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Depression: What Every Woman Should Know

The Types of Depressive Illnesses

In major depression, sometimes referred to as unipolar or clinical
depression, people have some or all of the symptoms listed below for at
least 2 weeks but frequently for several months or longer. Episodes of the
illness can occur once, twice, or several times in a lifetime.

In dysthymia, the same symptoms are present though milder and last at least
2 years. People with dysthymia are frequently lacking in zest and enthusiasm
for life, living a joyless and fatigued existence that seems almost a
natural outgrowth of their personalities. They also can experience major
depressive episodes.

Manic-depression, or bipolar disorder, is not nearly as common as other
forms of depressive illness and involves disruptive cycles of depressive
symptoms that alternate with mania. During manic episodes, people may become
overly active, talkative, euphoric, irritable, spend money irresponsibly,
and get involved in sexual misadventures. In some people, a milder form of
mania, called hypomania, alternates with depressive episodes. Unlike other
mood disorders, women and men are equally vulnerable to bipolar disorder;
however, women with bipolar disorder tend to have more episodes of
depression and fewer episodes of mania or hypomania.5

SYMPTOMS OF DEPRESSION AND MANIA
A thorough diagnostic evaluation is needed if three to five or more of the
following symptoms persist for more than 2 weeks (1 week in the case of
mania), or if they interfere with work or family life. An evaluation
involves a complete physical checkup and information gathering on family
health history. Not everyone with depression experiences each of these
symptoms. The severity of the symptoms also varies from person to person.

Depression

Persistent sad, anxious, or "empty" mood
Loss of interest or pleasure in activities, including sex
Restlessness, irritability, or excessive crying
Feelings of guilt, worthlessness, helplessness, hopelessness, pessimism
Sleeping too much or too little, early-morning awakening
Appetite and/or weight loss or overeating and weight gain
Decreased energy, fatigue, feeling "slowed down"
Thoughts of death or suicide, or suicide attempts
Difficulty concentrating, remembering, or making decisions
Persistent physical symptoms that do not respond to treatment, such as
headaches, digestive disorders, and chronic pain

Mania

Abnormally elevated mood
Irritability
Decreased need for sleep
Grandiose notions
Increased talking
Racing thoughts
Increased activity, including sexual activity
Markedly increased energy
Poor judgment that leads to risk-taking behavior
Inappropriate social behavior

CAUSES OF DEPRESSION
Genetic Factors

There is a risk for developing depression when there is a family history of
the illness, indicating that a biological vulnerability may be inherited.
The risk is somewhat higher for those with bipolar disorder. However, not
everybody with a family history develops the illness. In addition, major
depression can occur in people who have had no family members with the
illness. This suggests that additional factors, possibly biochemistry,
environmental stressors, and other psychosocial factors, are involved in the
onset of depression.

Biochemical Factors

Evidence indicates that brain biochemistry is a significant factor in
depressive disorders. It is known, for example, that individuals with major
depressive illness typically have dysregulation of certain brain chemicals,
called neurotransmitters. Additionally, sleep patterns, which are
biochemically influenced, are typically different in people with depressive
disorders. Depression can be induced or alleviated with certain medications,
and some hormones have mood-altering properties. What is not yet known is
whether the "biochemical disturbances" of depression are of genetic origin,
or are secondary to stress, trauma, physical illness, or some other
environmental condition.

Environmental and Other Stressors

Significant loss, a difficult relationship, financial problems, or a major
change in life pattern have all been cited as contributors to depressive
illness. Sometimes the onset of depression is associated with acute or
chronic physical illness. In addition, some form of substance abuse disorder
occurs in about one-third of people with any type of depressive disorder.7

Other Psychological and Social Factors

Persons with certain characteristics-pessimistic thinking, low self-esteem,
a sense of having little control over life events, and a tendency to worry
excessively-are more likely to develop depression. These attributes may
heighten the effect of stressful events or interfere with taking action to
cope with them or with getting well. Upbringing or sex role expectations may
contribute to the development of these traits. It appears that negative
thinking patterns typically develop in childhood or adolescence. Some
experts have suggested that the traditional upbringing of girls might foster
these traits and may be a factor in women's higher rate of depression.

