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Epidemiology

• Depression is a major cause of morbidity the world over: Is not over the world?

changed it to "worldwide" (the world over is a quaint english idiom anyway) Cheers, Casliber (talk · contribs) 10:39, 21 October 2008 (UTC)

• In the year 2030, it is predicted to be the second leading cause of disease burden worldwide (after HIV), according to the World Health Organization: Are the brackets really needed? (I would eliminate them)

parentheses duly removed Cheers, Casliber (talk · contribs) 10:39, 21 October 2008 (UTC)

Comments by delldot ∇.

Wow, very much improved since the peer review I gave it, it's a really great read now, very well organized and informative. Most of these are very minor points about wording.
Lead *However, the relief of symptoms usually occurs several weeks or more after changes in neurotransmitter levels, which suggests that the precise role of neurotransmitter levels in depressive illness is still not fully understood. - Sounds a little repetitive with two uses of 'neurotransmitter levels'. Also use of 'suggests' seems a little weird there; wouldn't we know for sure whether it's fully understood?

Has been changed in the course of this FAC, and you are right BTW Cheers, Casliber (talk · contribs) 10:56, 21 October 2008 (UTC)

*Is there a reason why 'percent' is used in the lead and % is used elsewhere? ::No idea...will check MOS, if nothing there then a symbol it shall be... Cheers, Casliber (talk · Misplaced Pages:MOS#Percentages - erm, not sure. Having read this, ee could go either way I guess. Cheers, Casliber (talk · contribs) 10:59, 21 October 2008 (UTC)

I would make it consistent one way or the other. I think more scientific articles tend to use %. delldot ∇. 03:11, 22 October 2008 (UTC)

agree on thinking about it; done Cheers, Casliber (talk · contribs) 15:01, 22 October 2008 (UTC)

Signs and symptoms

• Could you shorten this without losing meaning? in the typical pattern, a person reports waking very early and being unable to get back to sleep → in the typical pattern, a person wakes very early and is unable to get back to sleep (done) Cheers, Casliber (talk · contribs) 08:41, 21 October 2008 (UTC)
• Those older than 12 years may also begin abusing drugs or alcohol, or exhibit disruptive behavior. -- This kind of makes it sound like kids under 12 never do this, I imagine it's supposed to mean something more like kids over 12 are more likely to, but it's not impossible in younger kids either. Also, just mentioning drugs and alcohol in the peds para makes it sound like that's not a symptom in adults; I thought it was.

(forgot this one) - ok, although substance use does occur in adults with depression, these people are usually (a) more able to articulate their feelings and (b) more likely to have a low mood - teenagers are less likely and also often have an irritable mood, hence it is more in what else is seen around it so to be more mindful of it in this age group (as it is less obvious), or something like it :) Cheers, Casliber (talk · contribs) 03:48, 25 October 2008 (UTC)

I think I see what you're saying, it's not as much of a symptom in adults, more of a comorbidity? delldot ∇. 05:02, 27 October 2008 (UTC)

Causes

• ...the idea that some components of depression are adaptations. This is a surprising assertion, could we have an example? What could possibly be adaptive about depression?

• The elaboration currently comes toward the end of the article, in Sociocultural aspects--i.e., depression can elicit social support, or it can work in a way analogous to physical pain by preventing hasty actions. Maybe something about this should be said earlier? Cosmic Latte (talk) 07:07, 21 October 2008 (UTC)

• Maybe allude to that then (e.g. "see below", although I don't know if that per se is accepted practice). delldot ∇. 06:36, 24 October 2008 (UTC)

• Most antidepressants increase synaptic levels of the monoamine neurotransmitter serotonin. - this is the first use of 'monoamine', maybe give a bit of an explanation of what it means?
• tianeptine and opipramol, have been known about for a long time. -- 'been known about' sounds weird.
• A depressive episode may also be triggered by a loss of religious faith. - non-sequitur there, maybe would fit in with a list of events that can precipitate it (e.g. Vulnerability factors—namely early maternal loss...).
• an external locus of control, a tendency to attribute outcomes to external events perceived to be uncontrollable. - it's better to avoid reusing a word from the term you're trying to define in the definition (e.g. 'external is external').
• What's going on with the two different sets of quotation marks here: "In mourning 'it is the world that has become poor and empty; in it is the ego itself.'" Who's saying what?

