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Once laritis in the absence of symptoms or serologic pulmonary arteritis has been identified generic diclofenac 100mg with amex, antico- evidence of any detectable underlying systemic agulation should be avoided cheap diclofenac 100 mg visa. This one third of patients die within 2 years of pul- isolated pauci-immune pulmonary capillaritis is monary involvement 50mg diclofenac with mastercard, most from fatal pulmonary histopathologically indistinguishable from that hemorrhage order 100mg diclofenac amex. Depending on the severity of the dis- Immunofluorescence microscopy shows large ease process at the time of evaluation cheap diclofenac 50mg online, anemia and deposits of IgA in the skin and kidney. Only 26 physical trauma (eg, pulmonary contusion); and cases have been reported to date, and capillaritis increased vascular pressure within the capillaries has been documented histopathologically only in (eg, mitral stenosis or severe left ventricular fail- a minority of them. Progressively monary capillary walls, analogous to those found more bloody return indicates alveolar origin of the in vessels of the skin and glomeruli of affected blood. Other uncommon secondary vasculitic underlying cause and at prompt implementation entities include benign lymphocytic angiitis and of appropriate therapy. Consequently, Similarly, the initial physical examination should its consideration needs to be an integral part of the include a careful search for signs of comorbidities differential diagnostic evaluation of patients with and possible systemic autoimmune disorders. Isolated cases rupture of dilated and varicose bronchial veins have been reported with polymyositis, rheumatoid early in the course of mitral stenosis or as a result arthritis, and mixed connective tissue disease. The Amer- antiplatelet or anticoagulant effects such as abcix- ican College of Rheumatology 1990 criteria for the imab; immunosuppressive and chemotherapeutic classification of vasculitis: introduction. Are envi- antineutrophil cytoplasmic antibody testing to ronmental factors important in primary systemic diagnose vasculitis: can test-ordering guidelines vasculitis? Anti- domized trial of plasma exchange or high-dos- proteinase 3 antineutrophil cytoplasmic antibodies age methylprednisolone as adjunctive therapy for and disease activity in Wegener granulomatosis. Ritux- tection against premature ovarian failure during imab for refractory Wegener’s granulomatosis: cyclophosphamide therapy in women with severe report of a prospective, open-label pilot trial. Surgical ton syndrome: simultaneous occurrence of coeliac pathology of the lung in anti-basement membrane disease and idiopathic pulmonary haemosidero- antibody-associated Goodpasture’s syndrome. Diffuse alveo- alveolar hemorrhage in patients with primary lar hemorrhage in systemic lupus erythematosus: pulmonary hypertension-anticoagulation and a single center retrospective study in Taiwan. Pulmonary hemorrhage and capillaritis and diffuse alveolar hemorrhage: a pri- antiglomerular basement membrane antibody- mary manifestation of polymyositis. Diffuse alveolar hemorrhage in the alveolar hemorrhage with underlying pulmonary antiphospolipid syndrome: spectrum of disease capillaritis in the retinoic acid syndrome. Pulmo- capillary hemangiomatosis associated with pri- nary complications in adult blood and marrow mary pulmonary hypertension: report of 2 new transplant recipients: autopsy findings. Normal Cardiovascular Physiologic Changes Physiology of Pregnancy in Pregnancy During pregnancy, the body undergoes ana- Variables Change tomic and physiologic changes affecting both the Cardiac output Increased respiratory and cardiovascular systems. However, diaphragmatic dys- Gas Exchange: Gas exchange in pregnancy is function caused by pregnancy is unusual because, characterized by a mild compensated respiratory concurrent with these changes, there is a widening alkalosis secondary to an increase in minute ven- of the lower rib cage and alteration of the abdominal tilation out of proportion to maternal needs. Oxygen consumption these changes, functional residual capacity is, in increases by 20 to 30% during pregnancy, with a turn, decreased by 10 to 25% by the third trimester concomitant increase in carbon dioxide production of pregnancy. These changes are attributable to in- slightly, inspiratory capacity increases, and vital creased maternal and fetal metabolic requirements capacity does not change significantly during and increases in work of breathing and cardiac pregnancy. Closure of the small airways during normal normal physiologic changes during pregnancy, in tidal breathing caused by the reduction in func- particular the estrogen-related changes in upper tional residual