History

Fact Explanation
Syndromic diagnosis and can be graded in severity to mild, moderate and severe This has a collection of signs and symptoms (described below) and if they last for more than 2 weeks with significant effect on daily functioning, diagnosis is made. Depressive disorders were the second leading cause of YLDs (years lived with disability) in 2010 with females are commonly affected having 1:4 lifetime risk and men having 1:10 lifetime risk. More common in late twenties. The biochemical basis of depression is thought to be due to depletion of monoamines (Noradrenaline and Serotonin) in brain. There are various psychological theories which have been implicated to explain the aetiology as well. Depression is diagnosed using ICD-10 criteria and categorized as mild, moderate and severe. There are 3 core features (A symptoms) listed as first 3 in the symptoms and the next 7 are B symptoms. If there were 2 A symptoms and 2 B symptoms, it's mild depression. 2 A and 3 B symptoms it's moderate and 3A and 3B symptoms it's diagnosed as severe. Severe depression can be associated with Psychotic symptoms too which is explained in the examination part. [1] [2] [4] [5] [8]
Low mood/ Depressed mood [4] [6] [7] Low mood is seen. There could be diurnal variation in the mood, typically worsening in the morning but in mild depression, mood is low in the evening. This is listed as a core feature or A symptom. [4] [6] [7]
Loss of interest/ Anhedonia [4] [6] [7] There's loss of interest and pleasure in things that used to be interesting and pleasurable. This is listed as a core feature or A symptom. [4] [6] [7]
Reduced energy/ Decreased activity [4] [6] [7] Patients complain that they are tired always and are unable to function normally. This is listed as a core feature or A symptom. [4] [6] [7]
Difficulty in concentration [4] [6] [7] They have a trouble in concentrating. This is a B symptom. [4] [6] [7]
Ideas of guilt and worthlessness [4] [6] [7] They feel guilty or worthless due to even small reasons and this is a B symptom. [4] [6] [7]
Reduced self esteem and confidence [4] [6] [7] They have low self esteem and always look down upon themselves. This is a B symptom. [4] [6] [7]
Pessimistic thoughts [4] [6] [7] They have lots of negative thoughts. This is a B symptom. [4] [6] [7]
Ideas of self harm/ Suicide [4] [6] [7] Thoughts about death/ suicide/ or self harm are seen. This is a B symptom. [4] [6] [7]
Decreased appetite [4] [6] [7] Loss of appetite and/or weight loss is commonly seen but rarely,increase in appetite and/or undesired weight gain is complained in atypical depression. This is a B symptom. [4] [6] [7]
Disturbed sleep [4] [6] [7] Insomnia (Waking up early/ disturbed sleep/ difficulty in initiating sleep) is seen and can be very disturbing. This is a B symptom. [4] [6] [7]
Loss of libido [4] [3] [6] [7] These are considered biological symptoms of depression. [4] [5] [6] [7]
Constipation [4] [6] [7] These are considered biological symptoms of depression. [4] [6] [7]
References
  1. USTUN T. B.. Global burden of depressive disorders in the year 2000. The British Journal of Psychiatry [online] 2004 May, 184(5):386-392 [viewed 19 July 2014] Available from: doi:10.1192/bjp.184.5.386
  2. VILLANUEVA ROSA. Neurobiology of Major Depressive Disorder. Neural Plasticity [online] 2013 December, 2013:1-7 [viewed 19 July 2014] Available from: doi:10.1155/2013/873278
  3. BALDWIN D. S. Depression and sexual dysfunction. [online] 2001 March, 57(1):81-99 [viewed 19 July 2014] Available from: doi:10.1093/bmb/57.1.81
  4. BOCK CAMILLA, BUKH JENS, VINBERG MAJ, GETHER ULRIK, KESSING LARS. Validity of the diagnosis of a single depressive episode in a case register. Array [online] 2009 December [viewed 19 July 2014] Available from: doi:10.1186/1745-0179-5-4
  5. KAMENOV K, MELLOR-MARSá B, LEAL I, AYUSO-MATEOS JL, CABELLO M. Analysing Psychosocial Difficulties in Depression: A Content Comparison between Systematic Literature Review and Patient Perspective Biomed Res Int [online] 2014:319634 [viewed 19 July 2014] Available from: doi:10.1155/2014/319634
  6. HARRINGTON R.. Depression, suicide and deliberate self-harm in adolescence. [online] 2001 March, 57(1):47-60 [viewed 19 July 2014] Available from: doi:10.1093/bmb/57.1.47
  7. KESSING L. V.. Severity of depressive episodes according to ICD-10: prediction of risk of relapse and suicide. The British Journal of Psychiatry [online] 2004 February, 184(2):153-156 [viewed 19 July 2014] Available from: doi:10.1192/bjp.184.2.153
  8. FERRARI ALIZE J., CHARLSON FIONA J., NORMAN ROSANA E., PATTEN SCOTT B., FREEDMAN GREG, MURRAY CHRISTOPHER J.L., VOS THEO, WHITEFORD HARVEY A., HAY PHILLIPA J.. Burden of Depressive Disorders by Country, Sex, Age, and Year: Findings from the Global Burden of Disease Study 2010. PLoS Med [online] 2013 November [viewed 05 September 2014] Available from: doi:10.1371/journal.pmed.1001547

