Talk:Major depressive disorder/Archive 7

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 ^{Talk• Contributions} 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 ^{Talk• Contributions} 14:29, 15 October 2008 (UTC)

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)

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 ^{Talk• Contributions} 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 ^{Talk• Contributions} 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 ^{Talk• Contributions} 18:47, 17 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 [of] 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., [1], [2], [3]. 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 [4] 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,[5] 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. Wikipedia:Wikipedia 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. [Life crisis as a consequence of depression and anxiety] 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[6] 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)

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)

Yeah I was gonna add those last two aren't as promising as their titles might sound... EverSince (talk) 20:37, 11 November 2008 (UTC)

(deindent) I guess I'll start Causes of depression for now, to cover the above, since the naming issue hasn't been resolved. EverSince (talk) 20:37, 11 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[7] 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 [or useful] effect over placebo" with NICE specifying what short of improvement they regard as clinically useful? Colin°^Talk 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°^Talk 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.[154][155] 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.[154] 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.[155]

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

Yep. On it now. Cheers, Casliber (talk · contribs) 10:38, 7 November 2008 (UTC)

I have put it in corresponding sections; I left out the bit about SSRIs as it was a bit vague and I have seen other authors arguing the same for Tricyclics. Cheers, Casliber (talk · contribs) 10:50, 7 November 2008 (UTC)

Image question

Image:Sigmund freud um 1905.jpg. Caption: Freud Image:Hall Freud Jung in front of Clark 1909.jpg. Caption: Group photo 1909 in front of Clark University. Front row: Sigmund Freud, Granville Stanley Hall, Carl Jung; back row: Abraham A. Brill, Ernest Jones, Sandor Ferenczi. 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°^Talk 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)

That reason sounds like you are using an image for decorative purposes only. —Mattisse (Talk) 20:08, 8 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 in 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)

That is the problem of the title of the article. If it is titled Major depressive disorder, then the article begins to lose focus when it strays from that topic. Perhaps there should not be a sociocultural aspects section, if you take that to mean you can add tangentially related or misleading material. Johnson was never diagnosed with Major depressive disorder. This section is more of a Trivia section. —Mattisse (Talk) 21:54, 6 November 2008 (UTC)

Response here. Cosmic Latte (talk) 10:11, 7 November 2008 (UTC)

That does not address my objections. You are supporting the use of an image for decorative purposes only. —Mattisse (Talk) 20:08, 8 November 2008 (UTC)

Image suggestion

Image:Churchill 1904 Q 42037.jpg. Caption: Churchill in 1904

I think it would be better to have someone more widely known and recent than SJ for someone that had depression. Snowman (talk) 22:30, 6 November 2008 (UTC)

Maslow's hierarchy of needs image

Image:Maslow's hierarchy of needs.png. Caption: Maslow's hierarchy of needs]

• What is the justification for Image:Maslow's hierarchy of needs.png? The hierarchy itself never mentions depression. Maslow is not noted for his contributions to the theoretical conceptualizations of depression. It certainly was not a major focus of his writings. This article on depression only has one sentence on Maslow and that sentence does not even mention the hierarchy: "American psychologist Abraham Maslow theorized that depression is especially likely to arise when the world precludes a sense of "richness" or "totality" for the self-actualizer." I submit that this sentence makes no sense to a reader not already familiar with Maslow and his hierarchy. The concepts are very Western world biased. The caption on the hierarchy image contains more accurate information than does the article text. The hierarchy itself is not explained in the article text, so why such prominence pictorially, other than that it is pretty? —Mattisse (Talk) 15:09, 10 November 2008 (UTC)

• It's there to supplement the text, not simply to mirror it. See also Talk:Major_depressive_disorder#Verdict_on_Maslow_image. Cosmic Latte (talk) 15:17, 10 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.[31] 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.[31] 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)

(I had to upon readreading a few time. Sorry) Cheers, Casliber (talk · contribs) 06:21, 9 November 2008 (UTC)

• A further comment on the differential diagnosis section: I think that this would be better presented as running prose than a bullet list. Even though it says "including the following", it sort of gives the impression that these are the three "main" diagnoses to exclude. There are other important things to rule out, such as substance abuse, lowered mood as an effect of somatic condition, various psychotic syndromes... /skagedal^... 09:58, 7 November 2008 (UTC)

It says "the list includes:" and it is a list of diagnoses of conditions that may have a similar presentations, I think the list works well. Substance misuse may be a coexisting or different condition. Snowman (talk) 10:34, 7 November 2008 (UTC)