capacity can result in changes in airway patency, the incidence of snoring increases ventilation/perfusion matching and gas exchange during pregnancy. There is little or no change in worsening may lead to complications of maternal respiratory rate during pregnancy, and tachypnea hypertension and fetal growth retardation. Because of the increase in tinuous positive airway pressure has been used for tidal volume, there is a significant increase in resting treatment, same as in the nonpregnant individual. Mitral stenosis and rate as well as stroke volume and a decrease in other stenotic lesions may become apparent during systemic vascular resistance, partially as the result pregnancy, particularly in the third trimester when of shunting of blood to the low-resistance placental blood volume is at its maximum, and right-to-left bed and perhaps increased levels of vasodilator shunts tend to worsen. It is important that the pul- augmented by an additional 10 to 15% as the result monologist be aware of the management of these of catecholamine release. A category A drug means levels, resulting in a decrease of 5 mm Hg in plasma that well-controlled drug studies in pregnant oncotic pressures, predisposing patients to edema women have failed to demonstrate any risk to the formation, including pulmonary edema. A category B drug indicates that animal 8 L of water divided among the fetus, amniotic drug studies have shown that there was no demon- fluid, and intracellular and extracellular spaces, strated fetal risk, but controlled drug studies have and an increase in plasma volume of 1 to 1. A category C agent is a drug for which studies in animals have revealed adverse Dyspnea During Pregnancy effects on the fetus, including teratogenicity, and there are no controlled studies in women; or that Up to twothirds of pregnant women report studies in women and animals are not available. Although the etiology These drugs can be used if the potential benefit of of this normal physiologic dyspnea is not clearly the drug outweighs the potential risk to the fetus. A defined, it is most commonly reported in the first category D agent is a drug for which studies have and second trimesters, with improvement toward shown positive evidence of human fetal risks, but the end of the third trimester. These findings sup- in certain situations, these drugs may be of benefit port the fact that dyspnea is not purely related to if the risk is outweighed by potential gain. These effects inhaled corticosteroids are another alternative are likely attributable to hypoxemia, resulting in for the treatment of moderate persistent asthma decreased placental blood flow.

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Wilson [38] proposed a patho-anatomical model con- The prevalence of post-stroke anxiety buy cheap diclofenac 50mg, with or with- sisting of a putative fasciorespiratory control center out depression discount diclofenac 100mg with mastercard, is higher in hospital settings (acute for emotional expression located in the brainstem stroke patients: 28 cheap diclofenac 50 mg with amex, 15–17 and 3–13% diclofenac 50mg with amex, respectively; with a dual route of control from the motor cortex: stroke survivors: 24 generic 50mg diclofenac with amex, 6–17 and 3–11%, respectively) a voluntary pathway through the pyramidal and gen- than in community studies (11, 8 and 1–2%, respect- iculate tracts, which initiates voluntary laughter and ively). The prevalence of agoraphobia is estimated to be crying and inhibits involuntary initiated laughter or 17%. Anxiety disorders are often associated with major crying, and an involuntary pathway consisting of a or minor depression. Besides depression, other consist- frontal/temporal–basal ganglia–ventral brainstem cir- ent clinical and psychiatric correlates are previous cuitry, which initiates and also terminates involuntary psychiatric disorders, pre-stroke depression or anxiety laughter or crying. Less consistent correlates include could result from release of the fasciorespiratory con- younger age, female gender, aphasia, history of insom- trol center from the motor cortex or from disruption nia and cognitive impairment. Parvizi and the Damasios correlates of anxiety include impairment in activities of [39] proposed a modified version of Wilson’s model, daily living, impairment in social functioning, being in which the cerebellar structures play a role in single, living alone or having no social contacts outside adjusting the execution of laughter and crying to the the family [41–43]. There is recent evi- association of post-stroke anxiety was with anterior dence of disruption of ascending serotoninergic path- circulation strokes. Concerning the outcome of post-stroke anxiety, An uncontrollable prolonged burst of laughing, a