Examination

Fact Explanation
Neglected appearance [1] [2] [3] There's neglected dress and grooming seen as well as psycho motor retardation is seen. [1] [2] [3]
Facial features [1] [2] [3] Appearance of horizontal furrows in the forehead and gaze is directed downwards. Reduced rate of blinking and gestures seen.
Poverty of speech [1] [2] [3] There's reduced rate, variance in speech as well as hesitancy [1] [2] [3]
Miserable mood [1] [2] [3] The mood is low. Mood can also be anxious, irritable or agitated [1] [2] [3]
Morbid thoughts [2] [3] There's pessimistic thoughts regarding the past, present and the future. There's cognitive triad of hopelessness, helplessness and worthlessness. Homicidal/ Suicidal thoughts are seen as well [2] [3]
Delusions [2] [3] [4] Delusions of worthlessness/ guilt, impoverishment, nihilism, hypochondrial, and persecutory delusions. Persecutory delusions are mood congruent. [2] [3] [4]
Hallucinations [2] [3] [4] Second person auditory hallucinations of derogatory content are common. As well as visual hallucinations with scenes of death and destruction are seen. [2] [3] [4]
Impaired attention/ concentration [2] [3] [4] [5] "Depressive pseudo-dementia" is seen and this is due to impaired attention and concentration rather than due to true memory impairment. [2] [3] [4] [5]
References
  1. BOCK CAMILLA, BUKH JENS, VINBERG MAJ, GETHER ULRIK, KESSING LARS. Validity of the diagnosis of a single depressive episode in a case register. Array [online] 2009 December [viewed 19 July 2014] Available from: doi:10.1186/1745-0179-5-4
  2. HARRINGTON R.. Depression, suicide and deliberate self-harm in adolescence. [online] 2001 March, 57(1):47-60 [viewed 19 July 2014] Available from: doi:10.1093/bmb/57.1.47
  3. KESSING L. V.. Severity of depressive episodes according to ICD-10: prediction of risk of relapse and suicide. The British Journal of Psychiatry [online] 2004 February, 184(2):153-156 [viewed 19 July 2014] Available from: doi:10.1192/bjp.184.2.153
  4. GOEKOOP JAAP G., DE WINTER REMCO F. P.. Temperament and Character in Psychotic Depression Compared with Other Subcategories of Depression and Normal Controls. Depression Research and Treatment [online] 2011 December, 2011:1-7 [viewed 19 July 2014] Available from: doi:10.1155/2011/730295
  5. PATERNITI S.. Depressive symptoms and cognitive decline in elderly people: Longitudinal study. [online] 2002 November, 181(5):406-410 [viewed 19 July 2014] Available from: doi:10.1192/bjp.181.5.406