WOMEN ARE AT GREATER RISK FOR DEPRESSION THAN MEN
Major depression and dysthymia affect twice as many women as men. This
two-to-one ratio exists regardless of racial and ethnic background or
economic status. The same ratio has been reported in ten other countries all
over the world.12 Men and women have about the same rate of bipolar disorder
(manic-depression), though its course in women typically has more depressive
and fewer manic episodes. Also, a greater number of women have the rapid
cycling form of bipolar disorder, which may be more resistant to standard
treatments.5

A variety of factors unique to women's lives are suspected to play a role in
developing depression. Research is focused on understanding these,
including: reproductive, hormonal, genetic or other biological factors;
abuse and oppression; interpersonal factors; and certain psychological and
personality characteristics. And yet, the specific causes of depression in
women remain unclear; many women exposed to these factors do not develop
depression. What is clear is that regardless of the contributing factors,
depression is a highly treatable illness.

THE MANY DIMENSIONS OF DEPRESSION IN WOMEN
Investigators are focusing on the following areas in their study of
depression in women:

The Issues of Adolescence

Before adolescence, there is little difference in the rate of depression in
boys and girls. But between the ages of 11 and 13 there is a precipitous
rise in depression rates for girls. By the age of 15, females are twice as
likely to have experienced a major depressive episode as males.2 This comes
at a time in adolescence when roles and expectations change dramatically.
The stresses of adolescence include forming an identity, emerging sexuality,
separating from parents, and making decisions for the first time, along with
other physical, intellectual, and hormonal changes. These stresses are
generally different for boys and girls, and may be associated more often
with depression in females. Studies show that female high school students
have significantly higher rates of depression, anxiety disorders, eating
disorders, and adjustment disorders than male students, who have higher
rates of disruptive behavior disorders.6

Adulthood: Relationships and Work Roles

Stress in general can contribute to depression in persons biologically
vulnerable to the illness. Some have theorized that higher incidence of
depression in women is not due to greater vulnerability, but to the
particular stresses that many women face. These stresses include major
responsibilities at home and work, single parenthood, and caring for
children and aging parents. How these factors may uniquely affect women is
not yet fully understood.

For both women and men, rates of major depression are highest among the
separated and divorced, and lowest among the married, while remaining always
higher for women than for men. The quality of a marriage, however, may
contribute significantly to depression. Lack of an intimate, confiding
relationship, as well as overt marital disputes, have been shown to be
related to depression in women. In fact, rates of depression were shown to
be highest among unhappily married women.

Reproductive Events

Women's reproductive events include the menstrual cycle, pregnancy, the
postpregnancy period, infertility, menopause, and sometimes, the decision
not to have children. These events bring fluctuations in mood that for some
women include depression. Researchers have confirmed that hormones have an
effect on the brain chemistry that controls emotions and mood; a specific
biological mechanism explaining hormonal involvement is not known, however.

Many women experience certain behavioral and physical changes associated
with phases of their menstrual cycles. In some women, these changes are
severe, occur regularly, and include depressed feelings, irritability, and
other emotional and physical changes. Called premenstrual syndrome (PMS) or
premenstrual dysphoric disorder (PMDD), the changes typically begin after
ovulation and become gradually worse until menstruation starts. Scientists
are exploring how the cyclical rise and fall of estrogen and other hormones
may affect the brain chemistry that is associated with depressive illness.10

Postpartum mood changes can range from transient "blues" immediately
following childbirth to an episode of major depression to severe,
incapacitating, psychotic depression. Studies suggest that women who
experience major depression after childbirth very often have had prior
depressive episodes even though they may not have been diagnosed and
treated.