sizeable proportion, ranging from one-quarter to called after Féré fou rire prodromique, can exception- one-half, do not recover: post-stroke anxiety with ally anticipate by seconds to days the onset of the focal associated depression has an unfavorable prognosis deficit in acute stroke [40]. Post-stroke anxiety without depression does not influence functional or cognitive Disorders of emotional expression control (out- recovery but is associated with worse social function- bursts of laughing, crying or both) are frequent ing and quality of life. Post-stroke anxiety disorders are often associated with depression, previous psychiatric disorders and Anxiety disorders alcohol abuse. Post-stroke anxiety disorders have received compara- tively less attention than post-stroke depression. Post-traumatic stress depression ranges from 5 to 67% among all types of disorder is estimated to affect 10% to 31% [44]of stroke patients. Severe depression has a frequency stroke survivors and is associated with depression ranging from 9 to 26%, while in the acute phase and anxiety. Post-traumatic stress disorder after depression is present in 16–52% of the patients [46]. A systematic review of 51 studies reported neuroticism or with a negative affect or appraisal of a mean prevalence of 33% (29–36%) [47]. The symptomatology of post-stroke depression is dominated by depressed mood, closely followed by Post-stroke mania anhedonia. Loss of energy, decreased concentration and psychomotor retardation are also frequent, as Post-stroke mania is an infrequent complication of well as the somatic symptoms of decreased appetite stroke (1–2%) [45]. Guilt and suicidal ideation are less disturbance in mood characterized by elevated, common. Clinical features of Concerning the features of stroke which increase post-stroke mania also include increased rate or the risk of post-stroke depression, all stroke types are amount of speech, talkativeness, language thought similarly prone to depression. The hemispheric side is and content disturbance, such as flights of ideas, also not relevant [48], although in some studies the racing thoughts, grandiose ideation and lack of frequency and severity of depression were higher after insight, hyperactivity and social disinhibition and left-sided lesions, in particular during the first months decreased need for sleep. Higher lesion volumes, cerebral atrophy, ity, confusion, delusions and hallucinations may be silent infarcts and white matter lesions are all associ- also present. To distinguish between true post-stroke ated with a higher risk of post-stroke depression. Acute of post-stroke mania to predisposing genetic (family/ depressive symptoms mainly have a biological deter- personal history of mood disorder) factors, subcortical minism, while post-stroke depression at 1–2 years has brain atrophy and damage to the right corticolimbic an additional psycho-social determinism. However, mania can also be detected in stroke patients Post-stroke depression has a prevalence of about without personal or familial predisposing factors, after 30%. Personality changes Persistent personality disturbances, defined as a Post-stroke depression change from the previous characteristic personality, Post-stroke depression is a prominent and persistent are one of the most annoying behavioral disturbances mood disturbance characterized by depressed mood found after stroke. For the caregiver these changes are or lack of interest or lack of pleasure (anhedonia) in hard to cope with and they are difficult to control all or almost all activities. There are several types of person- two subtypes: with depressive features and similar to a ality changes in stroke patients: aggressive, disinhi- major depressive episode. In the Figures related to the epidemiological features of apathetic type the predominant feature is marked post-stroke depression are highly variable, because apathy and indifference. Apathy is a disorder of they depend on the setting of the study, the time since motivation. In severe forms, there is lack of feeling, 190 stroke, the case mix and the criteria/method used to emotion, interest and concern, flat affect, indifference, diagnose depression. The prevalence of post-stroke no initiative or decisions and little spontaneous Chapter 12: Behavioral neurology of stroke speech or actions. Responses are either absent, Neglect is an inability to attend to, orient or delayed or slow. A key feature is the dissociation explore the hemispace contralateral to a brain between impaired self-activation and preserved lesion, usually of the right hemisphere. Amnesia can result from thrombosis or response to other people, and lack of complaining. Relatives are more worried than the choroidal artery and anterior cerebral and anter- ior communicating arteries.