Differential Diagnoses

Fact Explanation
Adjustment disorder [1] [2] A loss event such as loss of a job, breaking up a relationship can follow with sadness and this is a normal response and commonly seen and does not meet the criteria to diagnose depression [1] [2]
Grief [1] [2] bereavement and grief occurs due to loss of someone to death. The duration of grief varies and does not meet the criteria for depression. [1] [2]
Anxiety [3] Mild depressive disorder maybe difficult to differentiate from anxiety. [3]
Schizophrenia [4] When depression is associated with psychosis, the differentiation from schizophrenia may be difficult. But in Schizophrenia delusions come first and they are mood incongruent. [4]
Dementia [5] In old people dementia maybe difficult to be differentiated from depression with low mood and impaired memory. But in depression the impairment of memory is not real. [5]
Bipolar depression [9] History of hypomanic or manic episodes should be recognized to diagnose bipolar depression [9]
Somatoform disorders [10] When somatic symptoms such as body aches, back pain, fatigue, burning sensation are common these need to be differentiated from a somatoform disorder [10]
Substance use [6] Various substance abuse can also lead to depression especially alcohol. Also heroine and cocaine [6]
Certain physical conditions [7] Rheumatoid arthritis, Diabetes Mellitus, Influenza, Post partum depression, Hypothyroidism can cause depression, therefore these illnesses need to be excluded first. [7] [8]
References
  1. ZISOOK S, SHEAR K. Grief and bereavement: what psychiatrists need to know World Psychiatry [online] 2009 Jun, 8(2):67-74 [viewed 19 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2691160
  2. SHEAR M. K.. Grief and Depression: Treatment Decisions for Bereaved Children and Adults. American Journal of Psychiatry [online] December, 166(7):746-748 [viewed 19 July 2014] Available from: doi:10.1176/appi.ajp.2009.09050698
  3. CUSIN CRISTINA, DOUGHERTY DARIN D. Somatic therapies for treatment-resistant depression: ECT, TMS, VNS, DBS. Array [online] 2012 December [viewed 19 July 2014] Available from: doi:10.1186/2045-5380-2-14
  4. POGUE-GEILE M. F., HARROW M.. Negative and Positive Symptoms in Schizophrenia and Depression: A Followup. Schizophrenia Bulletin [online] 1984 January, 10(3):371-387 [viewed 19 July 2014] Available from: doi:10.1093/schbul/10.3.371
  5. CURRAN ELEANOR M, LOI SAMANTHA. Depression and dementia. Med J Aust [online] 2012 October, 1(4):40-44 [viewed 19 July 2014] Available from: doi:10.5694/mjao12.10567
  6. MCINTOSH C.. Treating depression complicated by substance misuse. [online] 2001 September, 7(5):357-364 [viewed 19 July 2014] Available from: doi:10.1192/apt.7.5.357
  7. MACHALE S.. Managing depression in physical illness. [online] 2002 July, 8(4):297-305 [viewed 19 July 2014] Available from: doi:10.1192/apt.8.4.297
  8. PILHATSCH MAXIMILIAN, MARXEN MICHAEL, WINTER CHRISTINE, SMOLKA MICHAEL N, BAUER MICHAEL. Hypothyroidism and mood disorders: integrating novel insights from brain imaging techniques. Array [online] 2011 December [viewed 19 July 2014] Available from: doi:10.1186/1756-6614-4-S1-S3
  9. MARTINOWICH KERI, SCHLOESSER ROBERT J., MANJI HUSSEINI K.. Bipolar disorder: from genes to behavior pathways. J. Clin. Invest. [online] 2009 April, 119(4):726-736 [viewed 19 July 2014] Available from: doi:10.1172/JCI37703
  10. OWENS C.. Conversion disorder: the modern hysteria. Advances in Psychiatric Treatment [online] 2006 March, 12(2):152-157 [viewed 19 July 2014] Available from: doi:10.1192/apt.12.2.152

