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Any illness, severe or mild, can cause significant depression Conditions such as rheumatoid arthritis, multiple sclerosis, and chronic heart disease are particularly likely to be associated with depression, as are other chronic illnesses Hormonal variations clearly play a role in some depressions Varying degrees of depression occur at various times in schizophrenic disorders, central nervous system disease, and organic mental states Alcohol dependency frequently coexists with serious depression The classic model of drug-induced depression occurs with the use of reserpine, both in a clinical and a neurochemical sense Corticosteroids and oral contraceptives are commonly associated with affective changes Antihypertensive medications such as methyldopa, guanethidine, and clonidine have been associated with the development of depressive syndromes, as have digitalis and antiparkinsonism drugs (eg, levodopa) It is unusual for -blockers to produce depression when given for short periods, such as in the treatment of performance anxiety Sustained use of -blockers for medical conditions such as hypertension may produce depression in some patients, although the literature is unclear on this subject It is also unclear whether non lipid-soluble -blockers are less likely to be associated with depression than lipid-

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Keywords are special words reserved by the language that have a specific meaning within all C# programs, including if, while, and for You ll learn about these keywords in the coming chapters C# is considered safe because the language is type-safe, which is an important mechanism to help you find bugs early in the development process, as you ll see later This makes for code that is easier to maintain and programs that are more reliable C# was designed, from the very start, to support object-oriented programming In this book, we ll explain not only how to write object-oriented programs, but also why object-oriented programming has become so popular The short answer is this: programs are becoming increasingly complex, and object-oriented programming techniques help you manage that complexity C# was designed for NET, and NET was designed (in part) for developing web and web-aware programs.

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tazapine, (2) the TCAs and clinically similar drugs, and (3) the MAO inhibitors (see Table 25 8) These groups are described in greater detail below ECT is effective in all types of depression and will also rapidly resolve a manic episode It is also very effective for postpartum depression Megavitamin treatment, acupuncture, and electrosleep are of unproved usefulness for any psychiatric condition Hospitalization is necessary if suicide is a major consideration or if complex treatment modalities are required Drug selection is influenced by the history of previous responses if that information is available If a relative has responded to a particular drug, this suggests that the patient may respond similarly If no background information is available, a drug such as sertraline, 50 mg daily, or desipramine, starting with 50 mg and gradually increasing to 150 mg daily, can be selected and a full trial instituted The medication trial should be monitored with patient assessments every 1 2 weeks until week 6 If successful, the medication should be continued for 6 12 months at the full therapeutic dose before tapering is considered Antidepressants should usually be continued indefinitely at full dosage in individuals with more than two episodes after age 40 or one episode after age 50 If the response is inadequate the best alternatives are to switch to a second agent or to try augmenting the first agent according to the STAR*D study The latter course is often taken when there has been at least a partial response to the initial drug If a second drug is tried, it does not appear to matter whether that drug is from the same or different class If the second drug fails or augmentation was selected as the second step, the choices include lithium (eg, 600 900 mg/d), buspirone (eg, 30 60 mg/d), or thyroid medication (eg, liothyronine, 25 mcg/d) Dysthymia is also treated in this way The Agency for Health Care Policy and Research has produced clinical practice guidelines that outline one algorithm of treatment decisions (Figure 25 2) Psychotic depression can be treated with a combination of an antipsychotic such as olanzapine and an antidepressant such as an SSRI at their usual doses Mifepristone may have specific and early activity against psychotic depression Major depression with atypical features or seasonal onset can be treated with an MAO inhibitor or an SSRI with good results Stimulants such as dextroamphetamine (5 30 mg/d) and methylphenidate (10 45 mg/d) have enjoyed a resurgence of interest for the short-term treatment of depression in medically ill and geriatric patients Their 50 60% efficacy rate is slightly below that of other agents The stimulants are notable for rapid onset of action (hours) and a paucity of side effects (tachycardia, agitation) in most patients They are usually given in two divided doses early in the day (eg, 7 am and noon) so as to avoid interfering with sleep These agents may also be useful as adjunctive agents in refractory depression Caution: Depressed patients may have suicidal thoughts, and the amount of drug dispensed should be appropriately controlled The older TCAs have a narrow therapeutic index, and one advantage of the newer drugs is their wider margin of safety Nonetheless, even with newer agents, because of the possibility of suicidality early in antidepressant treatment, close follow-up is indicated This is particularly true in the treatment of children and adolescents where suicide risk has.

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