Multiple sclerosis MS is a chronic inflammatory demyelinating disorder of the central nervous system CNS with various degrees of axonal damage. MS affects mainly young adults with predominance for females. The disorder often leads to substantial disability summary by Bomprezzi et al.
In addition, the programs that best prevented depression comprised more than eight sessions, each lasting between 60 and 90 minutes, were provided by a combination of lay and professional workers, had a high-quality research design, reported attrition rates , and had a well-defined intervention.
The Netherlands mental health care system provides preventive interventions, such as the "Coping with Depression" course CWD for people with sub-threshold depression. The three most common treatments for depression are psychotherapy, medication, and electroconvulsive therapy. Psychotherapy is the treatment of choice over medication for people under The UK National Institute for Health and Care Excellence NICE guidelines indicate that antidepressants should not be used for the initial treatment of mild depression because the risk-benefit ratio is poor.
The guidelines recommend that antidepressants treatment in combination with psychosocial interventions should be considered for:. The guidelines further note that antidepressant treatment should be continued for at least six months to reduce the risk of relapse , and that SSRIs are better tolerated than tricyclic antidepressants. American Psychiatric Association treatment guidelines recommend that initial treatment should be individually tailored based on factors including severity of symptoms, co-existing disorders, prior treatment experience, and patient preference.
Options may include pharmacotherapy, psychotherapy, exercise, electroconvulsive therapy ECT , transcranial magnetic stimulation TMS or light therapy. Antidepressant medication is recommended as an initial treatment choice in people with mild, moderate, or severe major depression, and should be given to all patients with severe depression unless ECT is planned. Treatment options are much more limited in developing countries, where access to mental health staff, medication, and psychotherapy is often difficult.
Development of mental health services is minimal in many countries; depression is viewed as a phenomenon of the developed world despite evidence to the contrary, and not as an inherently life-threatening condition. Physical exercise is recommended for management of mild depression,  and has a moderate effect on symptoms.
There is a small amount of evidence that skipping a night's sleep may improve depressive symptoms, with the effects usually showing up within a day. This effect is usually temporary. Besides sleepiness, this method can cause a side effect of mania or hypomania. In observational studies, smoking cessation has benefits in depression as large as or larger than those of medications.
Besides exercise, sleep and diet may play a role in depression, and interventions in these areas may be an effective add-on to conventional methods. Talking therapy psychotherapy can be delivered to individuals, groups, or families by mental health professionals.
A review found that cognitive behavioral therapy appears to be similar to antidepressant medication in terms of effect. Psychotherapy has been shown to be effective in older people. Cognitive behavioral therapy CBT currently has the most research evidence for the treatment of depression in children and adolescents, and CBT and interpersonal psychotherapy IPT are preferred therapies for adolescent depression.
The most-studied form of psychotherapy for depression is CBT, which teaches clients to challenge self-defeating, but enduring ways of thinking cognitions and change counter-productive behaviors. Research beginning in the mids suggested that CBT could perform as well as or better than antidepressants in patients with moderate to severe depression.
Cognitive behavioral therapy and occupational programs including modification of work activities and assistance have been shown to be effective in reducing sick days taken by workers with depression. Several variants of cognitive behavior therapy have been used in those with depression, the most notable being rational emotive behavior therapy ,  and mindfulness-based cognitive therapy. Psychoanalysis is a school of thought, founded by Sigmund Freud , which emphasizes the resolution of unconscious mental conflicts.
It also tends to focus more on the person's immediate problems, and has an additional social and interpersonal focus. Conflicting results have arisen from studies that look at the effectiveness of antidepressants in people with acute, mild to moderate depression. While small benefits were found, researchers Irving Kirsch and Thomas Moore state they may be due to issues with the trials rather than a true effect of the medication. A Cochrane review on the combined use of antidepressants plus benzodiazepines demonstrated improved effectiveness when compared to antidepressants alone; however, these effects were not maintained in the acute or continuous phase.