• The article authors are quoting Freud, but the initial "In mourning" comes from the article authors themselves. Cosmic Latte (talk) 07:09, 21 October 2008 (UTC)

• Maybe reword to avoid having to quote the article writers then--two sets of quotes is confusing. delldot ∇. 06:36, 24 October 2008 (UTC)

• parents have problems with alcoholism -- this strikes me as redundant, maybe because it seems like alcoholism would always be problematic. Maybe parents are alcoholic or have problems with alcohol.

yep, good tautological pickup, changed to "..a parent with alcoholism" Cheers, Casliber (talk · contribs) 09:48, 21 October 2008 (UTC)

Diagnosis

• If you're looking for material to cut down for length, you could remove the para starting Specialist mental health services are rare in rural areas... this is not remarkable for depression probably, it would be the case for everything. (Or cut it down).

I have mixed feelings about this. Tony noted a first-world bias about the article and wondered if/how it could be addressed. I actually feel it is important to briefly touch on the contrast between urban first-world services and developing countries (and even rural Australia for that matter!). It is important WRT MDD as it is often thought a disorder of developed countries only, yet data shows it worldwide. Cheers, Casliber (talk · contribs) 09:43, 21 October 2008 (UTC)

Ah, no problem then. delldot ∇. 06:36, 24 October 2008 (UTC)

Prognosis

• I think it should be 40–70% rather than 40% to 70% per WP:MOSNUM# Percentages. (done)Cheers, Casliber (talk · contribs) 08:38, 21 October 2008 (UTC)

Refs

• Some journal titles are abbreviated, some aren't. Some abbreviations have periods, some don't. I don't mind helping to go through and make these consistent if you let me know which style you prefer for all of them.

• Aargh, thought I got 'em all. Go for it! Cheers, Casliber (talk · contribs) 08:37, 21 October 2008 (UTC)

Which style? delldot ∇. 03:11, 22 October 2008 (UTC)

• Isn't the first letter after a colon in an article title supposed to be capitalized? Again I don't mind doing it myself as long as I know I'm supposed to. Either way it should be made consistent.

Ditto. Cheers, Casliber (talk · contribs) 08:37, 21 October 2008 (UTC)

Caps after the colon, right? delldot ∇. 03:11, 22 October 2008 (UTC)

Great work overall! More comments to follow. delldot ∇. 06:43, 21 October 2008 (UTC)

• Support—although I must disclose that I copy-edited the lead and first one or two sections last month. I hope that this is the first of a run of articles in a woefully undertreated part of WP (psychiatry and psychology) in which Casliber puts his considerable expertise to great public benefit. I'd like to return and make a few detailed comments. Here's one: " A depressive episode may also be triggered by a loss of religious faith." I think this is oddly prominent in the rather short lead para to the section "Psychological", and the Journal of Religion and Health, although published by Springer, is hardly a mainstream source in the field. The article is from 36 years ago; is it relevant nowadays? BTW, can you insert "causes" after the solely adjectival subtitles in the "Causes" section? They look strange, and I think MoS says titles should usually be nominal groups. Tony (talk) 08:28, 22 October 2008 (UTC)

Thanks, I was trying to keep subheadings as succinct as possible, but agree above improvement sounds good. An opinion on whether a bracketed explanation of delusions and hallucinations (i.e. whether we should have them or not) would be appreciated, as I am torn/on the fence with this one. Cheers, Casliber (talk · contribs) 08:55, 22 October 2008 (UTC)

• Support as contributor. Cosmic Latte (talk) 09:31, 22 October 2008 (UTC)

• Support as a minor contributor. I think it was well-written, and this process is great. I must have read the article 5 times, and I didn't see half the points that have been pointed out. I'm embarrassed that I missed the Alzheimer's EEG issue, since I helped write the Alzheimer's with Garrondo. I'm kicking myself. Anyways, excellent article. OrangeMarlin 14:26, 22 October 2008 (UTC)

• Comment on prose - The prose is rather dull and repetitious. For example, the overuse of "may", which is a weak, vague word, in the Biological causes section:

They may also enhance the levels of two other neurotransmitters, norepinephrine and dopamine.

