Literature review on depressive disorders

Literature review on depressive incommodes slump is atomic number 53 of the or so prevailing medical ail custodyts. Depression has been recognized as a distinct pathological entity from early(a) Egyptian measures (Reus, 2000).Depression is the or so coarse psychiatric overthrows. Each year, more than 100 million pack worldwide smash clinical falling off (Bjornlund, 2010). During a lifetime, it is estimated that between 8% and 20% of the prevalent population will experience at to the lowest degree oneness clinically evidentiary contingency of embossment (Kessler et al., 1994).Major prohibitedset gear causes the fourth-highest burden of disease among all medical diseases. It is expected to rise to flash place, preceded only by cardiovascular disease by 2020 (Thompson, 2007).Depressive disorder has large potential morbidity and mortality. Suicide is the second leading cause of finis in souls aged 20-35 years. Depressive disorder is a study factor in around 50 % of these deaths (Semple et al., 2005).A felo-de-se attempt among patients with study depressive disorder is associated with the presence and severity of depressive symptoms. Lack of partner, previous self-destruction attempts and time washed-out in falloff atomic number 18 essay factors of suicide attempts. Reducing the time of stamp is a probably forbidive measure of suicide (Sokero et al., 2005).Depression is a medically probatory delay that involve to be diagnosed and in good order treated. It is a everlasting(a) disorder, tend to recur, and it costs the individual and society (Stefanis Stefanis, 2002).Epidemiology of Depressive Disorderspreponderance and IncidenceStudies show substantial variability in the lifetime put of low gear. Lifetime grade atomic number 18 ranging from under 5 percentage to 30 percent, but it is widely accepted that the lifetime prevalence is between 10 percent and 20 percent. The 6-month prevalence drift is considered to be betwe en 2 percent and 5 percent based on surveys in around(prenominal)(prenominal) countries (Young et al., 2010).A cross- sectional WHO world health survey carried out in 60 countries covering all regions of the world showed a 1-year prevalence of depressive issue of 3.2 percent, with a 95 percent office interval of 3.0 percent to 3.5 percent (Moussavi et al., 2007). The life time prevalence of depression for bountifuls varied from 3 percent in Japan to 16.9 percent in the US, with most countries in the range between 8 percent and 12 percent (Andrade et al., 2003).The prevalence of study depressive disorder is estimated to be somewhat 2 percent in electric razorren (Birmaher et al., 1996). Estimates of the foreland prevalence of MDD in adolescence is range from 0.4 percent to 8.3 percent. Lifetime prevalence rates across adolescence range is from 15 percent to 20 percent (Roberts Bishop, 2005).In Dubai the prevalence of depressive disorders were 13.7% among women mostly neurot ic depression (Ghubash et al., 1992).About 12-20% of persons experiencing an acute episode develop a continuing depressive syndrome, and up to 15% of patients who mother depression for more than one month commit suicide (Reus, 2000).Risk Factorsgenetic science in that location is at one time substantial evidence that the genetic factors atomic number 18 of study importance as encounter factors for vulnerability to major depression. Traditional estimates constitute put the heritability most 40 % (Joyce, 2003). Genetic influences are most pronounced in patients with more severe forms of depressivedisorder and biological symptoms. The morbid jeopardize in first-degree relatives is change magnitude in all studies. This elevation is independent of the effects of environment or upbringing. In fewer severe forms of depression, genetic factors are fewer probatory and environmental factors relatively more of the essence(predicate) (Souery et al., 1997). sex activityMajor dep ressive disorder is the twofold greater prevalence in women than in men independent of country or culture. The reasons for the difference are ruminated to reckon hormonal differences, the effects of childbirth, and differing on psychosocial handkors for women and for men (Sadock Sadock, 2007).AgeMajor depressive disorder passs in all cultures and affects all age groups. Depression is common in childishness and late adult. The mean age of onset is generally in the 30s (Dunner, 2008).Early-onset depression is associated with a higher female to a male proportionality than late-onset depression. The incidence of major depressive disorder in old age is degrade in both(prenominal) sexes. However, first incidence and prevalence of minor depressive disorder shows the opposite trend (Rihmer Angst, 2009).PersonalityIn younger pot, mild depression tends to affect anxious or dependent personalities with ugly tolerance of stress. distasteful depressive illness in middle age tends to affect hard- deeding, conventional raft with high standards and obsessional