In the U. Food and Drug Administration published a systematic review of all antidepressant maintenance trials submitted to the agency between and To find the most effective antidepressant medication with minimal side-effects, the dosages can be adjusted, and if necessary, combinations of different classes of antidepressants can be tried. SSRIs are the primary medications prescribed, owing to their relatively mild side-effects, and because they are less toxic in overdose than other antidepressants.
For children, some research has supported the use of the SSRI antidepressant fluoxetine. Irreversible monoamine oxidase inhibitors , an older class of antidepressants, have been plagued by potentially life-threatening dietary and drug interactions.
They are still used only rarely, although newer and better-tolerated agents of this class have been developed. It is unclear whether antidepressants affect a person's risk of suicide.
One review found no connection;  another an increased risk;  and a third no risk in those 25—65 years old and a decreased risk in those more than There is some evidence that omega-3 fatty acids fish oil supplements containing high levels of eicosapentaenoic acid EPA to docosahexaenoic acid DHA are effective in the treatment of, but not the prevention of major depression. Electroconvulsive therapy ECT is a standard psychiatric treatment in which seizures are electrically induced in patients to provide relief from psychiatric illnesses.
Aside from effects in the brain, the general physical risks of ECT are similar to those of brief general anesthesia. A usual course of ECT involves multiple administrations, typically given two or three times per week, until the patient is no longer suffering symptoms. ECT is administered under anesthesia with a muscle relaxant. These three forms of application have significant differences in both adverse side effects and symptom remission.
After treatment, drug therapy is usually continued, and some patients receive maintenance ECT. ECT appears to work in the short term via an anticonvulsant effect mostly in the frontal lobes , and longer term via neurotrophic effects primarily in the medial temporal lobe. Transcranial magnetic stimulation TMS or deep transcranial magnetic stimulation is a noninvasive method used to stimulate small regions of the brain. Transcranial direct current stimulation tDCS is another noninvasive method used to stimulate small regions of the brain with the help of a weak electric current.
Increasing evidence has been gathered for its efficiency as a depression treatment. A meta-analysis was published in summarising results across nine studies participants concluded that active tDCS was significantly superior to sham for response Bright light therapy reduces depression symptom severity, with benefit for both seasonal affective disorder and for nonseasonal depression, and an effect similar to those for conventional antidepressants.
For nonseasonal depression, adding light therapy to the standard antidepressant treatment was not effective. There is insufficient evidence for Reiki  and dance movement therapy in depression. Major depressive episodes often resolve over time whether or not they are treated.
A high proportion of people who experience full symptomatic remission still have at least one not fully resolved symptom after treatment. People experiencing repeated episodes of depression require ongoing treatment in order to prevent more severe, long-term depression.
In some cases, people must take medications for the rest of their lives. Cases when outcome is poor are associated with inappropriate treatment, severe initial symptoms including psychosis, early age of onset, previous episodes, incomplete recovery after one year of treatment, pre-existing severe mental or medical disorder, and family dysfunction. Depressed individuals have a shorter life expectancy than those without depression, in part because depressed patients are at risk of dying of suicide.
Major depression is currently the leading cause of disease burden in North America and other high-income countries, and the fourth-leading cause worldwide. In the year , it is predicted to be the second-leading cause of disease burden worldwide after HIV , according to the WHO.
People are most likely to develop their first depressive episode between the ages of 30 and 40, and there is a second, smaller peak of incidence between ages 50 and The Ancient Greek physician Hippocrates described a syndrome of melancholia as a distinct disease with particular mental and physical symptoms; he characterized all "fears and despondencies, if they last a long time" as being symptomatic of the ailment. The term depression itself was derived from the Latin verb deprimere , "to press down".
It was used in in English author Richard Baker's Chronicle to refer to someone having "a great depression of spirit", and by English author Samuel Johnson in a similar sense in An early usage referring to a psychiatric symptom was by French psychiatrist Louis Delasiauve in , and by the s it was appearing in medical dictionaries to refer to a physiological and metaphorical lowering of emotional function.
The newer concept abandoned these associations and through the 19th century, became more associated with women. Although melancholia remained the dominant diagnostic term, depression gained increasing currency in medical treatises and was a synonym by the end of the century; German psychiatrist Emil Kraepelin may have been the first to use it as the overarching term, referring to different kinds of melancholia as depressive states. Sigmund Freud likened the state of melancholia to mourning in his paper Mourning and Melancholia.