Pregnancy (if it is desired) seldom contributes to depression, and having an
abortion does not appear to lead to a higher incidence of depression. Women
with infertility problems may be subject to extreme anxiety or sadness,
though it is unclear if this contributes to a higher rate of depressive
illness. In addition, motherhood may be a time of heightened risk for
depression because of the stress and demands it imposes.

Menopause, in general, is not associated with an increased risk of
depression. In fact, while once considered a unique disorder, research has
shown that depressive illness at menopause is no different than at other
ages. The women more vulnerable to change-of-life depression are those with
a history of past depressive episodes.

Specific Cultural Considerations

As for depression in general, the prevalence rate of depression in African
American and Hispanic women remains about twice that of men. There is some
indication, however, that major depression and dysthymia may be diagnosed
less frequently in African American and slightly more frequently in Hispanic
than in Caucasian women. Prevalence information for other racial and ethnic
groups is not definitive.

Possible differences in symptom presentation may affect the way depression
is recognized and diagnosed among minorities. For example, African Americans
are more likely to report somatic symptoms, such as appetite change and body
aches and pains. In addition, people from various cultural backgrounds may
view depressive symptoms in different ways. Such factors should be
considered when working with women from special populations.

Victimization

Studies show that women molested as children are more likely to have
clinical depression at some time in their lives than those with no such
history. In addition, several studies show a higher incidence of depression
among women who have been raped as adolescents or adults. Since far more
women than men were sexually abused as children, these findings are
relevant. Women who experience other commonly occurring forms of abuse, such
as physical abuse and sexual harassment on the job, also may experience
higher rates of depression. Abuse may lead to depression by fostering low
self-esteem, a sense of helplessness, self-blame, and social isolation.
There may be biological and environmental risk factors for depression
resulting from growing up in a dysfunctional family. At present, more
research is needed to understand whether victimization is connected
specifically to depression.

Poverty

Women and children represent seventy-five percent of the U.S. population
considered poor. Low economic status brings with it many stresses, including
isolation, uncertainty, frequent negative events, and poor access to helpful
resources. Sadness and low morale are more common among persons with low
incomes and those lacking social supports. But research has not yet
established whether depressive illnesses are more prevalent among those
facing environmental stressors such as these.

Depression in Later Adulthood

At one time, it was commonly thought that women were particularly vulnerable
to depression when their children left home and they were confronted with
"empty nest syndrome" and experienced a profound loss of purpose and
identity. However, studies show no increase in depressive illness among
women at this stage of life.

As with younger age groups, more elderly women than men suffer from
depressive illness. Similarly, for all age groups, being unmarried (which
includes widowhood) is also a risk factor for depression. Most important,
depression should not be dismissed as a normal consequence of the physical,
social, and economic problems of later life. In fact, studies show that most
older people feel satisfied with their lives.

About 800,000 persons are widowed each year. Most of them are older, female,
and experience varying degrees of depressive symptomatology. Most do not
need formal treatment, but those who are moderately or severely sad appear
to benefit from self-help groups or various psychosocial treatments.
However, a third of widows/widowers do meet criteria for major depressive
episode in the first month after the death, and half of these remain
clinically depressed 1 year later. These depressions respond to standard
antidepressant treatments, although research on when to start treatment or
how medications should be combined with psychosocial treatments is still in
its early stages. 4,8

DEPRESSION IS A TREATABLE ILLNESS
Even severe depression can be highly responsive to treatment. Indeed,
believing one's condition is "incurable" is often part of the hopelessness
that accompanies serious depression. Such individuals should be provided
with the information about the effectiveness of modern treatments for
depression in a way that acknowledges their likely skepticism about whether
treatment will work for them. As with many illnesses, the earlier treatment
begins, the more effective and the greater the likelihood of preventing
serious recurrences. Of course, treatment will not eliminate life's
inevitable stresses and ups and downs. But it can greatly enhance the
ability to manage such challenges and lead to greater enjoyment of life.

The first step in treatment for depression should be a thorough examination
to rule out any physical illnesses that may cause depressive symptoms. Since
certain medications can cause the same symptoms as depression, the examining
physician should be made aware of any medications being used. If a physical
cause for the depression is not found, a psychological evaluation should be
conducted by the physician or a referral made to a mental health
professional.