traits. Obsessional personalities can find it, particularly arduous to adapt to stress or life changes, as in work or births, and this can come out as depression (Gill, 2007).Childhood experiencesEarly theorizing suggested that the loss of a call forth in childhood augmentd the later risk for major depression. However, many studies set about examined this issue they assume in un contrastingiatedly found it to be a risk factor foradult depression (Tennant, 1988). Childhood sexual abuse has been established as a risk factor for adult major depression (Joyce, 2003).Marital spatial relationRates of depressive illness is lower in the married man than in the single, widowed, or divorced. The protective effects of marriage are less marked in women. Young married women with children have high rates of depression single women have low rates (Gill, 2007). However, those in a vile marriage with deficient i ntimacy are at increase risk of depression (Weissman, 1987).Social classes and occupationPeople of low socio-economic status (i.e. low levels of income, employment, and education) are at higher risk of depression (Semple et al., 2005).While argumentation satisfaction can enhance mental well-being, the workplace can similarly be a source of stress and depression. However, the consequences of unemployment probably have out-of-the-way(prenominal) changed on mental health. The economic hardship to the unemployed and their families with depression overdue to long- edge unemployment hindering job seeking and re-employment chances, exacerbated by loss of confidence and perceived loss of skills (Strandh, 2001).Depression is more common in urban than a rural district (Gill, 2007).Physical illnessHaving a degenerative or severe physical illness is associated with an increased risk for depression. This suggests that the stress associated with a sedate or chronic physical illness white thorn act by bringing out an individuals lifetime vulnerability to depression (Joyce, 2003).Etiology of Depressive DisordersThe etiology of major depressive disorder is unknown (Dunner, 2008). Multiple etiologic factors genetic, biochemical, psychodynamics, and socio-environmental whitethorn interact in complex ways to cause major depressive disorder (Loosen Shelton, 2011).GENETIC MODELS OF economic crisis there is evidence to suggest a genetic basis for the major depression disorder. Occurrences of major depressive episodes are all the way cluster in families. This degree of increased risk is about trey to five quantify that of the normal population.Twin and adoption study is consistent with a genetic contribution to major depressive disorders. However, studies suggest that other factors similarly are important (Schiffer, 2008). Actually, it is the tendency to beget depressed in chemical reaction to life events that are inherited (Hirschfield Weissman, 2002). Moreover, fam ily and twin studies show a lighten genetic component of life events themselves (Kendler Karkowski, 1997).ENDOCRINE MODELS OF DEPRESSIONNeuroendocrine abnormalities that radiate the neurovegetative signs and symptoms of depression include first, increased cortisol and corticotrophin-releasing endocrine gland (CRH) secretion, second, an increase in adrenal size, third, a rock-bottom inhibitory response of glucocorticoids to dexamethasone, and fourth, a dulled response of thyroid-stimulating hormone (TSH) level to infusion of thyroid-releasing hormone (TRH). Antidepressant interposition leads to normalization of these pituitary-adrenal abnormalities (Reus, 2008).Thyroid hormone whitethorn potentiate both the secureness and the efficacy of antidepressant medication (Altshuler et al., 2001). Furthermore, there also evidence that patient resistant to other intercessions may respond to addition of thyroid hormone (Joffe Marriott, 2000).NEUROCHEMICAL MODELS OF DEPRESSIONThe most f amous hypotheses generated to account for the actual mechanism of the modality disorder focus on regulatory disturbances in the monoamine neurotransmitter systems, particularly that involving norepinephrine and serotonin (5-hydroxytryptamine). It has also been hypothesized that depression is associated with an alteration in the acetylcholine-adrenergic balance and characterized by a relative cholinergic dominance. In addition, there are suggestions that dopamine is functionally fall in some cases of major depression.Original authorships suggesting that patients with endogenic depression experienced each decrease noradrenergic or serotonergic activity now appear to be overly simplistic. All the monoamine neurotransmitter systems are interrelated and work to compensatory adaptation to perturbation over time (Reus, 2000).CELLULAR MODELS OF DEPRESSION just about current hypotheses of neurotransmitter function in altered body fluid states have cerebrate on changes in receptor se nsitivity and second messengersystems. With a few exceptions long-term antidepressant treatment is associated with reduced postsynaptic -adrenergic receptor sensitivity and