Norepinephrine may be related to alertness and energy as well as anxiety, attention, and interest in life;

Serotonin may help regulate other neurotransmitter systems,

and decreased serotonin activity may allow these systems to act in unusual and erratic ways

Facets of depression may be emergent properties of this dysregulation

There may be a link between depression and neurogenesis of the hippocampus

Drugs may increase serotonin levels in the brain

This increase may help to restore mood and memor

Depression may also be caused in part by an overactive hypothalamic-pituitary-adrenal axis

Depression may be affected by variations in the circadian rhythm.

Can this be worded better? There is one paragraph in this section that does not contain the word "may", starting with "In the past two decades, research has uncovered multiple limitations of the monoamine theory, and its inadequacy has been criticized within the psychiatric community..." and this paragraph is by far the clearest, most straightforward one in the section. And it does not use the passive voice which improves it. In general, so much use of the passive voice in this section makes for less interesting reading. —Mattisse (Talk) 00:56, 23 October 2008 (UTC)

delldot noted lots of "may"s a while ago and I did a big sweep through; I ddid notice some more but you have pointed out a fair few. The issue is alot of the ideas in the paragraph are not definite but conjectural. Nevertheless, I will do a sweep-through and see if we can "mix up" the prose a little. Cheers, Casliber (talk · contribs) 05:15, 23 October 2008 (UTC)

You can do better that "conjectural", can't you? "The evidence of .... indicates..."; The majority of recent literature supports the theory that..."; "There is evidence to support..."; Studies, including those of so-and-so, support the hypothesis that..." etc. Too tired now but I hope I am conveying the idea. —Mattisse (Talk) 05:57, 23 October 2008 (UTC)

Erm, I should have clarified - I wasn't going to use the word as such in the paragraph. Paul Gene added alot of those sources and he seems to be having a (hopefully temporary) wikibreak. Have to be wary of general "There is evidence.." type statements too, still mixing it up ain't a bad idea. Cheers, Casliber (talk · contribs) 11:51, 23 October 2008 (UTC)

More from delldot ∇.

Some more minor points about the writing:
Diagnosis

• "Postpartum depression, which has incidence rate of 10–15%," among who? Probably among new mothers, but it should be specified. (done)

Treatment

• Too many 'patients' in this sentence: Patients are usually assessed and managed as outpatients, and only admitted to an inpatient mental health unit if they are considered to pose a risk to themselves or others. (dammit, this is a hard one. I have been musing about it for a bit now)

• Maybe "care is usually given on an outpatient basis, but... when there is significant risk..."? Two 'patients' is OK IMO, I just thought three was too much. It's really not a big deal anyway. delldot ∇. 05:02, 27 October 2008 (UTC)

• their overall effect is low-to-moderate. I think this would be low to moderate when you're not using it as an adjective before the noun. (yeah, done)
• If you're looking for material to cut to shorten the article, you could move the discussion on the meta-analyses to another article, e.g. depression research or something. This is probably more detail than the average reader is looking for, is quite technical, and as has been mentioned the article's long. Besides, were these two studies so much more important than the tons of others that have been done that they deserve this prominent mention? I would get rid of the first para under 'Efficacy of medication and psychotherapy' (or leave one sentence of summary) and merge the second into the medication section. (no-one has actually jumped up and down about length this FAC, so right now I am not so fussed, however let's see if I mention it what happens)
• Awkward sentence: Short-term memory loss, disorientation, headache and other adverse effects are common, as are long-term memory and other cognitive deficits, which may persist. changed to "Common initial adverse effects include short-term memory loss, disorientation, headache; long-term memory and other cognitive deficits may persist."

