Depression (mood)

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Depression
A man diagnosed as suffering from melancholia with strong su Wellcome L0026693.jpg
Lithograph of a man diagnosed as suffering from melancholia with strong suicidal tendency (1892)
Specialty Psychiatry, Psychology
Symptoms Low mood, aversion to activity, loss of interest, loss of feeling pleasure
Risk factors Stigma of mental health disorder. [1]
Diagnostic method Patient Health Questionnaire, Beck Depression Inventory
Differential diagnosis Anxiety, Bipolar Disorder, Borderline personality disorder
PreventionSocial connections, Physical activity
Treatment Psychotherapy, Psychopharmacology

Depression is a state of low mood and aversion to activity. [2] Classified medically as a mental and behavioral disorder, [3] the experience of depression affects a person's thoughts, behavior, motivation, feelings, and sense of well-being. [4] The core symptom of depression is said to be anhedonia, which refers to loss of interest or a loss of feeling of pleasure in certain activities that usually bring joy to people. [5] Depressed mood is a symptom of some mood disorders such as major depressive disorder or dysthymia; [6] it is a normal temporary reaction to life events, such as the loss of a loved one; and it is also a symptom of some physical diseases and a side effect of some drugs and medical treatments. It may feature sadness, difficulty in thinking and concentration and a significant increase or decrease in appetite and time spent sleeping. People experiencing depression may have feelings of dejection, hopelessness and suicidal thoughts. It can either be short term or long term.

Contents

Factors

Allegory on melancholy, from circa 1729-40, etching and engraving, dimensions of the sheet: 42 x 25.7 cm, in the Metropolitan Museum of Art (New York City) Allegory on Melancholy Met DP885774.jpg
Allegory on melancholy, from circa 1729–40, etching and engraving, dimensions of the sheet: 42 × 25.7 cm, in the Metropolitan Museum of Art (New York City)

Life events

Adversity in childhood, such as bereavement, neglect, mental abuse, physical abuse, sexual abuse, or unequal parental treatment of siblings can contribute to depression in adulthood. [7] [8] Childhood physical or sexual abuse in particular significantly correlates with the likelihood of experiencing depression over the victim's lifetime. [9]

Life events and changes that may influence depressed moods include (but are not limited to): childbirth, menopause, financial difficulties, unemployment, stress (such as from work, education, family, living conditions etc.), a medical diagnosis (cancer, HIV, etc.), bullying, loss of a loved one, natural disasters, social isolation, rape, relationship troubles, jealousy, separation, or catastrophic injury. [10] [11] [12] [13] [14] Adolescents may be especially prone to experiencing a depressed mood following social rejection, peer pressure, or bullying. [15]

Globally, more than 264 million people of all ages suffer from depression. [16] The global pandemic of COVID-19 has negatively impacted upon many individuals’ mental health, causing levels of depression to surge, reaching devastating heights. A study conducted by the University of Surrey in Autumn 2019 and May/June 2020 looked into the impact of COVID-19 upon young peoples mental health. This study is published in the Journal of Psychiatry Research Report. [17] The study showed a significant rise in depression symptoms and a reduction in overall wellbeing during lockdown (May/June 2020) compared to the previous Autumn (2019). Levels of clinical depression in those surveyed in the study were found to have more than doubled, rising from 14.9 per cent in Autumn 2019 to 34.7 per cent in May/June 2020. [18] This study further emphasises the correlation that certain life events have with developing depression.

Personality

Changes in personality or in one's social environment can affect levels of depression. High scores on the personality domain neuroticism make the development of depressive symptoms as well as all kinds of depression diagnoses more likely, [19] and depression is associated with low extraversion. [20] Other personality indicators could be: temporary but rapid mood changes, short term hopelessness, loss of interest in activities that used to be of a part of one's life, sleep disruption, withdrawal from previous social life, appetite changes, and difficulty concentrating. [21]

Alcoholism

Alcohol can be a depressant which slows down some regions of the brain, like the prefrontal and temporal cortex, negatively affecting rationality and memory. [22] It also lowers the level of serotonin in the brain, which could potentially lead to higher chances of depressive mood. [23]