Investigations - for Diagnosis

Fact Explanation
Serum TSH level [1] Hypothyroidism can cause depression and the motor retardation in hypothyroidism could be difficult to differentiate from depression, therefore serum TSH level is done to exclude hypothyroidism. [1]
Fasting blood sugar [2] Diabetes Mellitus can cause depression therefore, this should be excluded. [2]
(CT) scanning or magnetic resonance imaging (MRI) of the brain [3] This maybe considered if organic brain disorder is considered as a differential diagnosis [3]
References
  1. PILHATSCH MAXIMILIAN, MARXEN MICHAEL, WINTER CHRISTINE, SMOLKA MICHAEL N, BAUER MICHAEL. Hypothyroidism and mood disorders: integrating novel insights from brain imaging techniques. Array [online] 2011 December [viewed 19 July 2014] Available from: doi:10.1186/1756-6614-4-S1-S3
  2. WILLIAMS M. M.. Treating Depression to Prevent Diabetes and Its Complications: Understanding Depression as a Medical Risk Factor. Clinical Diabetes [online] 2006 April, 24(2):79-86 [viewed 19 July 2014] Available from: doi:10.2337/diaclin.24.2.79
  3. O'BRIEN J.. Neuroimaging in dementia and depression. [online] 2000 March, 6(2):109-119 [viewed 19 July 2014] Available from: doi:10.1192/apt.6.2.109

Investigations - Fitness for Management

Fact Explanation
Electrocardiogram [1] [2] Arhythmias, and ischemic heart diseases are contraindications for tricyclic antidepressants. Therefore in elderly patients an ECG is done to assess the fitness to start these drugs. Also prior to electroconvulsive therapy (ECT), ECG is performed. [1] [2]
Chest X-ray [2] This is also done prior to general anesthesia for ECT [2]
Full blood count [2] This is also done prior to general anesthesia for ECT to exclude any anemia [2]
Serum electrolytes [2] [3] [4] This is also done prior to general anesthesia for ECT to exclude any renal impairment. Also prior starting serotonin reuptake inhibitors, serum electrolyte level is done as it can cause hyponatremia in elderly. [2] [3] [4]
Fasting Blood sugar [2] This is also done prior to general anesthesia to exclude any diabetes mellitus, in ECT [2]
References
  1. O'BRIEN P.. Psychotropic medication and the heart. Advances in Psychiatric Treatment [online] 2003 November, 9(6):414-423 [viewed 19 July 2014] Available from: doi:10.1192/apt.9.6.414
  2. UPPAL V., DOURISH J., MACFARLANE A.. Anaesthesia for electroconvulsive therapy. Continuing Education in Anaesthesia, Critical Care & Pain [online] December, 10(6):192-196 [viewed 19 July 2014] Available from: doi:10.1093/bjaceaccp/mkq039
  3. FERGUSON JM. SSRI Antidepressant Medications: Adverse Effects and Tolerability Prim Care Companion J Clin Psychiatry [online] 2001 Feb, 3(1):22-27 [viewed 19 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC181155
  4. HANNON M. J., THOMPSON C. J.. The syndrome of inappropriate antidiuretic hormone: prevalence, causes and consequences. European Journal of Endocrinology [online] December, 162(Suppl1):S5-S12 [viewed 19 July 2014] Available from: doi:10.1530/EJE-09-1063

Investigations - Followup

Fact Explanation
Serum electrolytes [1] [2] During serotonin reuptake inhibitors treatment, serum electrolyte level is done as it can cause hyponatremia in elderly. [1] [2]
References
  1. FERGUSON JM. SSRI Antidepressant Medications: Adverse Effects and Tolerability Prim Care Companion J Clin Psychiatry [online] 2001 Feb, 3(1):22-27 [viewed 19 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC181155
  2. HANNON M. J., THOMPSON C. J.. The syndrome of inappropriate antidiuretic hormone: prevalence, causes and consequences. European Journal of Endocrinology [online] December, 162(Suppl1):S5-S12 [viewed 19 July 2014] Available from: doi:10.1530/EJE-09-1063