Hopefully a somatic condition would be picked up by investigations and hence excluded, similarly substance use and depression not mutually exclusive and are often comorbid. Almost all other psychiatric conditions will have other symptoms elicited by a good history, but I agree it is sometimes hard to know where to draw the line. - i.e things which are going to be possibly similar even after investigations and a thorough psychiatric history is taken. Cheers, Casliber (talk · contribs) 10:55, 7 November 2008 (UTC)

I was thinking of the cases were the substance use or abuse is thought to be etiologically related to the mood disturbance (see [8]), in which case MDD is not diagnosed, according to criteria D of the major depressive episode diagnosis. Regarding somatic conditions, I'm thinking of Mood disorder due to a general medical condition; this is covered well in the "clinical assessment" section, though. But how about schizoaffective disorder? Isn't that just as relevant as adjustment disorder or bipolar disorder?

If these three are indeed the most relevant differential diagnoses, maybe the text should say so explicitly? "Including the following" could be read as: "here comes three arbitrary examples"... /skagedal^... 12:28, 7 November 2008 (UTC)

The site you linked to above gives a different list for differential diagnoses in DSM-IV for Major despressive disorder than those you have listed in the article. Besides Mood disorder due to a general medical condition, other diagnosis of Major depressive disorder - Differential diagnosis are given, such as Substance-Induced Mood Disorder, Dysthymic Disorder, and Schizoaffective Disorder, as well as mention of some other disorders in which depression may be a symptom. Where is the current list in the article coming from? Loneliness is not a diagnosis, so I am glad you moved it. —Mattisse (Talk) 16:01, 10 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)

I'm not disagreeing, in terms of officialdom. But the practice of many clinical psychologists doesn't otherwise revolve around what psychiatric category to stick clients in, but rather to assess an individual's unique issues within a dimensional (continous rather than categorical) model in a psychosocial context. As this US reviewer puts it "Clinical psychologists and social workers tend to be even less committed to it. However, it is the document that has been adopted by most bureaucratic and legislative organizations..." At one extreme in the US is clinical psychologist Paula Caplan], a former DSM consultant. EverSince (talk) 19:01, 6 November 2008 (UTC)

Your first source is a book reviewer's opinion. It is not my experience. There is no context I know of, unless you practice in your garage secretly and never share your clinical notes with other professionals and no one sues you for malpractice. The second reference you give really proves my point. It complains about the DSM categories because the practitioner is forced to use them and in many situations it is difficult to make the categories fit. —Mattisse (Talk) 22:41, 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)

"Major depression" is also widely used clinically/medically, check out Pubmed (more than twice as often in article titles) EverSince (talk) 01:58, 7 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)

Just want to point out that the title of the article is actually not of much importance to readers, so long as all of the reasonable alternatives redirect to the right place.

It is of some importance in determining the scope of the article and the uses of sources, as described above. It is also important stylistically, since the title will appear throughout the article. Major depressive disorder contravenes our style guidelines WP:MTAA and WP:JARGON. I prefer the previous title of Clinical depression. Colonel Warden (talk) 19:15, 6 November 2008 (UTC)

I think it mentioned APA & WHO in the criteria section... should be in history too. Nationalistic bias has to be avoided of course. Regarding the relative usage, it's already been noted elsewhere that an international survey of psychiatrists found "ICD-10 was more frequently used and more valued for clinical diagnosis and training and that DSM-IV was more valued for research]. EverSince (talk) 19:13, 6 November 2008 (UTC)

This is a more complete discussion: I believe the (current DSM) name accords with WP:MEDMOS. SandyGeorgia (Talk) 19:16, 6 November 2008 (UTC)

The section "Sociocultural aspects" is a problem currently, in my view, because, as one editor said, in that section the diagnosis is not important because anything relating to "depression" in general can pertain. Major depressive disorder is not just "depression", although I agree that seems to be what the article is becoming. The article lacks focus and seems to be a general treatise on "depression" or "clinical depression", a very broad topic. So in essence, anything related to "depression" can go into this article. Given that focus, it really should cover diagnoses of depression not included in the DSM Major depressive disorder. However, this article attempts to strattle the fence, and therefore, is a muddle. —Mattisse (Talk) 22:49, 6 November 2008 (UTC)

• Wow. That reference to a "This is a more complete discussion:" above is a total distraction as there is really a discrediting of the journal reference involved as "obscure" and only pertaining to "Danish". Just more opinions not more weighty than those here. Not proof at all of superiority of one diagnostic method over another, except preference and familiarity. —Mattisse (Talk) 02:37, 7 November 2008 (UTC)