The connection between the amount of alcohol intake, level of depressed mood, and how it affects the risks of experiencing consequences from alcoholism, were studied in a research done on college students. The study used 4 latent, distinct profiles of different alcohol intake and level of depression; Mild or Moderate Depression, and Heavy or Severe Drinkers. Other indicators consisting of social factors and individual behaviors were also taken into consideration in the research. Results showed that the level of depression as an emotion negatively affected the amount of risky behavior and consequence from drinking, while having an inverse relationship with protective behavioral strategies, which are behavioral actions taken by oneself for protection from the relative harm of alcohol intake. Having an elevated level of depressed mood does therefore lead to greater consequences from drinking. [24]

Bullying

Social abuse, such as bullying, are defined as actions of singling out and causing harm on vulnerable individuals. In order to capture a day-to-day observation of the relationship between the damaging effects of social abuse, the victim's mental health and depressive mood, a study was conducted on whether individuals would have a higher level of depressed mood when exposed to daily acts of negative behavior. The result concluded that being exposed daily to abusive behaviors such as bullying has a positive relationship to depressed mood on the same day.

The study has also gone beyond to compare the level of depressive mood between the victims and non-victims of the daily bullying. Although victims were predicted to have a higher level of depressive mood, the results have shown otherwise that exposure to negative acts has led to similar levels of depressive mood, regardless of the victim status. The results therefore have concluded that bystanders and non-victims feel as equally depressed as the victim when being exposed to acts such as social abuse. [25]

Medical treatments

Depression may also be the result of healthcare, such as with medication induced depression. Therapies associated with depression include interferon therapy, beta-blockers, isotretinoin, contraceptives, [26] anticonvulsants, antimigraine drugs, antipsychotics, hormonal agents such as gonadotropin-releasing hormone agonist, [27] magnetic stimulation to brain and electric therapy.

Substance-induced

Several drugs of abuse can cause or exacerbate depression, whether in intoxication, withdrawal, and from chronic use. These include alcohol, sedatives (including prescription benzodiazepines), opioids (including prescription pain killers and illicit drugs such as heroin), stimulants (such as cocaine and amphetamines), hallucinogens, and inhalants. [28]

Non-psychiatric illnesses

Depressed mood can be the result of a number of infectious diseases, nutritional deficiencies, neurological conditions, [29] and physiological problems, including hypoandrogenism (in men), Addison's disease, Cushing's syndrome, hypothyroidism, hyperparathyroidism, Lyme disease, multiple sclerosis, Parkinson's disease, chronic pain, stroke, [30] diabetes, [31] and cancer. [32]

Psychiatric syndromes

A number of psychiatric syndromes feature depressed mood as a main symptom. The mood disorders are a group of disorders considered to be primary disturbances of mood. These include major depressive disorder (MDD; commonly called major depression or clinical depression) where a person has at least two weeks of depressed mood or a loss of interest or pleasure in nearly all activities; and dysthymia, a state of chronic depressed mood, the symptoms of which do not meet the severity of a major depressive episode. Another mood disorder, bipolar disorder, features one or more episodes of abnormally elevated mood, cognition, and energy levels, but may also involve one or more episodes of depression. [33] When the course of depressive episodes follows a seasonal pattern, the disorder (major depressive disorder, bipolar disorder, etc.) may be described as a seasonal affective disorder. Outside the mood disorders: borderline personality disorder often features an extremely intense depressive mood; adjustment disorder with depressed mood is a mood disturbance appearing as a psychological response to an identifiable event or stressor, in which the resulting emotional or behavioral symptoms are significant but do not meet the criteria for a major depressive episode; [34] :355 and posttraumatic stress disorder, a mental disorder that sometimes follows trauma, is commonly accompanied by depressed mood. [35]

Historical legacy

Researchers have begun to conceptualize ways in which the historical legacies of racism and colonialism may create depressive conditions. [36] [37]

Measures

Measures of depression as an emotional disorder include, but are not limited to: Beck Depression Inventory-11 and the 9-item depression scale in the Patient Health Questionnaire (PHQ-9). [38] Both of these measures are psychological tests that ask personal questions of the participant, and have mostly been used to measure the severity of depression. The Beck Depression Inventory (BDI) is a self-report scale that helps a therapist identify the patterns of depression symptoms and monitor recovery. The responses on this scale can be discussed in therapy to devise interventions for the most distressing symptoms of depression. [5] Several studies, however, have used these measures to also determine healthy individuals who are not suffering from depression as a mental disorder, but as an occasional mood disorder. This is substantiated by the fact that depression as an emotional disorder displays similar symptoms to minimal depression and low levels of mental disorders such as major depressive disorder; therefore, researchers were able to use the same measure interchangeably. In terms of the scale, participants scoring between 0–13 and 0–4 respectively were considered healthy individuals. [24]