Investigations - Screening/Staging

Fact Explanation
Patient Health Questionnaire-9 (PHQ-9) [1] [2] This is self administered questionnaire having 9 components. [1] [2]
Beck Depression Inventory (BDI) [3] This is a self administered tool with 21 components. [3]
BDI for primary care [3] This is a self administered questionnaire with 7 questions. This is adapted from BDI [3]
Zung Self-Rating Depression Scale [4] This is a self administered questionnaire with 20 questions. [4]
Center for Epidemiologic Studies-Depression Scale (CES-D) [5] This is a self administered questionnaire with 20 questions. [5]
Hamilton Depression Rating Scale (HDRS) [6] This is performed by a health care professional who is trained for this. [6]
The Geriatric epression Scale (GDS) [7] This is for screening for depression in elderly. [7]
References
  1. INOUE TAKESHI, TANAKA TERUAKI, NAKAGAWA SHIN, NAKATO YASUYA, KAMEYAMA RIE, BOKU SHUKEN, TODA HIROYUKI, KURITA TSUGIKO, KOYAMA TSUKASA. Utility and limitations of PHQ-9 in a clinic specializing in psychiatric care. Array [online] 2012 December [viewed 19 July 2014] Available from: doi:10.1186/1471-244X-12-73
  2. KROENKE K, SPITZER RL, WILLIAMS JB. The PHQ-9: Validity of a Brief Depression Severity Measure J Gen Intern Med [online] 2001 Sep, 16(9):606-613 [viewed 19 July 2014] Available from: doi:10.1046/j.1525-1497.2001.016009606.x
  3. BELLIS C.. The Beck Depression Inventory for Primary Care accurately screened for major depressive disorders. Evidence-Based Nursing [online] 1999 October, 2(4):126-126 [viewed 19 July 2014] Available from: doi:10.1136/ebn.2.4.126
  4. FOUNTOULAKIS KONSTANTINOS N, LACOVIDES APOSTOLOS, SAMOLIS STAVROS, KLEANTHOUS SOULA, KAPRINIS STERGIOS G, KAPRINIS GEORGE ST, BECH PER. . BMC Psychiatr [online] 2001 December [viewed 19 July 2014] Available from: doi:10.1186/1471-244X-1-6
  5. RADLOFF L. S.. The CES-D Scale: A Self-Report Depression Scale for Research in the General Population. Applied Psychological Measurement [online] 1977 June, 1(3):385-401 [viewed 19 July 2014] Available from: doi:10.1177/014662167700100306
  6. HAMILTON M.. A RATING SCALE FOR DEPRESSION. Journal of Neurology, Neurosurgery & Psychiatry [online] 1960 February, 23(1):56-62 [viewed 19 July 2014] Available from: doi:10.1136/jnnp.23.1.56
  7. MARC LG, RAUE PJ, BRUCE ML. Screening Performance of the Geriatric Depression Scale (GDS-15) in a Diverse Elderly Home Care Population Am J Geriatr Psychiatry [online] 2008 Nov, 16(11):914-921 [viewed 19 July 2014] Available from: doi:10.1097/JGP.0b013e318186bd67

Management - General Measures

Fact Explanation
Risk assessment [1] [2] In a patient with depression, risk assessment plays an important role. Assessment of suicidal risk is important as well as homicidal risk. There's a risk of self neglect as well by reduction in food intake and social isolation.[1]
Deciding treatment setting [2] Depending on the severity of illness, social support, patient preference, treatment setting should be decided. In severe depression, psychotic depression, risk of self harm inward treatment is advised. [2]
Patient and family education [2] [3] Patient and the family should be educated about the aetiology, symptoms, treatment options, the effect of drug treatment may take some time and the need of continuation for sometime after the illness, and prognosis of the illness. [2] [3]
Identifying social support and ensuring optimal quality of life [2] [3] Social support for each patient should be assessed and it's important to ensure their quality of life is optimal.[2] [3]
Diet [4] Dietary restrictions are needed if they are put on monoamine oxidase inhibitors (MAOIs). Foods high in tyramine, cause a hypertensive crisis with MAOIs, therefore should be avoided. Cheese is one of these food items [4]
Activity [5] Activity may be helpful to reduce stress and also enhances the recovery [5]
References
  1. MCDOWELL AK, LINEBERRY TW, BOSTWICK JM. Practical Suicide-Risk Management for the Busy Primary Care Physician Mayo Clin Proc [online] 2011 Aug, 86(8):792-800 [viewed 20 July 2014] Available from: doi:10.4065/mcp.2011.0076
  2. GOLDMAN LS, NIELSEN NH, CHAMPION HC, FOR THE COUNCIL ON SCIENTIFIC AFFAIRS, AMERICAN MEDICAL ASSOCIATION. Awareness, Diagnosis, and Treatment of Depression J Gen Intern Med [online] 1999 Sep, 14(9):569-580 [viewed 20 July 2014] Available from: doi:10.1046/j.1525-1497.1999.03478.x
  3. SAVER B. G., VAN-NGUYEN V., KEPPEL G., DOESCHER M. P.. A Qualitative Study of Depression in Primary Care: Missed Opportunities for Diagnosis and Education. The Journal of the American Board of Family Medicine [online] 2007 January, 20(1):28-35 [viewed 20 July 2014] Available from: doi:10.3122/jabfm.2007.01.060026
  4. WIMBISCUS M., KOSTENKO O., MALONE D.. MAO inhibitors: Risks, benefits, and lore. Cleveland Clinic Journal of Medicine [online] December, 77(12):859-882 [viewed 20 July 2014] Available from: doi:10.3949/ccjm.77a.09103
  5. BLAKE HOLLY. Physical activity and exercise in the treatment of depression. Front. Psychiatry [online] 2012 December [viewed 20 July 2014] Available from: doi:10.3389/fpsyt.2012.00106

