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Depression is a psychiatric disorder characterized by a profound and long-lasting sadness or despair. It affects approximately 18 million people in the United States every year and not all of them are old enough to vote. Everyone experiences some unhappiness, often as a result of a change, either in the form of a setback or a loss. The painful feelings that accompany these events are usually appropriate, necessary, and transitory and can even present an opportunity for personal growth. However, when depression persists and impairs daily life, it may be an indication of a depressive disorder. Severity, duration, and the presence of other symptoms are the factors that distinguish normal sadness from a depressive disorder. Depression has been alluded to by a variety of names in both medical and popular literature for thousands of years. Early English texts refer to "melancholia," which was for centuries the generic term for all emotional disorders. Depression is now referred to as a mood disorder, and the primary subtypes are major depression, chronic and usually milder depression (dysthymia), and atypical depression. Other important forms of depression are premenstrual dysphoric disorder (PDD) and seasonal affective disorder (SAD). ƒË Major Depression In major, or acute, depression, at least five of the symptoms listed below must occur for a period of at least two weeks, and they must represent a change from previous behavior or mood. Depressed mood or loss of interest must be present. J.J.Daino IV Page2 "žY Depressed mood on most days for most of each day. (Irritability may be prominent in children and adolescents.) "žY Total or very noticeable loss of pleasure most of the time. "žY Significant increase or decrease in appetite, weight, or both. "žY Sleep disorders -- either insomnia or excessive sleepiness -- nearly every day. "žY Feelings of agitation or a sense of intense slowness. "žY Loss of energy and a daily sense of tiredness. "žY Sense of guilt and worthlessness nearly all the time. "žY Inability to concentrate occurring nearly every day. "žY Recurrent thoughts of death or suicide. In addition, other criteria must be met: the symptoms listed above should not follow or accompany manic episodes (such as in bipolar or other disorders); they should impair important normal functions (such as work or personal relationships); they are not caused by drugs, alcohol, or other substances; and they are not caused by normal grief (see below). One long-term study found that episodes of major depression usually last about twenty weeks. ƒË Chronic Depression (Dysthymia) Chronic, but mild depression, or dysthymia, is characterized by many of the same symptoms that occur in major depression but they are less intense and last much longer -- at least two years. The symptoms have been described as a "veil of sadness" that covers most activities. Typically, there are no disturbances in appetite or sexual drive; mania, severe agitation, and sedentary behavior are not present. Suicidal thoughts are not usually present. Possibly because of the duration of the symptoms, patients who suffer from chronic depression do not exhibit marked changes in mood or in daily functioning, although they have low energy, a general negativity, and a sense of dissatisfaction and hopelessness. J.J.Daino IV Page3 They may suffer from episodes of major depression; in such cases, the condition is known as double depression. The family life of such patients is often impaired because of their decreased level of emotional, psychic, and physical energies. ƒË Atypical Depression and Seasonal Affective Disorder People with atypical depression generally overeat, oversleep, have a general sense of heaviness, and have strong feelings of rejection. Seasonal affective disorder (SAD) is characterized by annual episodes of depression during fall or winter, which remit in the spring or summer, and which may be replaced by a manic phase. Other symptoms include fatigue, a tendency to overeat -- particularly carbohydrates -- and to oversleep in winter. (A minority of individuals with SAD has the more common depressive symptoms of under-eating and being sleepless). SAD tends to last about five months in those who live in the northern part of America. ƒË Premenstrual Dysphoric Disorder The syndrome of severe depression, irritability, and tension before menstruation is known as premenstrual dysphoric disorder (PDD) (also called late-luteal dysphoric disorder). It affects an estimated 3% to 8% of women in their reproductive years. A diagnosis of PDD depends on having five symptoms of depression (see above) that occur during most menstrual cycles, with symptoms worsening a week or so before the menstrual period and resolving afterward. J.J.Daino IV Page4 Depression is an illness that can afflict anyone, regardless of age, race, class, or gender. About 17 million Americans are estimated to develop depression each year. In one large survey, 8.6% of adults over the age of 18 reported having a mental health problem for at least two weeks. However, the incidence may be higher since many people fail to seek help for depression and physicians are often reluctant to diagnose depression. ƒË Treatment for Depression Most adult patients with major or chronic depression are given a trial period of an antidepressant. Some form of psychotherapy is also usually recommended; the type prescribed should be, like the medications, tailored to the needs of the patient. The combination of antidepressants and therapy appears to be more effective than either treatment alone for most patients, possibly because patients are more likely to take their medications regularly when they are also undergoing therapy. For those who fail medications and psychotherapy, other techniques, such as electroconvulsive therapy (ECT), are safe and effective. In severe cases that do not respond to any conservative treatment, psychosurgery may be beneficial. ƒË Children and Adolescents Studies indicate that children and adolescents with major depression respond as well to placebos -- so called "sugar pills" -- as they do to tricyclic antidepressants. Although, they tend to respond better to the newer J.J.Daino IV Page5 antidepressants known as selective serotonin reuptake inhibitors (SSRIs), some experts believe teenagers with mild to moderate depression should receive psychotherapy -- especially cognitive-behavioral therapy or supportive therapy -- before medications are tried. For children and adolescents with very severe depression that does not respond to psychotherapy, the American Academy of Child and Adolescent Psychiatry now recommends SSRIs. These drugs should be combined during the early acute phase with a mixture of psychotherapies, including cognitive-behavioral, interpersonal, and psychodynamic therapies. Initial drug treatments should continue for at least six months and a maintenance phase should last another year or longer. ƒË Elderly Adults Experts generally recommend SSRIs for elderly patients because they have fewer side effects than older antidepressants, particularly the tricyclics. One study found that in elderly patients with mild depression only the SSRIs and the new so-called heterocyclic drugs were helpful, but only modestly so. Because of these modest benefits and because all antidepressants increase the risk for falls in older people, some experts recommend psychotherapy or attention intervention for elderly patients with mild depression. Some studies indicate that for severe depression in the elderly, SSRIs are not as effective as tricyclic antidepressants. It should be noted, however, that tricyclics are more likely to cause adverse effects on the heart than SSRIs. The tricyclics J.J.Daino IV Page6 amitriptyline (Elavil) and imipramine (Tofranil) also have other severe side effects in older adults, who should use these drugs with caution. ƒË Drug Treatments for Depression Antidepressants are very effective; one study reported that up to 90% of patients with major depression will improve with good compliance and adequate doses of the right antidepressant drug. Side effects can be avoided or moderated if the regimen is started at low doses and built up over time. Current antidepressant

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