Another measure of depressed mood would be the IWP Multi-affect Indicator. [39] It is a psychological test that indicates various emotions, such as enthusiasm and depression, and asks for the degree of the emotions that the participants have felt in the past week. There are studies that have used lesser items from the IWP Multi-affect Indicator which was then scaled down to daily levels to measure the daily levels of depression as an emotional disorder. [25]

Creative thinking

Divergent thinking is defined as a thought process that generates creativity in ideas by exploring many possible solutions. Having a depressed mood will significantly reduce the possibility of divergent thinking, as it reduces the fluency, variety and the extent of originality of the possible ideas generated. [40]

Some depressive mood disorders might have a positive effect for creativity. Upon identifying several studies and analyzing data involving individuals with high levels of creativity, Christa Taylor was able to conclude that there is a clear positive relationship between creativity and depressive mood. A possible reason is that having a low mood could lead to new ways of perceiving and learning from the world, but it is unable to account for certain depressive disorders. The direct relationship between creativity and depression remains unclear, but the research conducted on this correlation has shed light that individuals who are struggling with a depressive disorder may be having even higher levels of creativity than a control group, and would be a close topic to monitor depending on the future trends of how creativity will be perceived and demanded. [41]

Theories

Schools of depression theories include:

Management

Depressed mood may not require professional treatment, and may be a normal temporary reaction to life events, a symptom of some medical condition, or a side effect of some drugs or medical treatments. A prolonged depressed mood, especially in combination with other symptoms, may lead to a diagnosis of a psychiatric or medical condition which may benefit from treatment. The UK National Institute for Health and Care Excellence (NICE) 2009 guidelines indicate that antidepressants should not be routinely used for the initial treatment of mild depression, because the risk-benefit ratio is poor. [42] Physical activity can have a protective effect against the emergence of depression. [43]

Physical activity can also decrease depressive symptoms due to the release of neurotrophic proteins in the brain that can help to rebuild the hippocampus that may be reduced due to depression. [44] Also yoga could be considered an ancillary treatment option for patients with depressive disorders and individuals with elevated levels of depression. [45] [46]

Reminiscence of old and fond memories is another alternative form of treatment, especially for the elderly who have lived longer and have more experiences in life. It is a method that causes a person to recollect memories of their own life, leading to a process of self-recognition and identifying familiar stimuli. By maintaining one's personal past and identity, it is a technique that stimulates people to view their lives in a more objective and balanced way, causing them to pay attention to positive information in their life stories, which would successfully reduce depressive mood levels. [47]

Self-help books are a growing form of treatment for peoples physiological distress. There may be a possible connection between consumers of unguided self-help books and higher levels of stress and depressive symptoms. Researchers took many factors into consideration to find a difference in consumers and nonconsumers of self-help books. The study recruited 32 people between the ages of 18 and 65; 18 consumers and 14 nonconsumers, in both groups 75% of them were female. Then they broke the consumers into 11 who preferred problem-focused and 7 preferred growth-oriented. Those groups were tested for many things including cortisol levels, depressive symptomatology, and stress reactivity levels. There were no large differences between consumers of self-help books and nonconsumers when it comes to diurnal cortisol level, there was a large difference in depressive symptomatology with consumers having a higher mean score. The growth-oriented group has higher stress reactivity levels than the problem-focused group. However, the problem-focused group shows higher depressive symptomatology. [48]

There is limited evidence that continuing antidepressant medication for one year reduces the risk of depression recurrence with no additional harm. [49] Recommendations for psychological treatments or combination treatments in preventing recurrence are not clear. [49]  

There are empirical evidences of a connection between the type of stress management techniques and the level of daily depressive mood. [40]

Problem-focused coping leads to lower level of depression. Focusing on the problem allows for the subjects to view the situation in an objective way, evaluating the severity of the threat in an unbiased way, thus it lowers the probability of having depressive responses. On the other hand, emotion-focused coping promotes a depressed mood in stressful situations. The person has been contaminated with too much irrelevant information and loses focus on the options for resolving the problem. They fail to consider the potential consequences and choose the option that minimizes stress and maximizes well-being.