• The link is to a broad dicussion at WP:MEDMOS (in which you participated and agreed), where it was decided to use DSM in naming articles: broader consensus than at one article. SandyGeorgia (Talk) 03:06, 7 November 2008 (UTC)

I agreed on the narrow issue of Borderline personality disorder, a specific and controversial diagnosis and I tried to make sure the article limited itself to the DSM criteria. I agreed to nothing so broad as to confine depression in its many variations to one term. —Mattisse (Talk) 03:23, 7 November 2008 (UTC)

Yeah the relevant point from that brief debate is that there's also http://www.ncbi.nlm.nih.gov/pubmed/18408417 that gives a different view on ICD vs DSM usage, in terms of journals. I agree that overall it's a wash in terms of proof of superiority. Also I'll just mention again (in case my back-insertion of it above is missed) that the term "Major depression" is at least as widely used as "Major depressive disorder" in Pubmed articles (twice as often in titles), as well as being used twice as often in websites generally. EverSince (talk) 03:43, 7 November 2008 (UTC)

WRT names and scope, there is no perfect answer to this question. I figured on major depressive disorder as that is the DSM IV name which most research etc is done under and hence figures for epidemiology, treatment etc. It more or less corresponds to the older endogenous depression, and to melancholia before that, though there have been shifts in diagnostic yardsticks, and to what is commonly termed depression (i.e. condtion of pervasive low mood impacting on function) in the community. Psych books etc. will talk about all these entities connected with each other when talking about impact/history/public perception etc. I agree the term major depression is commonly seen and repeat my frustration that DSM IV went with major depressive disorder but go with it they did. Now, as I said I am frustrated by a lack of solid material confirming that DSM IV is lingua franca and I will be chuffed if something turns up, but that is somewhat beuyond the scope of the article and more an issue for a DSM or ICD page, or mental health classification etc.

This is not perfect but as far as I can see is the best fit with all the literature, research and data at hand. I have seen the term clinical depression about half a dozen terms in my professional life and I work in mental health - no one in mental health calls it that, and outside of mental health it is often shortened to simply depression (as it is in lots of journal articles too). Cheers, Casliber (talk · contribs) 05:06, 7 November 2008 (UTC)

Do you have access to PMID 18408417 ? The abstract says DSM five times ICD. From a more practical point of view (since the FAC is frequently straying off topic), WP:MEDMOS is clear. SandyGeorgia (Talk) 05:12, 7 November 2008 (UTC)

WP:MEDMOS does not seem to conform to our policy which is superior. Wikipedia is a general reference work and so should avoid professional jargon. Colonel Warden (talk) 07:54, 7 November 2008 (UTC)

Yes, it explicitly does (differ, that is), and has for much longer than my three years on Wiki (although I've seen it sucessfully defended many times in the three years I've been here). I could go into a long explanation of the reasoning, including the number of times it has been looked at, but if you go into the WT:MEDMOS and WT:MED archives, you can find numerous editors who explain it much better than I can, and the discussion here would create an unnecessary diversion. The need for precise terminology in bio/med articles, rather than layperson jargon (which is frequently inaccurate), is better explained by others. SandyGeorgia (Talk) 16:22, 7 November 2008 (UTC)

• I do not have past knowledge of WP:MEDMOS as you do. Are you saying that those discussions conclude that a specific diagnostic term can be picked out from DSM (without conclusive evidence that DSM is the lingua franca for the diagnosis of general depression around the world) with the article content not reflecting the definition of the term as used in the US at least, nor as defined by DSM? You are saying it is agreed that a specific diagnosis can be used as a title for an article that is not primarily on that specific diagnosis but is on a generalized concept that the specific diagnosis on DSM takes care to exclude? —Mattisse (Talk) 17:04, 7 November 2008 (UTC)

• No, I don't believe my comments went into that territory at all. SandyGeorgia (Talk) 17:09, 7 November 2008 (UTC)

• But that is the issue of concern in this section. I assumed your repeated references are addressing the topic of concern here. If not, what is it addressing? —Mattisse (Talk) 17:25, 7 November 2008 (UTC)