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Some are used to make 21 fabrics diclofenac 50 mg without a prescription, whereas others are used to produce flaxseed oil purchase diclofenac 100mg without prescription, a valuable foodstuff 22 and medicinal product generic 100mg diclofenac overnight delivery. The herb consists of the ripe order 50mg diclofenac, dried seeds of 25 Linum usitatissimum and preparations of the same generic diclofenac 100 mg online. Some commercial flaxseeds 4 have been identified in the past that contain levels of cadmium beyond recom- 5 mended government limits. It has a very low rate of side effects and does 12 not interfere with the physiology of the bowels. The herb consists of the dried bark 21 of branches and twigs of Rhamnus frangula L. The liquefaction of the bowel 29 contents leads to an increase in intestinal filling pressure. Frangula bark should not be used by children under 10 years of age 34 or by pregnant or nursing mothers. Plant Summaries—F ➤ Herb–drug interactions:Because of the loss of calcium, the drug can increase 1 the effects of cardiac glycosides if taken concurrently. In North America, cascara sagrada (Rhamnus purshianus) is more com- 5 monly used in this way. Flavonoids (rutin), fumaric acid, and hydroxycinnamic acid 21 derivatives (caffeoylmalic acid) are also present. Z Allg Med 34 (1985), 1819; Hahn R, 48 Nahrstedt A: High Content of Hydroxycinnamic Acids Esterified with (+)-D- 49 Malic-Acid in the Upper Parts of Fumaria officinalis. Planta Med 59 (1993), 50 Plant Summaries—F 1 189; Roth L, Daunderer M, Kormann K: Giftpflanzen, Pflanzengifte. Clinical 11 studies demonstrated that the herb inhibits platelet aggregation, increases 12 the bleeding and coagulation times, lowers serum lipids in some individu- 13 als, and enhances fibrinolytic activity. Garlic must be crushed to 26 release allicin immediately before it is used in any way. The herb consists of the peeled fresh 3 or dried rhizomes of Zingiber officinalis R. Gingerols, diarylheptanoids (gingerenones A and B), and starch 7 (50%) are also present. It also 10 has known antibacterial, antifungal, molluscacidal, nematocidal, and anti- 11 platelet effects. The majority of clinical trials per- 36 formed showed a benefit for postoperative nausea, motion sickness, and 37 morning sickness, but a few studies showed no effect. In addition, it increases cere- 7 bral tolerance to hypoxia, reduces the age-related reduction of muscarin- 8 ergic choline receptors and α2-adrenoceptors, and increases the hip- 9 pocampal absorption of choline. In animals, bilobalide and ginkgolides 10 were found to improve the flow capacity of the blood by lowering viscosity, 11 inactivating toxic oxygen radicals and improving the circulation in cerebral 12 and peripheral arteries. Clinical, controlled double-blind 15 studies in humans have confirmed the results of animal experiments (gink- 16 go was found to improve the memory capacity and microcirculation and 17 reduce the viscosity of plasma). Several reports have indicated 29 modest benefit in controlled studies for Alzheimer’s and non-Alzheimer’s 30 dementia. Used for 6 to 8 weeks for treatment of vertigo and tinnitus; longer use 40 is only justified if some improvement can be registered. According to some 41 studies use for at least 3 months is necessary for full effect. Also improvement of walking performance in intermittent claudica- 2 tion has been shown. Despite some positive trials, memory enhancement in 3 healthy persons remains controversial. Treatment should not be initiated be- 4 fore consulting a qualified health care provider. Internationale und statis- 11 tische Klassifikation der Krankheiten und verwandter Gesundheitspro- 12 bleme. Urban & Schwarzenberg, München Wien Balti- 13 more 1994; Dingermann T: Phytopharmaka im Alter: Crataegus, Ginkgo, 14 Hypericum und Kava-Kava. Metaanalyse von 11 klinischen Studien bei Patienten mit 17 Hirnleistungsstörungen im Alter. Arzneim Forsch/Drug Res 44 (1994), 18 1005–1013; Joyeux M et al: Comparative antilipoperoxidant, antinecrotic 19 and scavenging properties of terpenes and biflavones from Ginkgo and 20 some flavonoids. Planta Med 61 (1995), 126–129; Kanowski S et al: Proof 21 of efficacy of the ginkgo biloba special extract Egb 761 in outpatients suf- 22 fering from primary degenerative dementia of the Alzheimer type and multi- 23 infarct dementia. Pharmacopsychiatry 4 (1995), 149–158; Pfister-Hotz G: 24 Phytotherapie in der Geriatrie.