Epidemiology

Depression is the leading cause of disability worldwide, the United Nations (UN) health agency reported, estimating that it affects more than 300 million people worldwide – the majority of them women, young people and the elderly. An estimated 4.4 percent of the global population suffers from depression, according to a report released by the UN World Health Organization (WHO), which shows an 18 percent increase in the number of people living with depression between 2005 and 2015. [50] [51] [52]

Depression is a major mental-health cause of disease burden. Its consequences further lead to significant burden in public health, including a higher risk of dementia, premature mortality arising from physical disorders, and maternal depression impacts on child growth and development. [53] Approximately 76% to 85% of depressed people in low- and middle-income countries do not receive treatment; [54] barriers to treatment include: inaccurate assessment, lack of trained health-care providers, social stigma and lack of resources. [55]

The stigma comes from misguided societal views that people with mental illness are different from everyone else, and they can choose to get better only if they wanted to. [56] Due to this more than half of the people with depression do not receive help with their disorders. The stigma leads to a strong preference for privacy.

The World Health Organization has constructed guidelines – known as The Mental Health Gap Action Programme (mhGAP) – aiming to increase services for people with mental, neurological and substance-use disorders. [55] Depression is listed as one of conditions prioritized by the programme. Trials conducted show possibilities for the implementation of the programme in low-resource primary-care settings dependent on primary-care practitioners and lay health-workers. [57] Examples of mhGAP-endorsed therapies targeting depression include Group Interpersonal Therapy as group treatment for depression and "Thinking Health", which utilizes cognitive behavioral therapy to tackle perinatal depression. [55] Furthermore, effective screening in primary care is crucial for the access of treatments. The mhGAP adopted its approach of improving detection rates of depression by training general practitioners. However, there is still weak evidence supporting this training. [53]

History

The Greco-Roman world used the tradition of the four humours to attempt to systematise sadness as "melancholia". This concept remained an important part of European and Islamic medicine until falling out of scientific favour in the 19th century. [58] Emil Kraepelin gave a noted scientific account of depression (German : das manisch-depressive Irresein) in his 1896 psychology encyclopedia "Psychiatrie". [59]

See also

Related Research Articles

Bipolar disorder Mental disorder that causes periods of depression and abnormally elevated mood

Bipolar disorder, previously known as manic depression, is a mood disorder characterized by periods of depression and periods of abnormally-elevated mood that last from days to weeks each. If the elevated mood is severe or associated with psychosis, it is called mania; if it is less severe, it is called hypomania. During mania, an individual behaves or feels abnormally energetic, happy or irritable, and they often make impulsive decisions with little regard for the consequences. There is usually also a reduced need for sleep during manic phases. During periods of depression, the individual may experience crying and have a negative outlook on life and poor eye contact with others. The risk of suicide is high; over a period of 20 years, 6% of those with bipolar disorder died by suicide, while 30–40% engaged in self-harm. Other mental health issues, such as anxiety disorders and substance use disorders, are commonly associated with bipolar disorder.

Cognitive behavioral therapy Therapy to improve mental health

Cognitive behavioral therapy (CBT) is a psycho-social intervention that aims to improve mental health. CBT focuses on challenging and changing cognitive distortions and behaviors, improving emotional regulation, and the development of personal coping strategies that target solving current problems. It was originally designed to treat depression, but its uses have been expanded to include treatment of a number of mental health conditions, including anxiety, alcohol and drug use problems, marital problems, and eating disorders. CBT includes a number of cognitive or behavior psychotherapies that treat defined psychopathologies using evidence-based techniques and strategies.

Major depressive disorder Mental disorder involving persistent low mood, low self-esteem, and loss of interest

Major depressive disorder (MDD), also known simply as depression, is a mental disorder characterized by at least two weeks of pervasive low mood. Low self-esteem, loss of interest in normally enjoyable activities, low energy, and pain without a clear cause are common symptoms. Those affected may also occasionally have delusions or hallucinations. Some people have periods of depression separated by years, while others nearly always have symptoms present. Major depression is more severe and lasts longer than sadness, which is a normal part of life.

A mental disorder, also called a mental illness or psychiatric disorder, is a behavioral or mental pattern that causes significant distress or impairment of personal functioning. Such features may be persistent, relapsing and remitting, or occur as a single episode. Many disorders have been described, with signs and symptoms that vary widely between specific disorders. Such disorders may be diagnosed by a mental health professional, usually a clinical psychologist or psychiatrist.