• The topic of concern is the article title (since I was specifically addressing Colonel Warden's question about MEDMOS). Per WP:MEDMOS, there is not a problem with the article title: that is the issue I'm addressing as it relates to WP:WIAFA (the article name is in accordance with practice). If you are separately arguing that the article content is not in agreement with the article title, that's another issue. You've elsewhere expressed frustration that the issues you are raising aren't being addressed quickly enough for you. I submit that the task before the FAC nominator would be much easier if your comments weren't spread over multiple sections of the FAC and the article talk page, and repeated in several places. Long discussions spread across multiple sections are hard to keep up with: perhaps you might start a list somewhere. SandyGeorgia (Talk) 17:39, 7 November 2008 (UTC)

• Side note: I have some concerns regarding the second sentence in the article: "The general term depression is better used to describe a temporary depressed or sad mood." I think this should instead clarify that "depression" is often actually used to describe the condition. A quick search on "depression" on Amazon finds books like The Cognitive Behavioral Workbook for Depression and Overcoming Depression One Step at a Time – these books are not about overcoming a "temporary depressed or sad mood". Even in diagnostic composites, we speak of "atypical depression", not "atypical major depressive disorder"... Also, I don't think normative language like "is better used" should be used. Descriptive language is better used. :) I've attempted to correct this. /skagedal^... 09:09, 7 November 2008 (UTC)

• Fully agreed! Cosmic Latte (talk) 10:09, 7 November 2008 (UTC)

I think that you have done a good job of the repair. Snowman (talk) 10:11, 7 November 2008 (UTC)

• Problem with title - The problem with the title is that it gives the impression that the article is really about Major depressive disorder, when it is not. It has been said that the justification for the title is that the use of DSM is worldwide, and therefore the use of the term Major depressive disorder is worldwide. However, there is no proof of this. If a specific diagnostic term is being used, then I think the article should be about the diagnostic term and reflect its definition accurately. The term does not mean depression in general. The way the article is now, 90% of it has nothing to do with the diagnostic term Major depressive disorder. This is misleading and disorienting to anyone who actually knows what the term means. —Mattisse (Talk) 16:40, 7 November 2008 (UTC)

Yes & the other inconsistency is that the subarticles are just called "whatever of depression", as Treatment of depression, Biology of depression, which doesn't even distinguish between this article and Depression (mood) (& that last is itself a bit ambiguous too, because major depression is of course considered a "mood" disorder) EverSince (talk) 05:08, 10 November 2008 (UTC)

To me, having separate articles for Major depressive disorder and Depression (mood) is a bit like having separate articles for "severe bronchitis" and "mild bronchitis." There is nothing magical or genuinely discontinuous about the two-week stipulation about when the mood becomes a disorder (am I just having a "mood" swing if I'm depressed for 1 1/2 weeks? do I have a "disorder" if I'm depressed for 2 1/2 weeks but elated for the rest of my life?). If we merged Depression (mood) into this article, and renamed this one "Depression (psychology)" or "Depression (mental health)" or something like that (just to distinguish it from Depression, which is a disambiguation page), then we could at least tone down the reification that the DSM so generously promotes. But even if we accept the DSM as the psychiatric lingua franca, we still don't hear "major depressive disorder" relatively often in clinical settings. To echo other editors, clinicians talk about "atypical depression," "severe depression," and "postpartum depression"--not "atypical major depressive disorder," "severe major depressive disorder," and "postpartum major depressive disorder"; and, indeed, articles like "Treatment of depression" and "Biology of depression" seem to reflect an understanding that simply calling the disorder "depression" will suffice. Cosmic Latte (talk) 14:55, 10 November 2008 (UTC)

I support the change of the name of this article for the reasons Cosmic Latte and EverSince detail. Also, almost none of the article's sources use the term "Major depressive disorder". I do not think it is a term the general reader would seek out. If a general reader were given a diagnosis of "depression", most likely that diagnosis would not be Major depressive disorder. I do not think Major depressive disorder is the diagnosis of most of the many, many persons taking antidepressants, for example, or probably of those seeking books at Amazon. If I were a general reader, and my doctor told me I was depressed and I went to Wikipedia to look up depression, I don't think Major depressive disorder, a specific disorder, should be what I am redirected to. —Mattisse (Talk) 16:26, 10 November 2008 (UTC)