Types of Treatment for Depression

The most commonly used treatments for depression are antidepressant
medication, psychotherapy, or a combination of the two. Which of these is
the right treatment for any one individual depends on the nature and
severity of the depression and, to some extent, on individual preference. In
mild or moderate depression, one or both of these treatments may be useful,
while in severe or incapacitating depression, medication is generally
recommended as a first step in the treatment.3 In combined treatment,
medication can relieve physical symptoms quickly, while psychotherapy allows
the opportunity to learn more effective ways of handling problems.

Medications

There are several types of antidepressant medications used to treat
depressive disorders. These include newer medications-chiefly the selective
serotonin reuptake inhibitors (SSRIs)-and the tricyclics and monoamine
oxidase inhibitors (MAOIs). The SSRIs-and other newer medications that
affect neurotransmitters such as dopamine or norepinephrine-generally have
fewer side effects than tricyclics. Each acts on different chemical pathways
of the human brain related to moods. Antidepressant medications are not
habit-forming. Although some individuals notice improvement in the first
couple of weeks, usually antidepressant medications must be taken regularly
for at least 4 weeks and, in some cases, as many as 8 weeks, before the full
therapeutic effect occurs. To be effective and to prevent a relapse of the
depression, medications must be taken for about 6 to 12 months, carefully
following the doctor's instructions. Medications must be monitored to ensure
the most effective dosage and to minimize side effects. For those who have
had several bouts of depression, long-term treatment with medication is the
most effective means of preventing recurring episodes.

The prescribing doctor will provide information about possible side effects
and, in the case of MAOIs, dietary and medication restrictions. In addition,
other prescribed and over-the-counter medications or dietary supplements
being used should be reviewed because some can interact negatively with
antidepressant medication. There may be restrictions during pregnancy.

For bipolar disorder, the treatment of choice for many years has been
lithium, as it can be effective in smoothing out the mood swings common to
this disorder. Its use must be carefully monitored, as the range between an
effective dose and a toxic one can be relatively small. However, lithium may
not be recommended if a person has pre-existing thyroid, kidney, or heart
disorders or epilepsy. Fortunately, other medications have been found
helpful in controlling mood swings. Among these are two mood-stabilizing
anticonvulsants, carbamazepine (Tegretol®) and valproate (Depakote®). Both
of these medications have gained wide acceptance in clinical practice, and
valproate has been approved by the Food and Drug Administration for
first-line treatment of acute mania. Studies conducted in Finland in
patients with epilepsy indicate that valproate may increase testosterone
levels in teenage girls and produce polycystic ovary syndrome in women who
began taking the medication before age 20. 11 Therefore, young female
patients should be monitored carefully by a physician. Other anticonvulsants
that are being used now include lamotrigine (Lamictal®) and gabapentin
(Neurontin®); their role in the treatment hierarchy of bipolar disorder
remains under study.

Most people who have bipolar disorder take more than one medication. Along
with lithium and/or an anticonvulsant, they often take a medication for
accompanying agitation, anxiety, insomnia, or depression. Some research
indicates that an antidepressant, when taken without a mood stabilizing
medication, can increase the risk of switching into mania or hypomania, or
of developing rapid cycling, in people with bipolar disorder. Finding the
best possible combination of these medications is of utmost importance to
the patient and requires close monitoring by the physician.

Herbal Therapy

In the past few years, much interest has risen in the use of herbs in the
treatment of both depression and anxiety. St. John's wort (Hypericum
perforatum), an herb used extensively in the treatment of mild to moderate
depression in Europe, has recently aroused interest in the United States.
St. John's wort, an attractive bushy, low-growing plant covered with yellow
flowers in summer, has been used for centuries in many folk and herbal
remedies. Today in Germany, Hypericum is used in the treatment of depression
more than any other antidepressant. However, the scientific studies that
have been conducted on its use have been short-term and have used several
different doses.

