distracting, etc., or is it helpful enough to keep? Cosmic Latte (talk) 18:44, 5 November 2008 (UTC)

I must admit I find that the whole loneliness segment I am having trouble gelling with the rest of the article and was pondering whether it should be removed, but am still thinking about it. Cheers, Casliber (talk · contribs) 23:36, 5 November 2008 (UTC)

I shortened the loneliness passage here, but feel free to move or remove the remainder of it if that's still a problem. Cosmic Latte (talk) 04:44, 6 November 2008 (UTC)

Diagnosis

"A diagnostic assessment may be conducted by a general practitioner or by a psychiatrist or psychologist". As far as I am aware in the UK a psychologist would not normally make the diagnosis, but might be involved later in the treatment or for specific assessment tasks. Sometimes CPN qualified nurses monitor patients in the community and is could be said that they diagnose or identify depression or a recurrence in the UK. This is based on locality in the UK. Should this line be modified? It is small print stuff, but perhaps this line in the article reflects a different locality position and might be better rephrased, but I do not known. Snowman (talk) 17:59, 5 November 2008 (UTC)

Theoretically a psychologist may be the first port of call diagnositcally if the GP was unclear about the diagnosis and asked for a second opinion. Many GPs may conduct a brief assessment without confirming the diagnosis (say, referring someone for what appeared to be bereavement or who is requesting counselling on an ongoing basis). A psychologist may also see someone after being referred for a medico-legal assessment, or as part of an Employee Assistance program in a large organization. As far as I know, these scenarios can occur in England (?). I only worked in England for a short time over 10 years ago. Cheers, Casliber (talk · contribs) 20:49, 5 November 2008 (UTC)

In the US a psychologist can have a private practice and see individuals who self-refer for whatever reason or are referred by friends, having nothing to do with a professional referral. Also, referrals come from other psychologists, lawyers, government agencies such as Child Protective Services or other such agencies; the court system refers individuals for assessment or treatment or both directly to psychologists. In these situations, generally a psychiatrist or other medical doctor has not been involved. Agencies also refer their personnel directly to psychologists. For example, where I live the sheriff and police departments rely on psychologists for employment evaluations, fitness for duty exams, evaluation and/or counseling after an incident like a use of arms. Also, within agencies, government or otherwise, a psychologist may be the first contact, for example, in the US military or in prison and jail systems. So, psychologists are the first mental health port of call often and the first to diagnose. —Mattisse (Talk) 21:13, 5 November 2008 (UTC)

But to keep to the point of illness diagnosis, as far as I am aware: it is different in the UK, where any illness related diagnosis would be made by a doctors (juniors, psychiatrists or GPs) or sometimes by a trained CPN nurse who would report to a doctor. Psychologists have a variety of roles and take referrals for various forms of therapy - anger management, phobia treatment or testing dementia and much more, but they are not used in the front line as diagnosticians and they can not prescribe in the UK. Psychologists might have a peripheral role in diagnosis in writing a psychological report for a doctor perhaps about some aspect of behaviour or aptitude, but it would be the doctor who would collate all the information and form an opinion about a diagnosis. Snowman (talk) 23:04, 5 November 2008 (UTC)

Snowman, the above has been traditionally true, but I would think Matisse's examples, and mine would bypass doctors in the UK enough times for it to be significant. In Australia, the medicare system insists the GP is the first port-of-call and other specialties only get reimbursed by the government (it is a fee-for-service model here) with a GP referral. However, if a person comes in with a problem that is clearly going to need specialist involvement, the assessment where the GP makes the referral may be very brief indeed, essentially acting as a triage service. Cheers, Casliber (talk · contribs) 23:21, 5 November 2008 (UTC)

PS: WRT the profession, psychologists practise in diverse ways; many do work like the above, that is only seeing people for a prescribed 12 sessions of CBT, IPT, family therapy or other regimen, but there are others who see patents on a longtidinal, open-ended basis using a mixutre of techniques - psychodynamic, CBT and supportive therapy as well, particularly in the private sector here. Cheers, Casliber (talk · contribs) 23:24, 5 November 2008 (UTC)