He theorized that objective loss, such as the loss of a valued relationship through death or a romantic break-up, results in subjective loss as well; the depressed individual has identified with the object of affection through an unconscious , narcissistic process called the libidinal cathexis of the ego. Such loss results in severe melancholic symptoms more profound than mourning; not only is the outside world viewed negatively but the ego itself is compromised.
In the midth century, researchers theorized that depression was caused by a chemical imbalance in neurotransmitters in the brain, a theory based on observations made in the s of the effects of reserpine and isoniazid in altering monoamine neurotransmitter levels and affecting depressive symptoms.
The term unipolar along with the related term bipolar was coined by the neurologist and psychiatrist Karl Kleist , and subsequently used by his disciples Edda Neele and Karl Leonhard.
The term Major depressive disorder was introduced by a group of US clinicians in the mids as part of proposals for diagnostic criteria based on patterns of symptoms called the "Research Diagnostic Criteria", building on earlier Feighner Criteria ,  and was incorporated into the DSM-III in The new definitions of depression were widely accepted, albeit with some conflicting findings and views.
There have been some continued empirically based arguments for a return to the diagnosis of melancholia. The term "depression" is used in a number of different ways.
It is often used to mean this syndrome but may refer to other mood disorders or simply to a low mood. People's conceptualizations of depression vary widely, both within and among cultures. What we call it—'disease,' 'disorder,' 'state of mind'—affects how we view, diagnose, and treat it. The diagnosis is less common in some countries, such as China. It has been argued that the Chinese traditionally deny or somatize emotional depression although since the early s, the Chinese denial of depression may have modified.
Australian professor Gordon Parker and others have argued that the Western concept of depression "medicalizes" sadness or misery. Historical figures were often reluctant to discuss or seek treatment for depression due to social stigma about the condition, or due to ignorance of diagnosis or treatments. Nevertheless, analysis or interpretation of letters, journals, artwork, writings, or statements of family and friends of some historical personalities has led to the presumption that they may have had some form of depression.
Watson ,  dealt with their own depression. There has been a continuing discussion of whether neurological disorders and mood disorders may be linked to creativity , a discussion that goes back to Aristotelian times. Social stigma of major depression is widespread, and contact with mental health services reduces this only slightly.
Public opinions on treatment differ markedly to those of health professionals; alternative treatments are held to be more helpful than pharmacological ones, which are viewed poorly. Depression is especially common among those over 65 years of age and increases in frequency beyond this age. As with many other diseases, it is common among the elderly not to present with classical depressive symptoms. Problem solving therapy was, as of , the only psychological therapy with proven effect, and can be likened to a simpler form of cognitive behavioral therapy.
The risks involved with treatment of depression among the elderly as opposed to benefits are not entirely clear. MRI scans of patients with depression have revealed a number of differences in brain structure compared to those who are not depressed.
Meta-analyses of neuroimaging studies in major depression reported that, compared to controls, depressed patients had increased volume of the lateral ventricles and adrenal gland and smaller volumes of the basal ganglia , thalamus , hippocampus , and frontal lobe including the orbitofrontal cortex and gyrus rectus.
Trials are looking at the effects of botulinum toxins on depression. The idea is that the drug is used to make the person look less frowning and that this stops the negative facial feedback from the face. Compass is a for-profit company studying psilocybin for treatment-resistant depression; Usona is a non-profit organization studying psilocybin for major depressive disorder more broadly.
The flow chart of the study design is shown in Fig. Prior to participation, consent to study participation must be given by the AYA or, for adolescents under the age of 16, by a person with custody.
As this is a pragmatic RCT, there are no further exclusion criteria. Recruitment start is scheduled for October The iCBT with its associated independence of space and time enables a recruitment strategy throughout Germany. Anxiety and depression will be screened as part of the clinical routine in hospitals, clinics, medical practices, and medical centres across Germany where AYA with type 1 diabetes, cystic fibrosis, or juvenile idiopathic arthritis receive medical treatment.