Because of the widespread interest in St. John's wort, the National
Institutes of Health (NIH) is conducting a 3-year study, sponsored by three
NIH components-the National Institute of Mental Health, the National
Institute for Complementary and Alternative Medicine, and the Office of
Dietary Supplements. The study is designed to include 336 patients with
major depression, randomly assigned to an 8-week trial with one-third of
patients receiving a uniform dose of St. John's wort, another third an SSRI
commonly prescribed for depression, and the final third a placebo (a pill
that looks exactly like the SSRI and the St. John's wort, but has no active
ingredients). The study participants who respond positively will be followed
for an additional 18 weeks. After the 3-year study has been completed,
results will be analyzed and published.

The Food and Drug Administration issued a Public Health Advisory on February
10, 2000. It stated that St. John's wort appears to affect an important
metabolic pathway that is used by many drugs prescribed to treat conditions
such as heart disease, depression, seizures, certain cancers, and rejection
of transplants. Therefore, health care providers should alert their patients
about these potential drug interactions. Any herbal supplement should be
taken only after consultation with the doctor or other health care provider.

Psychotherapy

In mild to moderate cases of depression, psychotherapy is also a treatment
option. Some short-term (10 to 20 week) therapies have been very effective
in several types of depression. "Talking" therapies help patients gain
insight into and resolve their problems through verbal give-and-take with
the therapist. "Behavioral" therapies help patients learn new behaviors that
lead to more satisfaction in life and "unlearn" counter-productive
behaviors. Research has shown that two short-term psychotherapies,
interpersonal and cognitive-behavioral, are helpful for some forms of
depression. Interpersonal therapy works to change interpersonal
relationships that cause or exacerbate depression. Cognitive-behavioral
therapy helps change negative styles of thinking and behaving that may
contribute to the depression.

Electroconvulsive Therapy

For individuals whose depression is severe or life threatening or for those
who cannot take antidepressant medication, electroconvulsive therapy (ECT)
is useful.3 This is particularly true for those with extreme suicide risk,
severe agitation, psychotic thinking, severe weight loss or physical
debilitation as a result of physical illness. Over the years, ECT has been
much improved. A muscle relaxant is given before treatment, which is done
under brief anesthesia. Electrodes are placed at precise locations on the
head to deliver electrical impulses. The stimulation causes a brief (about
30 seconds) seizure within the brain. The person receiving ECT does not
consciously experience the electrical stimulus. At least several sessions of
ECT, usually given at the rate of three per week, are required for full
therapeutic benefit.

Treating Recurrent Depression

Even when treatment is successful, depression may recur. Studies indicate
that certain treatment strategies are very useful in this instance.
Continuation of antidepressant medication at the same dose that successfully
treated the acute episode can often prevent recurrence. Monthly
interpersonal psychotherapy can lengthen the time between episodes in
patients not taking medication.

THE PATH TO HEALING
Reaping the benefits of treatment begins by recognizing the signs of
depression. The next step is to be evaluated by a qualified professional.
Although depression can be diagnosed and treated by primary care physicians,
often the physician will refer the patient to a psychiatrist, psychologist,
clinical social worker, or other mental health professional. Treatment is a
partnership between the patient and the health care provider. An informed
consumer knows her treatment options and discusses concerns with her
provider as they arise.

If there are no positive results after 2 to 3 months of treatment, or if
symptoms worsen, discuss another treatment approach with the provider.
Getting a second opinion from another health or mental health professional
may also be in order.

Here, again, are the steps to healing:

• Check your symptoms against the list.
• Talk to a health or mental health professional.
• Choose a treatment professional and a treatment approach with which you feel comfortable.
• Consider yourself a partner in treatment and be an informed consumer.

If you are not comfortable or satisfied after 2 to 3 months, discuss this
with your provider. Different or additional treatment may be recommended.
If you experience a recurrence, remember what you know about coping with
depression and don't shy away from seeking help again. In fact, the sooner a recurrence is treated, the shorter its duration will be.