enhanced postsynaptic serotonergic and cyclic adenosine monophosphate activity (Reus, 2000).A number of intracellular changes which need alterations in cellular second messenger systems and ion channels are postulated to transcend in depression. Intracellular changes may involve changes in guanine triphosphate cover song proteins, G-proteins on the receptor, cyclic adenosine monophosphate (cAMP) regulation, reduced protein kinase activity and thought derived neurotrophic factor (BDNF). Antidepressants as well as ECT increase BDNF and BDNF have been found to increase functioning of serotonin (Kay Tasman, 2006).NEUROIMAGING MODELS OF DEPRESSIONRecent rapid advances in neuroimaging methodology have attempted to relate the phenomenological abnormalities seen in depression tochanges in brain structure and functi on (Fu et al., 2003). There is increasing evidence that depression may be associated with morphologic brain pathology. Magnetic resonance imaging (MRI) has revealed decreased volume in cortical regions, particularly the frontal cortex, but also in subcortical structures, much(prenominal) as the hippocampus, amygdala, cau assignment, and putamen (Sheline Minyun, 2002).The most widely replicated positron emission tomography (PET) scanning (PET) finding in depression is decreased anterior brain metabolism, which is generally more pronounced on the go forth side. In addition, increased glucose metabolism has been observed in several limbic regions (Thase, 2009).Neuroimaging has also helped in the further investigation of the neurochemical deficits in depression. The largest study to date using PET found a marked global diminution in brain 5-HT2 receptor binding (22-27%) in various regions (Sheline Minyun, 2002).There is an increasing literature using neuroimaging to understand unsafeity, particularly in depression. Mann (2005) cites several imaging studies suggesting decreased serotonin function in suicidal individuals and decreased activity in associated areas of the dorsal system involved in sense regulation, such as the anterior cingulate. A number of regions more specic to suicidality are also highlighted, particularly those that seem to be involved in impulsivity and aggression, such as the accountability lateral temporal cortex, right frontopolar cortex, and right ventrolateral prefrontal cortex (Goethals et al., 2005). This literature has as well found structural abnormalities in relevant regions of the dorsal system, particularly the orbitofrontal cortex, which has specically been linked to potential finality qualification decits that could lead to suicidality. Thus, such data potentially suggest clinically important subtype differentiation in brain function for this symptom (Ingram, 2009).PSYCHOSOCIAL FACTORS stressful life events more ver y much precede first, instead than subsequent, episodes of mood disorders. somewhat clinicians believe that life events play the primary or principal case in depression others suggest that life events have only a limited character in the onset and timing of depression. Data signalize that the life event sometimes associated with development of depression is losing a parent before age 11. The loss of a spouse is the environmental stressor most a great dealassociated with the onset of an episode of depression.A nonher risk factor is unemployment persons out of work are three times more likely to report symptoms of an episode of major depression than those who are employed (Sadock Sadock, 2007).PSYCHOLOGICAL FACTORSPSYCHODYNAMIC THEORIES OF DEPRESSIONPsychoanalytic possibleness as postulated by both Freud and Abraham emphasized the companionship between mourning and melancholia. The melancholic patient experiences a loss of self-importance esteem with associated helplessness, bounteous viciousness and self deprecation. According to the theory, these symptoms result from internally directed anger or aggression turned a drawst the self, leading to a depressive experience (Kay Tasman, 2006).Melanie Klein understood depression as involving the expression of aggression toward love ones. Edward Bibring regarded depression as a phenomenon that sets in when a person becomes alive(predicate) of the discrepancy between extraordinarily high ideals and the inability to meet those goals. Edith Jacobson truism the state of depression as similar to a powerless, helpless child victimized by a tormenting parent.Silvano Arieti observed that many depressed people have lived their lives for someone else (a principle, an ideal, or an institution, as well as an individual) rather than for themselves. Heinz Kohuts conceptualization of depression, derived from his self-psychological theory, rests on the assumption that the create self has peculiar(prenominal) needs that essential be met by parents to give the child a irresponsible sense of self-esteem and self-cohesion. When others do not meet these needs, there is a massive loss of self-esteem that presents as depression. John Bowlby believed that damaged early