The screening data will be gathered in clinical centres and administered within these patient registries. AYA receive feedback on their mental well-being by their health care provider in charge. The informed consent will be obtained at the clinic by the attending physician, and all further recruitment activities will be conducted by researchers at Ulm University.
The participants are randomized by the program Sealed Envelope www. The block size is 6, 8, 10 participants per block and stratified according to the three chronic somatic conditions. Stratification is performed due to the strongly varying prevalence of chronic somatic conditions. Only RR, who is not involved otherwise in the trial process, will conduct the randomization process.
AG, FL study administration , and MM statistical evaluation are blinded and do not receive any information about the group allocation of study participants. The blinded members of the study team do not have access to documents showing group membership of participants.
Modules can be repeated as often as desired. The modules cover the topics motivation and resources, behavioural activation, understanding and coping with anxiety and depression, emotion regulation, communication, and social support as well as relapse prevention. The intervention is presented via information texts, videos, audio recordings, photos, metaphors, and therapeutic homework.
The content of the intervention is based on CBT principles for depression and anxiety, including elements of psychoeducation, individual resources of the AYA, active coping problem solving , restructuring of stressful disease-related thoughts, communication training, relaxation, and behaviour activation to model adaptive coping strategies.
The content of the intervention see Table 1 is developed for AYA and related to typical challenges and tasks of a life with a chronic somatic condition. The intervention is explained and presented in a youth-friendly manner. To improve patient adherence, interactive elements e. At the beginning of the intervention, participants are informed to receive daily reinforcing prompts via a mobile app during the intervention period.
The reminders are sent automatically after each module has been completed and coordinated with intervention content to transfer the learned skills into everyday life of the participants. The mobile-based reminders aim to increase motivation of participants, remind participants to complete homework assignments, and repeat intervention content. The software solutions for the iCBT intervention and the mobile app are both provided by Minddistrict www.
The intervention is therapist-guided by e-Coaches, who report semi-standardized feedback after each completed module on the intervention platform to the participant using an e-Coach manual. The e-Coach manual is standardized to guarantee protocol adherence by the e-Coaches. The feedback also includes positive reinforcement to motivate participants to continue the intervention.
For further questions, participants and e-Coaches can communicate via the intervention platform. The weekly schedule for processing a module is set by the participants themselves at the end of the previous module. In order to promote commitment, the intervention is blocked for the participant after three reminders without the participant reacting. Table 2 shows the intervention structure and implementation.
The sample size calculation was carried out by an external statistician from the Department of Psychological Research Methods at Ulm University MM based on a power of. Various measures will be taken to minimize study drop-outs. After successful completion of all assessments, participants can also take part in a prize draw. Medical record data of the participants are collected by physicians and are administered via the patient registers.
The data is linked by a patient code ID patient and a hash key, in order to combine the data sources in a pseudonymized manner. The research data are stored on a protected cloud using encryption software. Detailed study management protocols and lists are used to monitor data collection. This allows interruptions and protocol deviations to be detected. As part of clinical routine, AYA are screened for symptoms of depression and anxiety.
The German version of the GAD-7 is a self-report anxiety questionnaire. The German version of the PHQ-9 is administered as a screening inventory to detect depressive symptoms. As demographic data, we collect date of birth, gender, relationship status, type of school, grade of school or vocational training, and occupation. The collection of medical data takes place at the time of screening at the respective clinical centre.
If the relevant parameters were not collected for screening, the closest examination is used at the time of screening; if two examinations are equally far apart, the previous examination is used, maximum one year away from screening. The following medical data of the participants are collected in the disease-specific registers depending on the chronic somatic condition:.
Type 1 diabetes. Cystic fibrosis. Forced expiratory volume in 1 second FEV 1 , diabetes, pancreatic status, liver cirrhosis, pseudomonas infection, number of exacerbations, number of antibiotic therapies, and allergic bronchopulmonary aspergillosis ABPA.
