episodes interspersed with periods of hypomania. Some view this condition as a mild variant of bipolar disorder. Dementia. A group of mental disorders involving a general loss of intellectual abilities, including memory, judgment, and abstract thinking. There may be associated poor impulse control and/or personality change. Dementias may be progressive, reversible, or static and have a variety of causes. Dysthymia. A mood disorder characterized by depressed mood and loss of interest or pleasure in customary activities, with some additional signs and symptoms of depression, that is present most of the time for at least 2 years. Many patients with dysthymia go on to develop major depressive episodes. Electroconvulsive Therapy. A treatment method usually reserved for very severe or psychotic depressions or manic states that often are not responsive to medication treatment. A low-voltage alternating current is sent to the brain to induce a convulsion or seizure, which accounts for the therapeutic effect. Hypomania. An episode of illness that resembles mania, but is less intense and less disabling. The state is characterized by a euphoric mood, unrealistic optimism, increased speech and activity, and a decreased need for sleep. For some, there is increased creativity, while others evidence poor judgment and impaired function. Intent-to-Treat Analysis. Analysis of data in terms of the relationship between the number of patients randomized to treatment and the number whose condition improved. Interpersonal Psychotherapy. A time-limited psychotherapeutic approach that aims at clarification and resolution of one or more of the following interpersonal difficulties: role disputes, social isolation, prolonged grief reaction, or role transition. The patient and therapist define the nature of the difficulty and work to its resolution. Maintenance Treatment. Treatment designed to prevent a new mood episode (e.g., depression, mania, hypomania). Major Depressive Disorder. A major mood disorder characterized by one (single) or more (recurrent) episodes of major depression, with or without full recovery between episodes. Mania. An episode of illness usually seen in the course of bipolar I disorder and characterized by hyperexcitability, euphoria, and hyperactivity. Rapid thinking and speaking, agitation, a decreased need for sleep, and a marked increase in energy are nearly always present. During manic episodes, some patients also experience hallucinations or delusions. Manic episodes can also be caused by selected general medical disorders. Melancholic Features. Symptoms usually found in severe major depressive episodes, including marked loss of pleasure, psychomotor retardation or agitation, weight loss, and insomnia. Mood Disorders. A grouping of psychiatric conditions that have as a central feature a disturbance in mood (usually profound sadness or apathy, euphoria, or irritability). These disorders may be episodic or chronic. Obsessive-Compulsive Disorder. A condition that is characterized by the presence of obsessions and/or compulsions. Obsessions are recurrent, intrusive thoughts-usually irrational worries-that often necessitate behaviors to prevent untoward consequences (e.g., fears of contamination from dirt requiring the individual to wear gloves at all times). Compulsions are recurrent behaviors beyond the normal range that the individual feels compelled to undertake, usually to preserve personal safety, to avoid embarassment, or to perform adequately (e.g., checking multiple times to see that the gas is turned off before leaving home). The disorder affects 1 to 2 percent of the population. Open Trial. A trial of a treatment in which both patient and practitioner are aware of the treatment being used. Panic Disorder. An anxiety disorder characterized by discrete intense periods of fear and associated symptoms. Panic disorder may be accompanied by agoraphobia. Remission. A return to the asymptomatic state, usually accompanied by a return to the usual level of psychosocial functioning. Somatization Disorder. A disorder characterized by multiple, often longstanding somatic complaints of bodily dysfunction (e.g., pain complaints, gastrointestinal disturbances). The disorder usually begins before the age of 30 and has a chronic, albeit fluctuating, course. Supportive Therapy. Psychotherapy that focuses on the management and resolution of current difficulties and life decisions using the patient's strengths and available resources. Symptom Breakthrough. The return of symptoms in the course of either continuation or maintenance phase treatment. Vegetative Symptoms. A group of symptoms that refer to sleep, appetite, and/or weight regulation. Contributors These guidelines could not have been developed without the expertise and assistance of many types of contributors who, together, made the effort feasible. All of those listed here willingly assisted in the intense effort required to develop guidelines on an issue as complex as the appropriate treatment of major depressive disorder. The resulting document reflects the many important interactions that occurred during the guideline development process. Depression Guideline Panel Members: A. John Rush, MD, Chair Betty Jo Hay Distinguished Chair in Mental Health Professor and Vice Chairman for Research, Department of Psychiatry Dallas, Texas Dr. Rush received his BA from Princeton University and his MD from the College of Physicians and Surgeons of Columbia University. He is currently the Director of the Mental Health Clinical Research Center, an NIMH-funded center studying the biology, psychology, pharmacology, and psychotherapy of mood disorders. Dr. Rush has published extensively on both the psychology and biology of depression. He has received several NIMH grants to study depression and has helped develop and study the efficacy of cognitive therapy in treatment of depressed outpatients. His research has sought to identify biologic and psychological predictors of specific treatment responses, as well as relapse and recurrence. He serves as the Chair of the DSM-IV Work Group on Mood Disorders for the American Psychiatric Association. Dr. Rush is a Fellow of the American College of Psychiatry, the American Psychiatric Association, and the American College of Neuropsychopharmacology. He is Past President of the Society for Psychotherapy Research. William E. Golden, MD Director, General Internal Medicine Associate Professor, Department of Medicine Dr. Golden received his AB from Brown University (1975) and his MD from Baylor College of Medicine (1978). He completed his internal medicine residency and chief residency at Rush-Presbyterian St. Luke's Medical Center in Chicago (1983). Dr. Golden is Director of the Quality Assurance Research and Education Center, Director of the Division of General Internal Medicine, and Associate Professor of Medicine at the University of Arkansas for Medical Sciences. He is currently Chairman of the Quality Assurance Committee of University Hospital. He has had several funded projects in quality assurance and has expertise in perioperative care and medical informatics. He has authored more than 40 journal articles and book chapters on perioperative care, medical education, and quality improvement. Dr. Golden is a trustee of the American Society of Internal Medicine and a member of the board of directors of the American Medical Review Research Center. He serves on the American Medical Association Council on Medical Education and has recently been appointed to the Liaison Committee on Medical Education. He is a member of many internal medicine societies and has served numerous roles in educational activities and policy-making matters for these organizations. Gladys Walton Hall, PhD, MSW Associate Professor, School of Social Work Howard University Washington, District of Columbia Dr. Hall received her BS from Morgan State University (1966), MSW from the University of Connecticut (1971), and PhD from the University of Maryland (1982). She recently completed a post-doctoral fellowship at the National Institute of Mental Health (1990). Dr. Hall teaches clinical social work methods courses and is a licensed clinical social worker with experience in the private and public sectors. Her private practice is in a comprehensive medical setting and includes the treatment of depressed women. She has authored several publications in the area of depression (childhood depression) and served on various professional boards, both national and local (including the D.C. Mental Health Association). Her research focus is on the psychosocial factors related to the co-morbidity of depression and conduct disorder among children. Col. Moses Herrera, MD Dr. Herrera is a Fellow of the American Academy of Family Practice. He has many years of experience in the practice of family medicine, including obstetrics, geriatrics, pediatrics, and adolescent medicine, as well as in short-term psychotherapy and in the diagnosis and treatment of depression. He has served on the Mental Health Committee of the American Academy of Family Practice. With his experience, Dr. Herrera |