Mood disorder Group of conditions characterised by a disturbance in mood

Mood disorder, also known as mood affective disorders, is a group of conditions of mental and behavioral disorder where a disturbance in the person's mood is the main underlying feature. The classification is in the Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Classification of Diseases (ICD).

Seasonal affective disorder Medical condition

Seasonal affective disorder (SAD) is a mood disorder subset in which people who have normal mental health throughout most of the year exhibit depressive symptoms at the same time each year, most commonly in winter. Common symptoms include sleeping too much, having little to no energy, and overeating. The condition in the summer can include heightened anxiety.

Borderline personality disorder Personality disorder with strong emotions

Borderline personality disorder (BPD), also known as emotionally unstable personality disorder (EUPD) or borderline pattern personality disorder is a personality disorder characterized by a long-term pattern of unstable interpersonal relationships, distorted sense of self, and strong emotional reactions. Those affected often engage in self-harm and other dangerous behavior. They may also struggle with a feeling of emptiness, fear of abandonment, and detachment from reality. Symptoms of BPD may be triggered by events considered normal to others. BPD typically begins by early adulthood and occurs across a variety of situations. Substance use disorders, depression, and eating disorders are commonly associated with BPD. Approximately 10% of people affected with the disorder die by suicide. The disorder is stigmatized in both the media and the psychiatric field and as a result is often underdiagnosed.

Postpartum depression Endogenous major depressive episode experienced by women after giving birth

Postpartum depression (PPD), also called postnatal depression, is a type of mood disorder associated with childbirth, which can affect both sexes. Symptoms may include extreme sadness, low energy, anxiety, crying episodes, irritability, and changes in sleeping or eating patterns. Onset is typically between one week and one month following childbirth. PPD can also negatively affect the newborn child.

Premenstrual dysphoric disorder (PMDD) is a severe and disabling form of premenstrual syndrome affecting 1.8–5.8% of menstruating women. The disorder consists of a variety of affective, behavioral and somatic symptoms that recur monthly during the luteal phase of the menstrual cycle. It affects women from their early teens up until menopause, excluding those with hypothalamic amenorrhea or during pregnancy and breastfeeding. Those with PMDD are at higher risk of suicide, with rates of suicidal thoughts 2.8 times higher, history of suicidal planning 4.15 times, and suicide attempts 3.3 times.

Dysthymia Psychological disorder

Dysthymia, also known as persistent depressive disorder (PDD), is a mental and behavioral disorder, specifically a disorder primarily of mood, consisting of the same cognitive and physical problems as depression, but with longer-lasting symptoms. The concept was coined by Robert Spitzer as a replacement for the term "depressive personality" in the late 1970s.

Treatment-resistant depression (TRD) is a term used in clinical psychiatry to describe a condition that affects people with major depressive disorder (MDD) who do not respond adequately to a course of appropriate antidepressant medication within a certain time. Typical definitions of TRD vary, and they do not include a resistance to psychological therapies. Inadequate response has traditionally been defined as no clinical response whatsoever. However, many clinicians consider a response inadequate if the person does not achieve full remission of symptoms. People with treatment-resistant depression who do not adequately respond to antidepressant treatment are sometimes referred to as pseudoresistant. Some factors that contribute to inadequate treatment are: early discontinuation of treatment, insufficient dosage of medication, patient noncompliance, misdiagnosis, and concurrent psychiatric disorders. Cases of treatment-resistant depression may also be referred to by which medications people with TRD are resistant to. In TRD adding further treatments such as psychotherapy, lithium, or aripiprazole is weakly supported as of 2019.

Suicidal ideation Thoughts, ideas, or ruminations about the possibility of ending ones life

Suicidal ideation means having thoughts, ideas, or ruminations about the possibility of ending one's life. It is not a diagnosis, but is a symptom of some mental disorders and can also occur in response to adverse events without the presence of a mental disorder.

A major depressive episode (MDE) is a period characterized by the symptoms of major depressive disorder. Sufferers primarily have a depressed mood for two weeks or more, and a loss of interest or pleasure in everyday activities, accompanied by other symptoms such as feelings of emptiness, hopelessness, anxiety, worthlessness, guilt and irritability, changes in appetite, problems concentrating, remembering details or making decisions, and thoughts of suicide. Insomnia or hypersomnia, aches, pains, or digestive problems that are resistant to treatment may also be present. The description has been formalized in psychiatric diagnostic criteria such as the DSM-5 and ICD-10.