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Post-therapy follow-up Hormone replacement may be resumed two days after treatment order 50mg diclofenac with mastercard. In most centres generic 50 mg diclofenac overnight delivery, anterior and posterior images of the body are obtained a week to 10 days after 131I therapy to ensure targeting order diclofenac 50mg overnight delivery. This can be done most reliably when the patient is no longer on T4 or T3 treatment discount diclofenac 100 mg overnight delivery. When patients are treated at the maximum safe dose cheap diclofenac 100 mg with visa, haemato- logical evaluation should be carried out between four and six weeks after therapy, to ensure lack of haematopoietic toxicity. Patients are usually not re-treated earlier than six months after therapy, unless there is evidence of rapidly progressive disease as evidenced by a progressive rise in serum thyroglobulin and/or radiographic evidence of progressive disease. Two successive negative whole body studies, with concurrent non-measurable serum thyroglobulin levels, separated by intervals of at least six months, indicate successful therapy. The patient may then be managed by serum thyroglobulin estimations twice yearly for five years and then annually for at least another five years. Suggestions for a written instruction sheet for patients Why are you going to receive radioactive treatment? You are going to receive radioactive iodine treatment because your doctors have decided that this is the best option for your disease. This radiation damages the tissue, producing the desired beneficial effect for your 458 6. However, small quantities of the radiation present in your body may reach people close to you, exposing them to this radiation unnecessarily. Although there is no evidence that this radiation exposure has damaged other individuals, you should avoid exposing others to any unnecessary radiation. Radioactive iodine is given in a capsule or liquid form by mouth in variable quantities according to the type of your disease. Your treating doctor and the physician who will actually administer the treatment determine the dose. According to the administered dose and your condition, it is possible that you may be hospitalized for some days. Women must be absolutely sure that they are not pregnant at the time they receive the treatment and should not be breast feeding. Food should not be ingested in the two hours before treatment and, in some cases, a low iodine diet will be recommended for a few days. Most of the iodine not retained in thyroid tissue is eliminated through the urine within 48 hours. This means that the possibility of unnecessary radiation exposure to other people also decreases in a matter of days. Radiation emitted by the radioactive iodine in your body is very similar to the X rays used in radiological examinations. For this reason, people who remain close to you for prolonged times may be exposed to unnecessary and avoidable radiation. Besides the above mentioned radiation, there is the possibility that other people close to you may directly ingest small quantities of radioactive iodine eliminated by your body in the saliva or sweat. The three principles to avoid unnecessary radiation exposure are: (1) Distance: Do not get too close to any other person. Because most of the iodine is excreted in the urine it is very important that you wash your hands thoroughly after going to the toilet. Avoid close and prolonged contact with other people, especially children and pregnant women, who are more sensitive to radiation than the rest of the population. If you have a small child or you are in charge of one, request special instructions from your doctor. If you are breast feeding, you must stop before therapy begins because the iodine is excreted into breast milk. Men are advised to urinate sitting down to avoid splashing urine outside the toilet bowl or in its borders. Eat sweets or drink lemon juice to produce more saliva and in this way prevent iodine retention within your salivary glands. Wash your underwear and bed linen separately from those of the rest of the family and rinse several times. Clinical benefits The aim of radionuclide therapy for metastatic bone pain is to ameliorate pain, reduce the intake of analgesics and improve quality of life. The requirement for such treatment is the demonstration of good focal uptake of 99mTc bone-seeking radiopharmaceuticals in bone scintigraphy at sites corre- sponding to the bone pain. Between 60 and 75% of patients normally show a good response to such treatments; the duration of response lasts between 6 and 24 weeks (with a mean of 12 weeks) and is independent of the radioisotope used. A significant proportion (40–50%) of responders do not require analgesics, while the rest require only mild doses of oral analgesics in order to remain free of pain. Studies have also demonstrated that there is significantly delayed onset of new bone pain following therapy. Mild to moderate myelosuppression (thrombocytopenia, leucopoenia and rarely anaemia) is sometimes observed.