Juvenile idiopathic arthritis. Depression and anxiety symptoms at all other assessments will be considered as secondary outcomes. General perceived self-efficacy represents a personal coping resource with predictive value for well-being and a constructive coping with life [ 61 , 62 ]. The questions about trauma-specific symptoms are introduced by the request that the AYA refer to the currently most stressful event with regard to their chronic condition and describe it briefly.
Limitations of the functional level in different areas of life are also assessed. The Stress-Related Growth Scale SRGS serves to observe the changes that occur during treatment in relation to the individual development caused by the chronic disease. The Berlin Social Support Scales BSSS [ 68 ] differ from other questionnaire methods for social support by their multidimensional approach, that is, by their cognitive and behavioural aspects.
AYA are asked whom they relate their answers to. As such, it observes changes in activation within treatment. The generic EuroQol Five-Dimensional Questionnaire EQ-5D , measuring quality of life, is a short instrument that provides information on health states as a basis for the estimation of quality-adjusted life years QALYs [ 76 ]. The available utility value sets for adults have been found to be not applicable to children and adolescents [ 80 ].
In the absence of a utility value set for children and adolescents in Germany [ 77 ], the health states will be valued by means of the visual analogue scale VAS of the EQ-5D-Y. The EQ-5D-Y dimensions were found to be reliable on test-retest in The EQ-5D-Y not only serves as a secondary outcome, but is also used for economic evaluation. The MFQ parent report of depressive symptoms is useful both for preliminary screening and to monitor change in symptomatology [ 82 ].
The BSSS caregiver report is used to identify how the caregivers assess their own social support for the adolescent. The questions about trauma-specific symptoms are introduced by the request that the caregivers refer to the currently most stressful event for the respective AYA with regard to their chronic somatic condition and describe it briefly.
Limitations of the functional level in different areas of life are also assessed [ 64 ]. This is an adapted version of the Inventory for recording negative effects of psychotherapy that is specifically adjusted for online interventions [ 87 ]. The PHQ-ADS [ 50 ] is not only used as a primary or secondary outcome, depending on the assessment time point, but also to determine depression and anxiety symptom deterioration. The IUES consists of eight items with a two-factor structure, that is positive and avoidance expectancies.
This may show that there is additional need for interventions that focus on ADLs. The number of older adults with musculoskeletal complaints who experience problems in household activities and mobility in this study clearly demonstrates the need for functional assessment and corresponding interventions to prevent worsening and further ADL-, health and social problems which would consequently raise also costs for the individual and society.
This group of people should therefore be a priority target for specialists of physical medicine and rehabilitation and occupational therapists, as well as other health professionals who aim to achieve optimal functioning in daily life.
Physicians, nurses and therapists may be recommended to screen older adults for ADL problems and in case refer them to these specialists. If ADL problems are not taken seriously e. Interestingly, similar activities were experienced more often as problematic across these three health conditions.
Hand-based activities were one separate dimension in the factor analysis on ADL problems in these 3 musculoskeletal diseases. While this is obvious in osteoarthritis osteoarthritis is most common in hips, knees and hands , back pain and osteoporosis do not mainly affect the hands. Those two areas and corresponding ICF chapters mobility and domestic life could therefore be important areas to consider in the assessment of older adults with different musculoskeletal complaints.
We therefore concluded that the ADL deficits are partly related to the factors for which we controlled in the multivariate models, such as pain, mental health [ 18 — 20 ] etc. However, some relationships such as between osteoarthritis and ADL deficits in dimension 1 and 4 or osteoporosis and ADL deficits in dimension 1 and 2 appear also in the models - indicating that ADL problems in these dimensions are related to these conditions and not influenced by the other factors controlled for in the models.
Female sex was associated with increased deficits in intense ADLs dimension 1 and decreased deficits in basic ADLs dimension 2. In one of our recent qualitative studies, the life stories of women and men with arthritis reflected how contextual factors such the healthcare system, the support of families and social and cultural values shaped their everyday activities.
Men for example had more difficulties to develop a non-paid-work related role in their lives than women [ 21 ]. Especially dimension 2 basic IADLs in our study includes several activities that are primarily done by women in Austria, such as washing clothes, preparing food and regular light housework.