Depressive illnesses make you feel exhausted, worthless, helpless, and
hopeless. Such feelings make some people want to give up. It is important to realize that these negative feelings are part of the depression and will
fade as treatment begins to take effect.

Along with professional treatment, there are other things you can do to help
yourself get better. Some people find participating in support groups very
helpful. It may also help to spend some time with other people and to
participate in activities that make you feel better, such as mild exercise
or yoga. Just don't expect too much from yourself right away. Feeling better
takes time.

WHERE TO GET HELP
If unsure where to go for help, ask your family doctor, OB/GYN physician, or
health clinic for assistance. You can also check the Yellow Pages under
"mental health," "health," "social services," "suicide prevention," "crisis
intervention services," "hotlines," "hospitals," or "physicians" for phone
numbers and addresses. In times of crisis, the emergency room doctor at a
hospital may be able to provide temporary help for an emotional problem and
will be able to tell you where and how to get further help.

Listed below are the types of people and places that will make a referral
to, or provide, diagnostic and treatment services.

• Family doctors

• Mental health specialists such as psychiatrists, psychologists, social
  workers, or mental health counselors

• Health maintenance organizations
• Community mental health centers
• Hospital psychiatry departments and outpatient clinics
• University- or medical school-affiliated programs
• State hospital outpatient clinics
• Family service/social agencies
• Private clinics and facilities
• Employee assistance programs
• Local medical and/or psychiatric societies

FURTHER INFORMATION
National Institute of Mental Health
Information Resources and Inquiries Branch
6001 Executive Boulevard
Room 8184, MSC 9663
Bethesda, MD 20892-9663
Telephone: 1-301-443-4513
FAX: 1-301-443-4279
TTY: 1-301-443-8431
FAX4U: 1-301-443-5158
Website: http://www.nimh.nih.gov
E-mail: nimhinfo@nih.gov

National Alliance for the Mentally Ill (NAMI)
Colonial Place Three
2107 Wilson Blvd., Suite 300
Arlington, VA 22201
Phone: 1-800-950-NAMI (6264) or (703) 524-7600
Internet: http://www.nami.org
A support and advocacy organization of consumers, families, and friends of
people with severe mental illness-over 1,200 state and local affiliates.
Local affiliates can often give guidance to finding treatment.

Depression & Bipolar Support Alliance (DBSA)
730 N. Franklin St. - #501
Chicago, IL 60610-7224
Telephone: (312) 988-1150
Fax: (312) 642-7243
Internet: www.DBSAlliance.org
Purpose is to educate patients, families, and the public concerning the
nature of depressive illnesses. Maintains an extensive catalog of helpful
books.

National Foundation for Depressive Illness, Inc.
P.O. Box 2257
New York, NY 10016
Telephone: 1-212-268-4260; 1-800-239-1265
Website: http://www.depression.org
A foundation that informs the public about depressive illness and its
treatability and promotes programs of research, education and treatment.

National Mental Health Association (NMHA)
2001 N. Beauregard Street, 12th Floor
Alexandria, VA 22311
Phone: 1-800-969-6942 or (703) 684-7722
TTY-800-443-5959
Internet: http://www.nmha.org
An association that works with 340 affiliates to promote mental health
through advocacy, education, research, and services.

REFERENCES
1 Blehar MC, Oren DA. Gender differences in depression. Medscape Women's
Health, 1997;2:3. Revised from: Women's increased vulnerability to mood
disorders: Integrating psychobiology and epidemiology. Depression,
1995;3:3-12.

2 Cyranowski JM, Frank E, Young E, Shear MK. Adolescent onset of the gender
difference in lifetime rates of major depression. Archives of General
Psychiatry, 2000; 57:21-27.

3 Frank E, Karp JF, and Rush AJ. Efficacy of treatments for major
depression. Psychopharmacology Bulletin, 1993;29:457-75.