Management - Specific Treatments

Fact Explanation
Pharmacological therapy with Selective serotonin reuptake inhibitors (SSRIs), [1] This is considered as the first line drug. Easy dosage and low toxicity in overdose are their advantages.[1]
Pharmacological therapy with Serotonin/norepinephrine reuptake inhibitors (SNRIs) [17] SNRIs, which include venlafaxine, duloxetine, play an important role as second-line agents in patients who fail to respond to SSRIs. [17]
Pharmacological therapy with atypical antidepressants [16] Atypical antidepressants include mirtazapine, trazodone are effective in monotherapy in major depressive disorder and can be used in combination therapy as well. [16]
Pharmacological therapy with Tricyclic antidepressants (TCAs) [2] [4] They are not used commonly now because of their side-effect profile and their high toxicity in overdose [2] [4]
Pharmacological therapy with Monoamine oxidase inhibitors (MAOIs) [3] Hypertensive crisis with some food items has reduced the use of MAOIs in depression. [3]
Electroconvulsive therapy [5] [6] Onset of action is rapid than from drug treatment. Indications for the use of ECT include drug resistant depression, patient preference, high risk of suicide, psychotic depression and severe postpartum depression. [5]
Supportive psychotherapy [7] This includes praise, reassurance and encouragement to become physically active and engage in activities. [7]
Cognitive behavior therapy (CBT) [8] CBT is a first-line treatment for depression and it's particularly helpful to prevent relapses. It includes behavioral therapy with activity rescheduling, and cognitive component is managed with maintaining a diary to manage their thoughts. They are helped to identify morbid thoughts,to challenge negative thoughts and develop rational alternative thoughts. [8]
Interpersonal psychotherapy [9] This is also helpful as a method of treatment for depression [9]
Transcranial magnetic stimulation (TMS) [10] This has shown to be effective in major depression. [10]
Vagus nerve stimulation (VNS) [11] This has shown to be effective in treatment resistant depression as well [11]
Deep brain stimulation (DBS) [12] This seems to be a safe and effective for treatment-resistant depression. [12]
Augmentation therapy [13] Augmentation with Lithium, Triiodothyronine with any antidepressant may help. [13]
Bright light therapy [14] This is mainly done for seasonal affective disorder [14]
Treatment of postpartum depression [15] [18] Electroconvulsive therapy gives a rapid response and safe in pregnancy. Additionally psychotherapy can be given. From anti depressants, Paroxetine, sertraline, and nortriptyline are considered safe [15] [18]
References
  1. FERGUSON JM. SSRI Antidepressant Medications: Adverse Effects and Tolerability Prim Care Companion J Clin Psychiatry [online] 2001 Feb, 3(1):22-27 [viewed 20 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC181155
  2. O'BRIEN P.. Psychotropic medication and the heart. Advances in Psychiatric Treatment [online] 2003 November, 9(6):414-423 [viewed 20 July 2014] Available from: doi:10.1192/apt.9.6.414
  3. WIMBISCUS M., KOSTENKO O., MALONE D.. MAO inhibitors: Risks, benefits, and lore. Cleveland Clinic Journal of Medicine [online] December, 77(12):859-882 [viewed 20 July 2014] Available from: doi:10.3949/ccjm.77a.09103