Also, in the US psychologists are directly reimbursed by Medicare, Medicad, Blue Cross/Blue Shield etc. and the diagnosis by the psychologist is accepted. Also, psychologists do evaluations for Social Security Disability (SSI), a federal program, that involves rendering a diagnosis. In fact, it is possible to make a living in independent practice doing just SSI evaluations. In other words, it is possible to practice psychology completely independently, and providing diagnoses is part of that practice. —Mattisse (Talk) 02:46, 6 November 2008 (UTC)

Good point - they are employed by Centrelink (our dss) here too in Oz. Cheers, Casliber (talk · contribs) 02:48, 6 November 2008 (UTC)

The more specific category of licensed clinical psychologists's should perhaps also be mentioned? But even they don't always diagnose in psychiatric manual terms (though may have to where financial reimbursement is based on it). And also that, ultimately, the majority of major depression is informally assessed by primary care doctors, in 10-minute (5 if poss.) chats comprising a few stereotyped questions, usually resulting in blister packs of SSRIs. EverSince (talk) 15:02, 6 November 2008 (UTC)

In the US, all mental health practitioners, including psychologists and primary care physicians, diagnose mental health problems in DSM terms. There are no other acceptable standards of diagosis. Even if reimbursement were not the issue, malpractice concerns are. So I do not know what you mean: "they don't always diagnose in psychiatric manual terms". What other terms are there, except possibly ICD in research? —Mattisse (Talk) 16:26, 6 November 2008 (UTC)

Major depressive disorder is wrong name for this article

I think the problem with this article is that the title uses the formal term used by DSM as a diagnostic category with specific criteria. ICD uses a different term. Therefore, the DSM criteria of Mood disorder, which specifies the categories of depression Depressive disorders, should be used. Schizophrenia is a more general term, not as restrictive as Major Depressive Disorder, but the article is nonetheless clear about its various definitions depending on what diagnostic criteria are being used.

This article is not clear. Although it is termed Major depressive disorder, implying to me at least, the DSM criteria, the article itself seems to cover depression in general and seems to use terms haphazardly. Granted that the articles on psychological/psychiatric disorders are a mess, but should not this article try to clarify? Perhaps it should be renamed Major depression, or some other name that is not associated with a specific diagnostic manual.

Schizophrenia is a much better article. It is clear and well focused. This article jumps all over the map. I think we should use the Schizophrenia article as a model. —Mattisse (Talk) 20:03, 5 November 2008 (UTC)

DSM III's decision to use MDD rather than Major depression is a frustrating one, as it is one step further from the lay term depression. Schizophrenia has been lucky in having the one name, though has had similar issues with changing standards of diagnosis (scz used to be more inclusive, and the UK and US definitions differed). Defining lay terms never equates exactly with clinical definitions. MDD is the entity used in research so all the epidemiology and treatment etc. refers to that entity. Mood disorder already has an article and refers to a family of disorders (including bipolar disorder and several other distinct entities such a dysthymia). If the consensus was that major depressive disorder=major depression, and that that was the much mor recognised name (in th same way that William Clinton is Bill Clinton, say - the quickest analogy I cna think of), I'd be open to that I guess. Cheers, Casliber (talk · contribs) 21:11, 5 November 2008 (UTC)

Except that one of the problems with this article's sources is that they generally use the term "depression" and not "major depression" and so it is not clear what they mean or if they are differentiating between subtypes, or which of the various subtypes they are including. Plus the article itself is unclear. It throws around words like mild, moderate, severe, when if I look at the sources it is not clear what is meant. Is it including the subtypes in these qualitative terms? What is the rational for the subtypes vs. the differential diagnosis, and are you discussing all of these in the article? Dysthymia is a differential diagnosis in the article, a rule out. Yet it is used in the article as an example of a condition effectively treated by an antidepressant. Also, some sources use persons diagnosed with Dysthymia. It is confusing to me. Of course, I am not British or Australian. ICD does not use the term. When you say "MDD is the entity used in research so all the epidemiology and treatment etc. refers to that entity", is this true? As it is not so in the US. —Mattisse (Talk) 21:37, 5 November 2008 (UTC)