This dimension seems to be an important aspect for the possibility of living independently in the community, whereas the activities in dimension 1 could be taken over by social networks. Basic ADLs BADLs consist of self-care tasks, including bathing and showering washing the body , bowel and bladder management recognizing the need to relieve oneself , dressing, eating including chewing and swallowing , feeding setting up food and bringing it to the mouth , functional mobility moving from one place to another while performing activities , personal device care, personal hygiene and grooming including washing hair , sexual activity and toilet hygiene completing the act of relieving oneself [ 22 ].
Instrumental activities of daily living IADLs are not necessary for fundamental functioning, but they let an individual live independently in a community. Examples are housework, taking medications as prescribed, managing money, shopping for groceries or clothing, use of telephone or other form of communication, using technology and transportation within the community [ 23 ].
Participants with only secondary education were less likely to have ADL problems in dimension 2, while age and pain were clearly associated with more ADL problems in all dimensions. While age without any health problems also increases ADL problems, the highest ORs in our study were associated with anxiety and depression. However, we cannot determine the causal relationship because anxiety and depression can lead to increased ADL problems, but also vice-versa, ADL problems leading to increased anxiety and depression.
The age-dependent loss of independent eating, dressing or toileting is an important aspect because of the rising age of the population. A strength of our study is the fact that the survey was population-based. Thus, selection bias that would occur, if only participants living in clinical or nursing home settings were interviewed, could be avoided. Some limitations of our study have to be mentioned. Data were gathered in the Austrian Health Survey and we could not influence the list of activities that were included.
Also there was no question on the priority of the activities, nor a question asking each individual to name one primary ADL-problem. Diagnoses were self-reported; people thus may have overestimated certain symptoms, such as joint pain, and on the other hand may not have known about other health conditions, such as osteoporosis.
All questions focused mainly on activities, but not on body functions or structures, nor on environmental factors influencing the performance of these activities. Furthermore, the question for anxiety and depression is very personal and will therefore be not always honestly answered in such an interview survey. A possible reason can be that all three items in the 4 th dimension included two concepts to score in one item stretch hand AND shake hands; turn on a tap OR unscrew a can; use fingers to grab AND use small things — this is difficult to sore and participants may have understood and consequently scored these items differently [ 24 ].
Older adults with musculoskeletal complaints could be a special target group for ADL specialists such as physical medicine and rehabilitation physicians and occupational therapists.
More attention should be paid to the high impact of pain intensity as well as anxiety and depression on ADLs. Too often, a child is simply given an antibiotic and sent back to school.
Sick children need care and rest. Parents should let acute illnesses run their course and not suppress symptoms such as fever unless dangerously high. Parents need to acquire some basic medical knowledge. For example, one of the rationales given by health care providers to justify the rotavirus vaccine is that parents are not able to recognize and deal with dehydration, which may accompany the diarrhea characteristic of rotavirus.
Many children have an inadequate diet. Parents should encourage gradual changes toward a diet that will support the immune system. A national and state profile of leading health problems and health care quality for US children: key insurance disparities and across-state variations.
Acad Pediatr ;11 3 Suppl :SS Ward BJ. Vaccine adverse events in the new millennium: is there reason for concern? Bull World Health Organ ;78 2 Jaxen J. Health Impact News. Allergic diseases in children with attention deficit hyperactivity disorder: a systematic review and meta-analysis. BMC Psychiatry ;17 1 J Child Neurol ;31 11 Analysis of comorbidities and therapeutic approach for allergic rhinitis in a pediatric population in Spain.
Pediatr Allergy Immunol ;24 7 Autism Res ;8 5 Richey W. The Christian Science Monitor , Feb. Pilot comparative study on the health of vaccinated and unvaccinated 6- to year-old U.The Flying Luttenbachers are an American instrumental unit led by multi-instrumentalist / composer / producer Weasel Walter. The Luttenbachers have created a body of work focused on musical extremity and lucbabobfilante.svizokagluricocoveswaytsunucuph.co the course of the band, the personnel has shifted numerous times around the artistic leadership of Walter.