attachments and traumatic separation in childhood predispose to depression. Adult losings are said to revive the traumatic childhood loss and so precipitate adult depressive episodes (Sadock Sadock, 2007).Interpersonal Theory (IPT)Interpersonal theory focuses on difficulties in current interpersonal functioning. In IPT, depression is held to relate to one or more of four functional areas grief, interpersonal role disputes, role transitions, and interpersonal deficits.In IPT, the reciprocal relationship between ones mood and interpersonal events is investigated. Stressful life events may overwhelm coping ability and call forth a depressed mood, which then contributes to ongoing interpersonal difficulties. Once this relationship is ident ified, modifying it becomes the focus of treatment (Grunze et al., 2008).THE COGNITIVE MODELCognitive theories of depression hypothesize that particular negative ways of thinking increase individuals probability of developing and maintaining depression when they experience stressful life events. According to these theories, individuals that possess specific maladaptive cognitive patterns are vulnerable to depression because they tend to develop negative information actioning about themselves and their experiences (Sanderson McGinn, 2001).Behavioral ModelsMartin Seligman developed the theory of learned helplessness as he was searching for an animal ride of depression. In this formulation, individuals in stressful situations in which they are unable to prevent or alter an aversive stimulus (i.e., physical or mentalal pain) withdraw and make no further attempts to escape even when opportunities to ameliorate the situation become available (Reus, 2000).Clinical Features of Depressi ve Disorders blue mood is the most characteristic symptom, occurring in over 90% of patients. The patient usually describes himself or herself as flavor sad, low, empty, hopeless, gloomy, or down in the dumps. The physician often observes changes in the patients posture, speech, faces, dress, and grooming consistent with the patients self-report. A small percentage of patients does not report a depressed mood, usually referred to as masked depression. Similarly, some children and adolescents do not exhibit a sad demeanor, presenting instead as rasping or odd (Loose Shelton, 2008).Anhedonia manifests with a lose of interest in formerly pleasurable activities sports and hobbies, etc. no longer arouse patients, and if they puff themselves to partake, they take no amusement in such activities. Libido is routinely deep in thought(p) and there is no pleasure in sexual activity (Moore, 2008).Depressed individuals frequently report cognitive changes that include impaired attention, concentration, and decision qualification (Woo Keatinge, 2008).Sleep may be increased or decreased. Insomnia is one of the major manifestations of depressive illness and is characterized more by multiple awakenings, especially in the early hours of the morning than by difficulty falling a quiet. Young depressive patients, especially those with bipolar tendencies, typically complain of hypersomnia, sleeping as long as 12 to 15 hours a day. Obviously, such patients will have difficulty getting up in the morning.Although decreased sexual desire occurs in both men and women, women are more likely to complain of infrequent stop or cessation of menses. Decrease or loss of libido in men often results in erectile failure (Dunner, 2008).Appetite can be decreased or increased with or without weight loss or gain the most typical pattern is a decrease in desire with weight loss (Faravelli et al., 2005).Psychomotor disturbances include, on the one hand, tumult and on the other, ineptness. Agitation, usually accompanied by anxiety, irritability and restlessness, is a common symptom of depression. In contrast, retardation, manifested as slowing of bodily movements, mask-like facial expression, continuation of reaction time to stimuli, increased speech paucity. The extreme form of retardation is an inability to move or to be mentally and emotionally spark off (stupor) (Stefanis Stefanis, 2002).The attitude and outlook of these patients may become profoundly negative and pessimistic. They have no hope for themselves or for the future. Self-esteem sinks and the workings of conscience become prominent. Patients see themselves as worthless, as having never done anything of value. Rather they see their sins multiply before them (Moore Jefferson, 2004).Suicidal ideation is almost always present. At times this may be merely passive and patients may wish loudly that they might die of some disease or accident. Conversely, it may be active, and patients may consider hanging o r shooting themselves, jumping from bridges, or overdosing on theirmedications. Often the risk of suicide greatest as patients go about to recover. Still seeing themselves worthless and hopeless sinners, these patients, now with some residuum from grind, may find themselves with enough energy to carry out their suicidal