  4. ARROLL B.. Efficacy and Tolerability of Tricyclic Antidepressants and SSRIs Compared With Placebo for Treatment of Depression in Primary Care: A Meta-Analysis. The Annals of Family Medicine [online] 2005 September, 3(5):449-456 [viewed 20 July 2014] Available from: doi:10.1370/afm.349
  5. UPPAL V., DOURISH J., MACFARLANE A.. Anaesthesia for electroconvulsive therapy. Continuing Education in Anaesthesia, Critical Care & Pain [online] December, 10(6):192-196 [viewed 20 July 2014] Available from: doi:10.1093/bjaceaccp/mkq039
  6. CUSIN CRISTINA, DOUGHERTY DARIN D. Somatic therapies for treatment-resistant depression: ECT, TMS, VNS, DBS. Array [online] 2012 December [viewed 20 July 2014] Available from: doi:10.1186/2045-5380-2-14
  7. BEDI N., VASSILIADIS H.. Supervised case experience in supportive psychotherapy: suggestions for trainers. Advances in Psychiatric Treatment [online] December, 16(3):184-192 [viewed 20 July 2014] Available from: doi:10.1192/apt.bp.107.003855
  8. SCOTT J.. Cognitive therapy for depression. [online] 2001 March, 57(1):101-113 [viewed 20 July 2014] Available from: doi:10.1093/bmb/57.1.101
  9. CUIJPERS PIM. Interpersonal Psychotherapy for Depression: A Meta-Analysis. Am J Psychiatry [online] 2011 June [viewed 20 July 2014] Available from: doi:10.1176/appi.ajp.2010.10101411
  10. PAUS T, BARRETT J. Transcranial magnetic stimulation (TMS) of the human frontal cortex: implications for repetitive TMS treatment of depression J Psychiatry Neurosci [online] 2004 Jul, 29(4):268-279 [viewed 20 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC446221
  11. CORCORAN C. D.. Vagus nerve stimulation in chronic treatment-resistant depression: Preliminary findings of an open-label study. The British Journal of Psychiatry [online] 2006 September, 189(3):282-283 [viewed 20 July 2014] Available from: doi:10.1192/bjp.bp.105.018689
  12. MALONE D. A.. Use of deep brain stimulation in treatment-resistant depression. Cleveland Clinic Journal of Medicine [online] December, 77(Suppl_3):S77-S80 [viewed 20 July 2014] Available from: doi:10.3949/ccjm.77.s3.14
  13. ANDERSON I. M.. Drug treatment of depression: reflections on the evidence. [online] 2003 January, 9(1):11-20 [viewed 20 July 2014] Available from: doi:10.1192/apt.9.1.11
  14. GOLDEN R. N.. The Efficacy of Light Therapy in the Treatment of Mood Disorders: A Review and Meta-Analysis of the Evidence. American Journal of Psychiatry [online] 2005 April, 162(4):656-662 [viewed 20 July 2014] Available from: doi:10.1176/appi.ajp.162.4.656
  15. YAWN BARBARA P., OLSON ARDIS L., BERTRAM SUSAN, PACE WILSON, WOLLAN PETER, DIETRICH ALLEN J.. Postpartum Depression: Screening, Diagnosis, and Management Programs 2000 through 2010. Depression Research and Treatment [online] 2012 December, 2012:1-9 [viewed 20 July 2014] Available from: doi:10.1155/2012/363964
  16. PALANIYAPPAN L., INSOLE L., FERRIER N.. Combining antidepressants: a review of evidence. Advances in Psychiatric Treatment [online] December, 15(2):90-99 [viewed 20 July 2014] Available from: doi:10.1192/apt.bp.107.004820
  17. SHULTZ E., MALONE D. A.. A practical approach to prescribing antidepressants. Cleveland Clinic Journal of Medicine [online] December, 80(10):625-631 [viewed 20 July 2014] Available from: doi:10.3949/ccjm.80a.12133
  18. GJERDINGEN D.. The Effectiveness of Various Postpartum Depression Treatments and the Impact of Antidepressant Drugs on Nursing Infants. The Journal of the American Board of Family Medicine [online] 2003 September, 16(5):372-382 [viewed 05 September 2014] Available from: doi:10.3122/jabfm.16.5.372