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Diagnosis Biological signs � Diurnal variation in mood; could also be agitation � Sleep disturbance especially with frequent or early morning waking Psychological symptoms � Persistent, pervasive low mood with lack of pleasure and enjoyment � Withdrawal from relationships and activities � Morbid guilt, feelings of helplessness and worthlessness/low vanity � Persistent negative pondering fashion relating to all features of life, past, present and future � Excessive rumination � Suicidal concepts and intentions Causes/Risk components � Past history of despair � Need to adjust to many life adjustments over a brief time frame � Loss of earlier roles, loss of planned future � Poor symptom control � Immobility and isolation with poor high quality of life and lack of help � Uncertainty about sickness or prognosis � Early dementia � Drugs � corticosteroids (long run use, or on withdrawal), benzodiazepines, some cytotoxics, antihypertensives and narcoleptics Management A Consider reversible causes Minimise the causes: see above B Non-drug measures Provide psychological support or therapies C Drug therapies are really helpful in average or severe despair. 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