Bipolar II disorder Bipolar spectrum disorder

Bipolar II disorder is a bipolar spectrum disorder characterized by at least one episode of hypomania and at least one episode of major depression. Diagnosis for bipolar II disorder requires that the individual must never have experienced a full manic episode. Otherwise, one manic episode meets the criteria for bipolar I disorder.

Minor depressive disorder, also known as minor depression, is a mood disorder that does not meet the full criteria for major depressive disorder but at least two depressive symptoms are present for a long time. These symptoms can be seen in many different psychiatric and mental disorders, which can lead to more specific diagnoses of an individual's condition. However, some of the situations might not fall under specific categories listed in the Diagnostic and Statistical Manual of Mental Disorders. Minor depressive disorder is an example of one of these nonspecific diagnoses, as it is a disorder classified in the DSM-IV-TR under the category Depressive Disorder Not Otherwise Specified (DD-NOS). The classification of NOS depressive disorders is up for debate. Minor depressive disorder as a term was never an officially accepted term, but was listed in Appendix B of the DSM-IV-TR. This is the only version of the DSM that contains the term, as the prior versions and the most recent edition, DSM-5, does not mention it.

Depression is a symptom of some physical diseases; a side effect of some drugs and medical treatments; and a symptom of some mood disorders such as major depressive disorder or dysthymia. Physical causes are ruled out with a clinical assessment of depression that measures vitamins, minerals, electrolytes, and hormones. Management of depression may involve a number of different therapies: medications, behavior therapy, psychotherapy, and medical devices.

Depression in childhood and adolescence Pediatric depressive disorders

Depression is a mental disorder characterized by prolonged unhappiness or irritability, accompanied by a constellation of somatic and cognitive signs and symptoms such as fatigue, apathy, sleep problems, loss of appetite, loss of engagement; low self-regard or worthlessness; difficulty concentrating or indecisiveness; or recurrent thoughts of death or suicide. Depression in childhood and adolescence is similar to adult major depressive disorder, although young sufferers may exhibit increased irritability or behavioral dyscontrol instead of the more common sad, empty, or hopeless feelings seen with adults. Children who are under stress, experiencing loss, have attention, learning, behavioral, or anxiety disorders are at a higher risk for depression. Childhood depression is often comorbid with mental disorders outside of other mood disorders; most commonly anxiety disorder and conduct disorder. Depression also tends to run in families. In a 2016 Cochrane review cognitive behavior therapy (CBT), third wave CBT and interpersonal therapy demonstrated small positive benefits in the prevention of depression. Psychologists have developed different treatments to assist children and adolescents suffering from depression, though the legitimacy of the diagnosis of childhood depression as a psychiatric disorder, as well as the efficacy of various methods of assessment and treatment, remains controversial.

Late-life depression refers to a major depressive episode occurring for the first time in an older person. The term can also include depression that develops in an older person who suffered from the illness earlier in life. Concurrent medical problems and lower functional expectations of elderly patients often obscure the degree of impairment. Typically, elderly patients with depression do not report depressed mood, but instead present with less specific symptoms such as insomnia, anorexia, and fatigue. Elderly persons sometimes dismiss less severe depression as an acceptable response to life stress or a normal part of aging.

Differential diagnoses of depression Differential diagnoses

Depression, one of the most commonly diagnosed psychiatric disorders, is being diagnosed in increasing numbers in various segments of the population worldwide. Depression in the United States alone affects 17.6 million Americans each year or 1 in 6 people. Depressed patients are at increased risk of type 2 diabetes, cardiovascular disease and suicide. Within the next twenty years depression is expected to become the second leading cause of disability worldwide and the leading cause in high-income nations, including the United States. In approximately 75% of completed suicides, the individuals had seen a physician within the prior year before their death, 45–66% within the prior month. About a third of those who completed suicide had contact with mental health services in the prior year, a fifth within the preceding month.

Immuno-psychiatry, according to Pariante, is a discipline that studies the connection between the brain and the immune system. It differs from psychoneuroimmunology by postulating that behaviors and emotions are governed by peripheral immune mechanisms. Depression, for instance, is seen as malfunctioning of the immune system.

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