plans.The overall suicide rate in major depressive disorder is about 4 percent among those with depressive episodes severe enough to prompt hospitalization, however, the rate rises to about 9 percent (Moore, 2008). Up to 15 percent of untreated or unsatisfactorily treated patients give up hope of ever convalescent and kill themselves (Akiskal, 2009).Proximal risk factors for suicide include agitation, current suicidal intent or plan, severe depression and/or anhedonia, instability (e.g., intoxicant abuse or decline in health), recent loss, and availability of a lethal agent. Distal risk factors include a current suicidal intent with a plan, personal or family his tory of suicide, aggressive or impulsive behavioral pattern, poor response to treatment for depression, poor treatment alliance, a history of abuse or trauma, and/or middle or alcohol abuse (Hawton Harriss, 2007).Paranoid symptoms can occur among patients with major depression. There are usually exaggerated ideas of reference associated with notions of maladroitness. Characteristic delusions of patients with depression are those of a hypochondriacal or nihilistic type. Hallucinations may also occur in major depression. These commonly involve accusatory voices or visions of dead person relatives associated with feelings of guilt (North Yutzy, 2010).Adolescent-onset depression often takes on a more chronic course associated with dysthymic symptoms. In adolescence, MDD appears to be associated with greater frighten off, worthlessness and more prominent vegetative signs. The sequelae of depression in children and adolescents are sometimes characterized by severance in school perf ormance, social withdrawal, increased behavioral disruption and substance abuse (Kay Tasman, 2006).Among the elderly, agitation and hypochondriacal concerns are common, and indeed the patient may deny feeling depressed at all. Memory and concentration may be so impaired in demented elderly. In the past, this has been called a pseudodementia, presumably to distinguish it from other kinds of dementia. However, a better, more recent term is dementia syndrome of depression (Moore Jefferson, 2004).Elderly people are more likely than younger adults to have a depressive illness that goes undetected and thus untreated, which may contribute to the high riskof suicide among older patients. The suicide rate of this population is higher than for any other age group, and the attempts are serious One out of four succeeds, compared with one out of two cardinal for young adults (Bjornlund, 2010).Diagnosis and Classification of Depressive DisordersDepression conceives a variety of psychic and som atic syndromes, and the diagnosis is derived from diligent clinical musing (Grunze et al., 2008).Depression as a term in popular use is mostly considered to be synonymous with low mood or grief. Depression mental (and medical) disorder, however, is different, and as well as low mood, is characterized by a variety of additional symptoms (Grunze et al., 2008).Depressive disorders are delimit by clinically derived standard diagnostic criteria of emotional, behavioral, cognitive, and somatic symptoms, and associated with functional impairment. They are assessed through structured clinical interviews and rumination. The symptomatic and Statistical Manual of amiable Disorders (DSM-IV American psychiatric Association, 2000) and International Classification of Diseases 10 (ICD-10 World wellness Organization, 1992) use the selfsame(prenominal) criteria to diagnose depressive disorders in children, adolescents, and adults (Roberts Bishop, 2005).The term affect usually refers to the out ward and changeable manifestation of a persons emotional tone, whereas mood is a more enduring emotional orientation that colors the persons psychology (American psychiatrical Association, 1984).Subtypes of Depressive DisordersMajor Depressive Disorder (MDD)According to DSM-IV-TR, a major depressive disorder occurs without a history of a manic, mixed, or hypomanic episode. A major depressive episode mustiness last at least 2 weeks. Typically, a person with a diagnosis of a major depressive episode also experiences at least four symptoms from a list that includes changes in lust and weight, changes in sleep and activity, lack of energy, feelings of guilt, problems thinking and making decisions, and recurring thoughts of death or suicide (Sadock Sadock, 2007). instrument panel 1.1.1 shows DSM-IV-TR criteria for major depressive episode.Unipolar and Bipolar DepressionWhen a person develops an episode of mania they are conventionally identified as wretched from bipolar disorder. P atients with depressive episodes only are diagnosed as having unipolar depression (Baldwin Birtwistle, 2002). melancholic DepressionIndividuals with melancholic depression experience a loss of pleasure in all or almost all activities or are nonreactive to usually pleasurable activities (American Psychiatric Association, 2000). In addition, according to the DSM-IV-TR, the individual