Prognosis

• Do the refs at the end of the para cover the sentence beginning Recurrence occurs in 40–70% ? (they can do, but I didn't enter much of this and I am wondering if a reference was lost or mixed up here. There is no review article for some reason. I will see what I can do) (Actually, that statement duplicated material elsewhere, so I removed it and buffed the sentence two before it.)

Epidemiology

• Researchers who compared epidemiological factors in Canada and the US found the rate of major depression to be twice as high for Americans... Could you just say The rate of major depression is twice as high for Americans... or is the 'researchers' part necessary info? (Upon reading it, yeah, I think it needs a bit of context as it is an interesting stat and maybe kept as qualified - I changed it to " A 2007 study...")
• The epidemiology section could use better organization, it kind of skips around. e.g. Depressive episodes following a heart attack might even correspond with an increased risk of further cardiac complications, including death. and Depressed people also have a higher rate of dying from other causes. could be grouped together as similar concepts. First and third paras both mention gender, and the first and last paras discuss morbidity and disease burden respectively. (reorganised so first para is more prevalence and incidence/age etc, second is more social, 3rd is suicide related. Much of this section was moved from elsewhere late in the peace)

Refs

• There are (were) several links to articles you have to pay to get--I think the consensus is to remove these and link only the abstracts (if there's no PMID, you can link to the abstract like this: "Melancholia: A Historical Review" (abstract). I took out the ones I saw, but can you check the links to make sure the rest are accessible? I didn't take this one out because a lot of people might be able to access it. (NYtimes is free to register I think) (I have checked up to ref 131 but I need to sleep now, more later all good now, removed a couple more. There are some duplicate abstracts still)

Keep up the good work. delldot ∇. 05:03, 25 October 2008 (UTC)

Support. A tough subject, thoroughly handled. It is not an easy read, partly due to the subject matter, but also the prose is quite demanding of the general reader. I couldn't get past the Causes section the first time I tried to read this. A few points:

• "In such cases, clients may be especially unaffected by therapeutic intervention" The word "clients" is inappropriate here. (yep; changed to "patients")
• The quotation beginning "a profoundly painful dejection" isn't verbatim. The quotation beginning "In mourning 'it is the world..." contains single quotes that aren't in the source.
• Lithium isn't wikilinked. (wikilinked now to Lithium#Medical_use)
• The Efficacy subsection has a number of problems.

• The "Two recent meta-analyses" suffers from WP:DATED and should state it looked at SSRIs. It can then be noted that this compares against the older tricyclic imipramine.
• The "Despite obtaining similar results, the authors argued about their interpretation. One author concluded that.. The other author agreed that..He pointed out that" has problems because both meta analyses are multi-author papers and the comments attributed to the second "author" came from a later editorial by two of the five authors of the second meta-analysis. The reader wouldn't be interested in the opinion of (apparently) just two people here. It looks like the statement (which you quote) about "seems little evidence to support" has provoked discussion and is worth citing and attributing to the authors of the first study. My guess is the editorial was just one example of the debate that followed and so that debate should probably be described differently to how it is here. In particular, the glass half empty quote is pretty meaningless and remains so even when you know why glasses are mentioned.
• What isn't clear to the reader (until they get to Prognosis) is what is meant by "improvement" wrt treating depression. With most diseases, folk want to be cured, and might regard treatment as making someone no longer depressed. But it looks like improvment can be regarded as being just a little bit less depressed, and the editorial focussed on how much less depressed is needed in order to judge clinical significance.
• The terms "clinically significant" and "effect size" aren't defined wrt these treatments.
• I'm not sure "their overall effect is low to moderate" is justified by the sources. I may be wrong but it looks more like "non-existent to low".
• It is quite disconcernting to read the Psychotherapy and Medication sections and the discussion of X is "effective" and Y is "effective" and then discover the effect is minimal when you get to the "Efficacy" section. 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."