P.S. When you say "MDD is the entity used in research", do you mean they are using the DSM criteria? Or what criteria are they using? Where do they get that term? Are the ICD terms irrelevant and unused? —Mattisse (Talk) 21:39, 5 November 2008 (UTC)

DSM is becoming lingua franca and DSM criteria are used alot more than ICD all over the place, it is even creeping in in the UK and Europe, and certainly australia has gone completely DSM in the past 15-20 years or so. I was keen to find a comprehensive ref on this but haven't been able to, yet it's pretty well known in mental health. Cheers, Casliber (talk · contribs) 23:13, 5 November 2008 (UTC)

But then, should you not clarify that in the article and stick to the DSM specified criteria etc. rather than use it as a general term for depression? In practice, in the US, DSM is taken very seriously in diagnosis and used strictly as intended by DSM. To see a DSM term used so freely and applied to topics it is never intended to address seems so "off" to me. —Mattisse (Talk) 02:52, 6 November 2008 (UTC)

Googling "Major depression" -wikipedia seems to give about twice as many pages as "Major depressive disorder". That term does seem less biased to either DSM or ICD, both of which are widely used around the world. And maybe goes some way to addressing the issues Mattisse raises. Ultimately whatever the term, it's going to involve inconsistent artifical cut-offs from depression (mood) and from the full spectrum of human emotion and life. EverSince (talk) 15:23, 6 November 2008 (UTC)

I think ""Major depressive disorder" is a clinical term used by clinicians and not the general public. —Mattisse (Talk) 16:00, 6 November 2008 (UTC)

That is probably correct, but Med:MOS uses the medical names for headings, and it is standard on the wiki. There is "Herpes zoster" and not "Shingles". Questions might be what medical name is the best one, and what is the article about? I am neutral on the name of the page, except I think that a lay term would be even more confusing. Snowman (talk) 16:47, 6 November 2008 (UTC)

• I find it strange that, as quoted from above, "DSM is becoming lingua franca and DSM criteria are used alot more than ICD all over the place". Yet this article does not even mention the American Psychiatric Association who developed DSM. Why the WP:UNDUE on "black dog" and the "Black Dog Institute" in the article (which has nothing to do with DSM), yet so little on the developers and development of DSM? The reference to the "Black Dog Institute" (http://www.blackdoginstitute.org.au/aboutus/overview.cfm) uses the term "depression" and not "Major depressive disorder". Why so much on black dog? —Mattisse (Talk) 16:12, 6 November 2008 (UTC)

• I don't see how WP:UNDUE applies to Winston Churchill or to a major Australian research/education institute...although if something about the APA can be added to the section, it certainly couldn't hurt. Cosmic Latte (talk) 16:38, 6 November 2008 (UTC)

Change and needed formatting

I took the intiative to replace a bit of text that was a original research concern to me. I used an on-topic source and followed the indications regarding the subtopic in that reference. I also moved the text to the opening of the paragraph to contextualize the statements that follow. If this is a problem, please feel free to revert and let me know why it is problematic.

Also, the references need to placed into a single standardized format. I recommend using {{harvnb}} for the footnotes and the various "cite" templates (such as {{cite book}}) for the "cited texts" list. The texts list should also be alphabetized or placed in chronological order. If I can find the time and energy over the next day, I will begin updating the references in such a fashion myself, barring any significant objections. Vassyana (talk) 17:50, 6 November 2008 (UTC)

I wouldn't recommend that, Vassyana. Harvnbs seem to be standard to some other topic areas (like literature), while the cite journal format used in this article is actually very typical of other medical articles, and if the format is changed, it becomes hard to move citations between articles (something I learned while working on Samuel Johnson, where the format used by the literary types forced me to rewrite all citations used in other medical articles in order to transport them). I found a couple of sources that weren't in alphabetical order, but other than that, I'm not seeing a problem here. The "Cited texts" section already used standardized Cite book templates, and cite xxx is used throughout, with shortened footnotes linking to the texts—it's a very standard format for medical articles. SandyGeorgia (Talk) 18:03, 6 November 2008 (UTC)

I'm fine with the actual edit to the text. It makes sense and flows well for me. Cosmic Latte (talk) 18:10, 6 November 2008 (UTC)

1. http://www.medscape.com/viewarticle/430545_8

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