must display three or more symptoms from a list of six, such as worsening depression in the morning, early morning awakening, significant weight loss or anorexia, and the perception that ones mood is qualitatively different from that experienced in other contexts. Melancholic depression is considered a severe form of affective illness (Woo Keatinge, 2008).Self-belittlement, an exaggerated sense of guilt, a feeling that life is pointless and that one has failed in everything are very often accompanied by severe recurrent suicidal thoughts and thoughts about death. However, the risk of suicide usually fir st becomes prominent when the patient is in the process ofimprovement and the psychomotor inhibition decreases while, at the same time, expectations about the mental object to cope with the psychosocial situation are still very negative (Wasserman, 2001). tabular array 1.1.1 DSM-IV-TR criteria for major depressive episodeFive (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.Note Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations.depressed mood most of the day, nearly every day, as proved by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). Note In children and adolescents, can be irritable mood.markedly diminished interest or pleasure in all, or almost all, activities most of t he day, nearly every day (as indicated by either subjective account or observation made by others)significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note In children, consider failure to make expected weight gains.insomnia or hypersomnia nearly every daypsychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)fatigue or loss of energy nearly every dayfeelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)recurrent thoughts of death (not just disquietude of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a spec ific plan for committing suicideThe symptoms do not meet criteria for a mixed episode.The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).The symptoms are not better accounted for by bereavement, i.e., after(prenominal) the loss of a loved one. The symptoms persist for longer than two months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, insane symptoms, or psychomotor retardation.Source. Reprinted from American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000.Masked DepressionAbout 50% of major depressive episodes are unrecognized because depressed mood is less obvious than other symptoms of the disorder. Alexithymia, or inability to express emotions in words, can focus a patients attention on physical symptoms of depression, such as insomnia, low energy,and difficulty concentrating, without any sensation of feeling depressed. Common masked presentations of major depression include marital and family conflicts, absenteeism from work, poor school performance, social withdrawal, loss of a sense of humor, and lack of motivation (Joska Stein, 2008).Seasonal depressionSeasonal depression is a condition in which depressed mood accompanied by lethargy, excessive sleep, increased appetite, and irritability recurs each winter. It was believed to respond exclusively to light treatment. However, recent studies indicate it can be just as effectively managed with standard methods of treatment, such as medication (Gill, 2007).Psychotic DepressionThe term psychotic depression (or delusional depression) refers to a major depressive episode accompanied by psychotic features (i.e., delusions and/or hallucinations). Most studies report that 16%-54% of depressed patients have psychotic symptoms. Delusions occur without hallucinations in one-half to two-thirds of the adults with psychotic depression, whereas hallucinations are unaccompanied by delusions in 3%-25% of patients. Half of all psychotically depressed patients experience more than one kind of delusion (Dubovsky Thomas, 1992).Dysthymic DisorderDysthymia refers to symptoms of mild depression, which have persisted for at least two years. Symptoms fluctuate more than in major depression, and they are typical including insomnia, lack of appetite, or poor concentration (Bech, 2003). two-bagger DepressionDouble depression characterized by the development of MDD superimposed upon a mild, chronic dysthymic disorder (DD). Individuals with double depression often demonstrate poor interepisode recovery. Furthermore,25% of the depressed individuals manifest double depression (First Tas man, 2006).Table 1.1.2 shows DSM-IV-TR criteria for dysthymic disorder.Table 1.1.2 DSM-IV-TR diagnostic criteria for dysthymic disorderDepressed mood for most of the day, for more eld than not, as indicated either by subjective account or observation by others, for at least 2 years. Note In children and adolescents, mood can be irritable and duration must be at least 1 year.Presence, while depressed, of two (or more) of the followingpoor appetite or overeatinginsomnia or hypersomnialow energy or fatiguelow self-esteempoor concentration or difficulty making decisionsfeelings of hopelessness