4 Lebowitz BD, Pearson JL, Schneider LS, Reynolds CF, Alexopoulos GS, Bruce
ML, Conwell Y, Katz IR, Meyers BS, Morrison MF, Mossey J, Niederehe G, and
Parmelee P. Diagnosis and treatment of depression in late life: Consensus
statement update. Journal of the American Medical Association,
1997;278:1186-90.

5 Leibenluft E. Issues in the treatment of women with bipolar illness.
Journal of Clinical Psychiatry (supplement 15), 1997;58:5-11.

6 Lewisohn PM, Hyman H, Roberts RE, Seeley JR, and Andrews JA. Adolescent
psychopathology: 1. Prevalence and incidence of depression and other
DSM-III-R disorders in high school students. Journal of Abnormal Psychology,
1993;102:133-44.

7 Regier DA, Farmer ME, Rae DS, Locke BZ, Keith SJ, Judd LL, and Goodwin FK.
Comorbidity of mental disorders with alcohol and other drug abuse: Results
from the epidemiologic catchment area (ECA) study. Journal of the American
Medical Association, 1993;264:2511-8.

8 Reynolds CF, Miller MD, Pasternak RE, Frank E, Perel JM, Cornes C, Houck
PR, Mazumdar S, Dew MA, and Kupfer DJ. Treatment of bereavement-related
major depressive episodes in later life: A controlled study of acute and
continuation treatment with nortriptyline and interpersonal psychotherapy.
American Journal of Psychiatry, 1999;156:202-8.

9 Robins LN and Regier DA (Eds). Psychiatric Disorders in America, The
Epidemiologic Catchment Area Study. New York: The Free Press, 1990.

10 Rubinow DR, Schmidt PJ, and Roca CA. Estrogen-serotonin interactions:
Implications for affective regulation. Biological Psychiatry,
1998;44(9):839-50.

11 Vainionpaa LK, Rattya J, Knip M, Tapanainen JS, Pakarinen AJ, Lanning P,
Tekay, A, Myllyla, VV, Isojarvi JI. Valproate-induced hyperandrogenism
during pubertal maturation in girls with epilepsy. Annals of Neurology,
1999;45(4):444-50.

12 Weissman MM, Bland RC, Canino GJ, Faravelli C, Greenwald S, Hwu HG, Joyce
PR, Karam EG, Lee CK, Lellouch J, Lepine JP, Newman SC, Rubin-Stiper M,
Wells JE, Wickramaratne PJ, Wittchen H, and Yeh EK. Cross-national
epidemiology of major depression and bipolar disorder. Journal of the
American Medical Association, 1996;276:293-9.

HELPFUL BOOKS
Many books have been written on major depression and bipolar disorder. The
following are a few that may help you understand these illnesses better.

Andreasen, Nancy. The Broken Brain: The Biological Revolution in Psychiatry.
New York: Harper & Row, 1984.

Carter, Rosalyn. Helping Someone With Mental Illness: A Compassionate Guide
for Family, Friends and Caregivers. New York: Times Books, 1998.

Duke, Patty and Turan, Kenneth. Call Me Anna, The Autobiography of Patty
Duke. New York: Bantam Books, 1987.

Dumquah, Meri Nana-Ama. Willow Weep for Me, A Black Woman's Journey Through
Depression: A Memoir. New York: W.W. Norton & Co., Inc., 1998.

Fieve, Ronald R. Moodswing. New York: Bantam Books, 1997.

Jamison, Kay Redfield. An Unquiet Mind, A Memoir of Moods and Madness. New
York: Random House, 1996.

The following three booklets are available from the Madison Institute of
Medicine, 7617 Mineral Point Road, Suite 300, Madison, WI 53717, telephone
1-608-827-2470:

Tunali D, Jefferson JW, and Greist JH, Depression & Antidepressants: A
Guide, rev. ed. 1997.

Jefferson JW and Greist JH. Divalproex and Manic Depression: A Guide, 1996
(formerly Valproate guide).

Bohn J and Jefferson JW. Lithium and Manic Depression: A Guide, rev. ed.
1996.