Second edition

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210 Syndromes of disturbances of mood and affect
Table 6.2 Causes of depression
Primary or idiopathic disorders
Major depressive disorder
Bipolar disorder
Dysthymia
Premenstrual dysphoric disorder
Post-partum blues
Post-partum depression
Schizoaffective disorder
Post-psychotic depression in schizophrenia
Toxic depressions
Medication-induced
Prednisone (Wolkowitz et al. 1990)
Alpha-interferon (Fried et al. 2002; Krauss et al. 2003;
Raison et al. 2005; Torriani et al. 2004)
Beta 1b-interferon (Neilley et al. 1996)
Metoclopramide (Friend and Young 1997)
Pimozide (Bloch et al. 1997b)
Propranolol (Petrie et al. 1982; Pollack et al. 1985)
Nifedipine (Hullett et al. 1988)
Cimetidine (Billings et al. 1981)
Ranitidine (Billings and Stein 1986)
Subdermal estrogen–progestin (Wagner 1996; Wagner and
Berenson 1994)
Alpha-methyl dopa (DeMuth and Ackerman 1983)
Reserpine (Jensen 1959; Quetsch et al. 1959)
Levetiracetam (Mula et al. 2003; Wier et al. 2006)
Isotretinoin (Wysowski et al. 2001)
Bismuth (Supino-Viterbo et al. 1977)
Substances of abuse or toxins
Chronic alcoholism
Lead intoxication
Metabolic depressions
Obstructive sleep apnea
Chronic hypercalcemia
Vitamin deficiencies
Vitamin B12 deficiency
the metoclopramide is discontinued. In this instance, it is
reasonable to assume that the medication triggered a new
depressive episode of the major depressive disorder, which
then persisted.
Major depressive disorder and bipolar disorder are both
characterized by recurrent episodes of depression, the two
disorders being distinguished by the fact that in bipolar disorder
one also sees, at some point in the patient’s history, a
manic episode, whereas in major depressive disorder, manic
episodes never occur. Given that bipolar disorder may commence
with one, or several, episodes of depression before
the first episode of mania occurs, one must, in evaluating a
patient who has had only depressive episodes, allow a
lengthy period of observation to pass before making a firm
diagnosis of major depression. Statistically speaking, in
patients with bipolar disorder, the first episode of mania
Pellagra
Pancreatic cancer
Medication or substance withdrawal
Cholinergic rebound
Stimulants
Anabolic steroids
Endocrinologic disorders
Hypothyroidism
Hyperthyroidism
Cushing’s syndrome
Adrenocortical insufficiency
Hyperaldosteronism
Hyperprolactinemia
Neurodegenerative and dementing disorders
Parkinson’s disease
Diffuse Lewy body disease
Hereditary mental depression with parkinsonism
Huntington’s disease
Alzheimer’s disease
Multi-infarct dementia
Other intracranial disorders
Stroke
Traumatic brain injury
Multiple sclerosis
Epilepsy-associated depression
Ictal depression
Interictal depression
Tumors
Hydrocephalus
Fahr’s syndrome
Systemic lupus erythematosus
Limbic encephalitis
Tertiary neurosyphilis
New-variant Creutzfeldt–Jakob disease
Down’s syndrome
will, in over 90 percent of cases, occur within 10 years of the
first depressive episode or by the time five or more episodes
of depression have occurred, whichever comes first (Dunner
et al. 1976).
Although not as reliable, certain clinical characteristics of
the depressive episode may also suggest whether that depressive
episode is occurring on a basis of bipolar disorder or
major depression. Specifically, depressive episodes of bipolar
disorder are, in contrast with those of major depression,
more likely to have an acute onset (over weeks rather than
months) (Winokur et al. 1993) and are also more likely to be
accompanied by delusions or hallucinations (Guze et al.
1975).
Dysthymia is characterized by chronic, low-level, and
generally fluctuating depressive symptoms. This condition
is of uncertain nosologic status. In many cases, there will be