Colin° 23:51, 27 October 2008 (UTC)

The more I look at the section - Major_depressive_disorder#Efficacy_of_medication_and_psychotherapy - the more I am unsure if its presence actually benefits the article. There are a whole heap of issues regarding antidepressants used in studies - higher effects due to nonpublication of negative results, and lower effects due to differing populations used (eg nonsuicidal patients in trials, whereas a large number do in clinical practice do (which suggests the population we treat are more severe anyway, and many have been depressed alot longer than those entering trials. Looking at it, it needs more material on studies of depressed people etc. to help the reader understand the results, and as it is, it may be too much depth for this general article, and better placed in Treatment for depression, where it can be done justice, with the section reduced to a couple of lines and added to Treatment section (at bottom). What do you reckon, or do you reckon the studies were too important not to be at least discussed here. Cheers, Casliber (talk · contribs) 09:22, 29 October 2008 (UTC)

Whoa! Thanks for the support vote, I will see what I can do. You are welcome to substitute any plainer english word for more technical one without loss of meaning. I do sometimes forget which words are more jargony than others, being 'in the field' and all... :) Cheers, Casliber (talk · contribs) 01:42, 28 October 2008 (UTC)

Image review - There are serious problems with the images in this article:

• Image concerns have now been resolved. Awadewit (talk) 20:27, 29 October 2008 (UTC)

• Image:Synapse Illustration2 tweaked.svg - The image description needs to list the source for the information contained in the image itself.

• I don't know where the image's creator got the info, although it's fairly common knowledge--anyway I added a source that contains the information. Cosmic Latte (talk) 15:46, 29 October 2008 (UTC)

• Image:Sigmund Freud-loc.jpg - "No known restrictions" is not the same as the public domain. You must establish that this image is in the public domain in some way. I am thinking that "copyright not renewed" might be the only way, but that is difficult.

• image is not absolutely central, we only got it as we thought it was PD, so removed

• Image:Albert Ellis 2003 emocionalmente sentado.jpg - We need proof that the copyright owner released this image - I am thinking an OTRS ticket might be required.

• I have commented out ellis image for the moment until OTRS can be done. Cheers, Casliber (talk · contribs) 08:33, 29 October 2008 (UTC)

• Image:Lavater1.jpg - We need the full publication information for the book from which this image came - who published it and where? Were there multiple editions? Also, was the image scanned directly from the book or is this from a website? The commons bot has erased the source information, sadly.

Now I have looked at Public Domain - it is an old drawing from a book published 1775-1778 (Physiognomische Fragmente zur Beförderung der Menschenkenntnis und Menschenliebe), and I can pretty well guarantee the orginal uploader must have had a newer reproduction of the image, but even if newer, isn't it clear that it was first published 330 years ago? I guess I should brush up on these, as I am not so crash hot as we always get free images for bird articles. Cheers, Casliber (talk · contribs) 12:43, 29 October 2008 (UTC)

Image:LavaterHollowayFaces.png - I have uploaded a copy from the English translation with all of the appropriate information. Clearly this is not as good as the original version, but until we can obtain all of the information for the German version, etc., will this suffice? Awadewit (talk) 15:27, 29 October 2008 (UTC)

Fantastic, thankyou very much. I was/am quite fond of the illustration (audible sigh of relief) Cheers, Casliber (talk · contribs) 20:14, 29 October 2008 (UTC)

• Image:Emil Kraepelin.png - There is no source, date, or photographer for this image. The license cannot be verified.

• removed, we'll find some free images, wasn't absolutely central anyway. Cheers, Casliber (talk · contribs) 09:06, 29 October 2008 (UTC)

• Image:Wm james.jpg - There is no source, date, or photographer for this image. The license cannot be verified.

• removed, we'll find some free images, wasn't absolutely central anyway. Cheers, Casliber (talk · contribs) 09:06, 29 October 2008 (UTC)

Sorry to be the bearer of bad tidings! Awadewit (talk) 13:39, 28 October 2008 (UTC)

Fair enough, you gotta do what you gotta do. The synapse one I can find a source for the information (and is probably the most important of those listed). Others are not so, but will see what I can do. I am a little bit tied up till November 1 but will have a look around. Cheers, Casliber (talk · contribs) 03:41, 29 October 2008 (UTC)