Unfortunately, many articles are written like this one where depression is used in the title but major depressive disorder is used throughout the article. The term depression is thus used as shorthand for MDD (or the ICD term) in many cases in medical texts, while it has a broader use elsewhere, lay use can include low mood, bereavement, adjustment disorder as well as all the depressions (and dysthymia). If depression (mood) can easily incorporate much of this. I can see the analogy with bronchitis above but heart attack redirects to Myocardial infarction, whereas unstable angina which some may consider a 'heart attack' redirects to angina pectoris - all these things have technical definitions; whereas heart attack and depression don't. MDD is already huge and making it more inclusive would make it enormous. Cheers, Casliber (talk · contribs) 05:35, 11 November 2008 (UTC)

in fact, let's look at which sections are more on MDD and which ones aren't. Symptoms and signs=MDD, Causes=MDD (some of psychological more general but some not, and evolutionary bit more general), Diagnosis=definitely MDD, Treatment = definitely MDD, Prognosis = definitely MDD, Epidemiology (and Comorbidity) = definitely MDD, History is arguable, much of it talks of melancholia which is clearly a pervasive disturbance equated by other authors to MDD more or less and certainly discussed as such, Sociocultural aspects = difficult to say authoritatively as they are historical figures, but often a more pervasive malady is noted. Cheers, Casliber (talk · contribs) 03:24, 12 November 2008 (UTC)

I agree there needs to be a defined scope to this article, but since when did the aim in Wikipedia become deciding which POV to adopt rather than how to best achieve NPOV? It's been implied by omission that MEDMOS favors the DSM-IV term (or others have interpreted statements up above that way) but I assume it only favors a clinical term. All the terms being discussed are used clinically. And the actual Wikipedia naming guidelines say to use the most familiar to readers. Which as has been pointed out is probably not MDD (& the historical source on it in the article says Major depression gained international usage*, it doesn't say MDD did). And while the DSM manual is used more in some ways/regions, the ICD is used more in some (the EU probably & e.g. the British NICE depression guidelines are ICD). Btw I had a look at the MEDLINE MESH subject categories and they use the terms Emotional depression and Depressive disorder, major. On the other hand, PsycInfo, the other database often used in conjunction with MEDLINE in literature reviews on this topic, uses Depression (emotion) and Major depression. EverSince (talk) 03:42, 13 November 2008 (UTC) *although it also notes that of course the ICD avoided the term major depression... & re. the database terms, have to say the distinction between emotion and disorder is also problematic...I recall a book by an Irish psychiatrist, Depression: An Emotion not a Disease. EverSince (talk) 04:12, 13 November 2008 (UTC)

I did think of just plain depression, yet that title is ambiguous (clinical syndrome vs. colloquial usage for state of low mood) - and there is nothing to stop depression (mood) being worked up as a comprehensive GA or FA, as WP is not paper. The vast majoritiy of content here refers to MDD, and yes I am annoyed they didn't leave it at Major depression but had to change it with DSM IV Cheers, Casliber (talk · contribs) 10:14, 13 November 2008 (UTC)

I'm not sure what the reluctance is to take the World Health Organization's ICD in to proper account...only DSM is mentioned in the lead now, justified by title. The recent epidemiological reviews from Canadian journals that Eubulides posted below discuss both DSM & ICD (& the artifical cut-off problem, & consequent high use of "Depression not otherwise specified", how about that for a title? ;) The 2007 World Health Survey results on depression are cited, which used ICD criteria (in 26 countries from the European region, 15 from the African region, six from the Americas, four from the eastern Mediterranean region, five from the southeast Asia region, and four from the western Pacific region, giving a total of 60 countries). Regardless of DSM currently haing a majority here, both are notable, present throughout & worldwide, and so the issue is NPOV (and most titles/abstracts use other clinical terms that don't commit to either). Depression on its own is too unqualified 'cos not even specific to psych usage, but there must be a way of framing this article that is consistent with NPOV & Wikipedia naming guidelines. EverSince (talk) 20:18, 13 November 2008 (UTC)

I agree with EverSince. When this FAC opened, DSM was barely mentioned in the article. It is only after many, many complaints that given that the title was a specific diagnosis from a specific diagnostic manual, the article should conform to this and the article has been increasing subsequently modified to support the title. ICD now is barely mentioned. Yet there is no justification for preferring DSM to ICD.

In the version that was nominated DSM was not even mentioned in the lead.[9] DSM was not mentioned until 3.3 DSM IV-TR and ICD-10 criteria, half way through the article. This has had the effect of limiting the scope of the article (rightfully if it really is on the DSM diagnosis) and preventing an open examination of depression, the problem of artificial cut-off points, the consequent use of vague categories, like "Depression not otherwise specified" or "Adjustment disorder, with depressed mood" and other relevant issues. How many outpatient are told by their "mental health professional" that their diagnosis is "Major depressive disorder"? I would think that number is low to almost none, regardless of how the disorder is coded by the professional. —Mattisse (Talk) 20:58, 13 November 2008 (UTC)