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F32 Depressive episode may be mild/moderate/severe (the first 2 with/without somatic symptoms best diclofenac 50 mg, the last with/without psychotic symptoms) purchase 100mg diclofenac with visa, other (included atypical depression) or unspecified buy 50 mg diclofenac overnight delivery. F33 Recurrent depressive disorder – the current episode may be mild/moderate/severe (the first 2 with/without somatic symptoms diclofenac 100mg sale, the last with/without psychotic symptoms) discount 50 mg diclofenac free shipping, other or unspecified, or the patient may be in remission. F34 Persistent mood (affective) disorder may be classified as cyclothymia,* dysthymia,** other or unspecified. F38 Other mood (affective) disorders may be classified as a single episode (state if mixed) or recurrent (state if brief depressive), or other. It includes ‘affective personality disorder’, ‘cycloid personality’ and ‘cyclothymic personality’. It includes ‘depressive neurosis’, ‘depressive personality disorder’, ‘neurotic depression’ with over 2 years’ duration, and ‘persistent anxiety depression’. According to Michels and Marzuk (1993), ‘The boundaries between dysthymia, chronic unremitting major depression, and depressive personality traits remain controversial. The latter is chronic and lifelong, whereas the former is episodic, can occur at any time, and usually has a precipitating stressor. A number of experts believe that the cycloid psychoses were a variant of bipolar disorder with an unusually sudden onset. Atypical features: mood reactivity (cheered by good news) plus 2 or more of – significant weight gain or increase in appetite, hypersomnia, leaden paralysis (heavy, leaden feelings in arms/legs), or a long-standing pattern of rejection sensitivity (not only when ill) that causes significant social/occupational impairment. Rapid-cycling: at least 4 episodes of a mood disturbance in the past 12 months meeting criteria for major depressive, manic, mixed, or hypomanic episode. In cases of relatively mild severity, resentment of others may be more prominent than guilt. They can be as short as days in duration, or they can last for so long as to be difficult to 1344 distinguish from personality disorder. About 10-20% of bipolars may experience a number of depressive episodes before having a manic one, and the risk for bipolar disorder may be higher in adolescent major depression and even higher in depressed children. In a 15-year prospective study of consenting offspring of bipolar parents Duffy ea (2009) found that major mood episodes began in adolescence and not before this and nearly all index episodes were depressive, as 1345 were the first few recurrences. Severe, chronic bipolars may have neuropsychological dysfunction even when in remission. Also, sub-syndromal residual symptoms are common in bipolar disorder (Paykel ea, 2006) and are predictive of relapse. Children and adolescents may have adult features of depression together with pain (head, abdomen, chest), separation anxiety or school refusal, unexplained fall in scholastic performance, over-eating and increased weight, and new conduct symptoms such as defiance and aggression. Dementia v Pseudodementia 1348 Wernicke, in the 1880s, replaced the older term vesanic dementia with pseudodementia. One common denominator in pseudodementia induction is the ability to impair cognition or to disable the mechanisms by which cognition is expressed. Depression and dementia may co-exist; both occur most 1344 According to Morey ea (2010) a diagnosis of personality disorder made while the patient is depressed is valid and not an artefact of low mood because in their 6-year outcome study they found that the outcome for major depression ‘with comorbid personality disorder’ was similar to that of ‘pure personality disorder’ and much worse than for those with ‘pure major depressive disorder’. Pure depressive pseudodementia is associated with tardy responses, reduced speech output, and poor concentration without dysphasia or agnosia. Depressed females are more likely to report a poor early relationship with their mothers, but not with their fathers, low care and high overprotection, a poor marriage, poor current relationships with their own mothers, much poorer relationships with parents-in-law, and more poor family relationships in general. Fatigue and anxiety symptoms, both psychic and somatic, are said to be very common in depressed women. However, some authors find no difference in symptomatology between depressed men and women. It is usually stated that the evidence is against a direct aetiological connection between depression and the 1350 menopause ,(O’Shea, 2000b) although this important event can mean freedom for one woman and perceived loss of role for her sister (the same applies to conditions such as endometriosis). The latter are best measured shortly after menstruation (their lowest concentration is expected at this time) since levels may rise to premenopausal figures later (with highest recordings midway through the cycle). New onset and recurrence of major depression may be more likely at the perimenopause in women with a history of premenstrual syndrome or postpartum depression. Mood disorders in youth 1351 Depression is more likely in adolescence , especially in females, but is still not uncommon even in early childhood, when it is possibly commoner in boys. Depression before puberty may present as physical concerns, agitation/anxiety/phobia, or avoidance of other people. The depressed adolescent may show poor academic performance, feelings of not being listened to or of not being understood, antisocial or aggressive behaviour, negativism, restlessness, alcohol/substance abuse, or avoidance of other people. Subjective complaints of depression should be sought in childhood because the disorder may be missed if too much reliance is placed on parental information. Childhood depression is often comorbid with other psychiatric conditions such as phobic or conduct disorders.