As much as I hated to do it, I've removed the unsourced James and Kreapelin images. The caption for the James image contained information that wasn't in the text, so I rephrased it slightly and added it to the text. I suppose that, in the future, one or more of us could add properly sourced images of these folks to the Commons. Cosmic Latte (talk) 09:03, 29 October 2008 (UTC)

Please let me strike my own comments per WP:TALK - thanks! It helps me keep things organized! Awadewit (talk) 12:07, 29 October 2008 (UTC)

OK, sorry about that. I will look for some images I can guarantee are in the public domain or otherwise get permission from copyright holder. I am not too fussed though. Cheers, Casliber (talk · contribs) 12:33, 29 October 2008 (UTC)

• Comment - I have been making multiple changes in parts I found a little inaccurate. I hope you don't mind. One suggestion I have is changing the paragraph order in Diagnosis > Clinical assessment. In the U.S., the first point of patient contact could be a general practitioner, psychologist, or other mental health professional who would conduct an assessment. A general pracitioner might prescribe antidepressants without referral to a psychiatrist. A psychiatrist would typically prescribe medication without a medical assessment as described a doctor would do. A psychologist, in those states where psychologists do not have prescribing privileges, would refer to a psychiatrist if a need for a medication assessment were deemed necessary. Without getting into all of this, I would suggest switching the first two paragraphs in the Clinical assessment section, as the complete assessment by a doctor is usually not the first step, in the U.S. at least. —Mattisse (Talk) 19:33, 29 October 2008 (UTC)

I have kept an eye on the changes and have been happy thus far - the two paragraphs currently underneath Clinical assessment to me are interchangeable - there is a valid case for either of them coming first. The more I think about it, Oz and the UK are not too different, as we can be alerted by social workers, etc. as well as GPs. Cheers, Casliber (talk · contribs) 20:14, 29 October 2008 (UTC)

• Question - I am wondering about the accuracy of this statement: "The Beck Depression Inventory, is one of the most widely used tools in the diagnosis of depression,". Are you saying in the U.S. or where? —Mattisse (Talk) 01:43, 30 October 2008 (UTC)

• WP:ITALICS check, why are any of those tools in italics?

• The Beck Depression Inventory is one of the most widely used tools in the diagnosis of depression, although its main purpose is not diagnosis, but determining the presence and severity of symptoms. ... Other scales commonly used include the Geriatric Depression Scale in older populations, which is also valid in patients with mild to moderate dementia; the Hamilton Depression Rating Scale (HRSD-21) designed by psychiatrist Max Hamilton in 1960; and the Montgomery-Åsberg Depression Rating Scale (MADRS).

• SandyGeorgia (Talk) 01:48, 30 October 2008 (UTC)

I don't think naming all these rating scales, many of which I have never heard of, adds to the article, especially since the Rating scales section starts out by saying that evidence indicates rating scales are ineffective as diagnostic instruments for depression anyway. —Mattisse (Talk) 01:57, 30 October 2008 (UTC)

OK, the Beck and Hamilton (and to a lesser extent the other two) are highly notable and often-quoted. I even saw the Beck (BDI) parodied as 'beady-eye' in a comic skit by English comedian Jo Brand. The Hamilton has been the most widely used for about 30 years but I don't have a ref for it (got a ref saying it was the most widley used in the 80s and not been able to find a more recent one). I wasn't sure about italics or not, I guess I saw them as a "work" of some sort, and used the italics for emphasis mor than anything else as well. I think rewording Beck to "widely used" is better. Cheers, Casliber (talk · contribs) 02:04, 30 October 2008 (UTC)

PS: They are the four most notable (by far) out of a large number of raiting scales, so my feeling was/is providing a note on them is good. Cheers, Casliber (talk · contribs) 02:06, 30 October 2008 (UTC)

O.K. The Beck of course for historical reasons and because it is frequently used in research and because Beck is an important figure in depression research. And perhaps one or two others. But I question the statement for the rating scale "which is also valid in patients with mild to moderate dementia"; it has only a 1988 journal reference. I would like to see more than that one journal article. And two of the references in that section have invalid pmid numbers. Not to be hard on you. Sorry to freak out over rating scales! —Mattisse (Talk) 02:26, 30 October 2008 (UTC)