Leanne: A Case Study in Major Depressive Disorder, Recurrent
Leanne came to the office because she stated that her depression had worsened in recent months and that she was feeling nervous and panicky almost daily. She is 31 years old. Leanne described her home situation as "less than ideal." She separated from her husband two years ago and found herself barely able to meet her financial obligations of the mortgage that was once shared and the other household bills. She noted that she was laid off about 18 months ago from her former job and was unemployed for one year. During this time she returned to school for a Master's degree. Leanne's financial crisis deepened with the layoff and she was forced to sell her home and move in with her boyfriend about three months ago. She found a new job in her field about six months ago, but she is making less money than she was even receiving from unemployment benefits.
Leanne describes the living arrangement as difficult. Her boyfriend's chronically ill best friend also lives in the house. Leanne states that the house is too small to accommodate her belongings and she is storing things in her camper in the backyard. She misses her old house which was bigger and had a nice yard. She also misses her dogs that live with her ex-husband. She stated that she feels like she is "walking on eggshells" around her boyfriend all of the time because the living arrangement is only supposed to last until she finishes her Master's degree next summer. She said that she feels like a long-term houseguest and that her presence is an intrusion. She said that her boyfriend's actions sometimes confirm this feeling.
Leanne's job, in addition to not paying as much as she needs to remain independent, she also finds the work mundane and unchallenging. She found her former position to be stimulating and exciting. Now she feels like she is just "wasting her days there and not trying to excel." She states that her supervisors do not value her opinion or utilize her recommendations regarding projects. Leanne feels that the job description misrepresented the actual duties and that she is basically fulfilling the obligations of a secretary, rather than a marketing professional. She says that she completes her tasks quickly and then spends quite a bit of time each week "looking busy" because her supervisors do not have additional work for her and she has to stay.
Diagnosis
Leanne had symptoms that included all of the DSM-IV-TR criteria for an axis I diagnosis of major depressive episode, except weight change and psychomotor agitation. Figure 1 (below) lists the criteria for a major depressive episode. Axis II includes personality disorders and developmental disorders. Leanne does not fit the criteria for an Axis II diagnosis. Axis III covers physical conditions that would precipitate the symptoms of Axis I. Leanne has been regularly seen by her general practitioner and has no illnesses that would fit the criteria for an Axis III diagnosis. Axis IV covers severity of psychosocial issues. Under this diagnostic section notation is made regarding problems with primary support group, educational issues, social environment problems, occupational problems, housing problems, economic problems and legal issues. (American Psychiatric Association, 2000) Leanne has marked disturbances with her support system (recent divorce), housing (living arrangement primary complaint), educational (stress from grad school), social environment (inadequate social support), occupational (job dissatisfaction), housing (discord with tenancy arrangement), and economic (inadequate financial resources). Axis V rates the level of functioning at its highest during the past year and where it is currently. This rating is done on a scale of 0-100, with 100 being superior functioning. Leanne presents with a current rating of 20, as she is functioning by going to work and attending class, but also having suicidal ideations and performance issues. Her functioning has declined from a high of 75, where she was experiencing only minor symptoms of depression, but was not having functional issues related to it.
Figure 1
DSM-IV TR Criteria for Major Depressive Episode
Must have a total of 5 symptoms for at least 2 weeks:
One of the symptoms must be depressed mood or loss of interest.
1. Depressed mood.
2. Markedly diminished interest or pleasure in all or almost all activities.
3. Significant (>5% body weight) weight loss or gain or increase or decrease in appetite.
4. Insomnia or hypersomnia.
5. Psychomotor agitation or retardation.
6. Fatigue or loss of energy.
7. Feelings of worthlessness or inappropriate guilt.
8. Diminished concentration or indecisiveness.
9. Recurrent thoughts of death or suicide.
The symptoms do not meet the criteria for a mixed episode.
The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).
The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.
Leanne's diagnosis from previous clinicians of major depression is supported by DSM-IV criteria. I have no reason to suspect that her symptoms are caused by a mood disorder like bipolar because she exhibits no manic episodes, nor has she ever.
Social History
Leanne was depressed as a child. Her mother first noticed symptoms at 6 years old, she said. Her mother took her to her first therapist that year and she participated in therapy sessions several times over the next 7 years. She states that she did not trust her therapists because they were always discussing her behavior and her conversations with her mother and stepfather. She began acting out by saying she wanted to die and cutting herself. At age 13 she attempted suicide because she felt alienated at home. She describes her mother and step father as verbally abusive. She says that they were always yelling at her for things, but they were lax in providing discipline or guidance to help her improve her behavior. After the suicide attempt Leanne was admitted to an in-patient hospital where she remained for six months. Here she was first prescribed anti-depressant medication.
During her teenage years, Leanne continued therapy and medications. She also experimented heavily with drugs and alcohol during this time. She describes her parents as continuing their verbal abuse until age 16 when they moved to another state and she stayed behind to live with friends and finish high school. Despite her behavioral issues and depression, Leanne always excelled at school. She credits this as part of the reason why her parents did not appropriately discipline her. She reports that she felt abandoned by her parents' move and that her behavior did not improve and for that reason she bounced around between different friend's houses because she did not follow the rules set by their parents. After high school Leanne received a scholarship and attended the local university; graduating with a BA in Communications. Leanne got a job as an editor for a local newspaper after graduation and eventually took a better position at another newspaper in California. She describes her career as "very fulfilling and successful" up to the point that she was laid off and collecting unemployment while searching for a new job. Leanne describes the period of time before the layoff as a time where her depression was well managed with medication. She met her husband during this time and got married. She says that her depression was not part of why she got divorced. Her husband was transferred for his job and while they were living apart, being long distance spousal partners, they grew apart and amicably split.
Leanne cites the perceived failure of her marriage, her current position at work, the loss of her home and the unhappy living situation she is currently in for the escalation in her depression and new symptoms of anxiety. She mentioned that she has been having trouble concentrating at work and sleeping at night. She stated that she is also seeing a reemergence of thoughts about death, like those she faced as a teenager before her suicide attempt. She stated that she does not wish to die, but the thoughts keep happening; especially after a confrontation. She has been referred for counseling by her psychiatrist. She has been taking Lexapro for the last eight years and she was prescribed Ativan just before her referral for counseling.
Conceptualization
Leanne and I discussed her major concerns about the change in her symptoms that has happened recently. Primarily she is concerned about the way her depressive symptoms are affecting her job performance and her personal relationships. She has frequent disagreements with her boyfriend, she feels unmotivated and unchallenged at work and she has a persistent state of anxiety, where her thoughts shift between her financial obligations, thoughts of death (although she states she is afraid of these thoughts and does not wish to die), and fear that she will never recover from her depressed mood. Her sleep disturbances she said are related to the anxiety that plagues her thoughts, despite feeling tired nearly all day every day. She described repetitive thoughts about what she sees as shortcomings in her life; a failed marriage, a failed career, a failing new relationship.
A psychodynamic view of Leanne's depressive symptoms would take into consideration the difficulties Leanne faced as a child. Since her depression appeared early and she described her parents as verbally and emotionally abusive, this approach would focus on the subconscious influences her early experiences would place on her current relationships. Psychodynamic theory maintains that there is a conscious and a subconscious component to all people. In other words, there are decisions that a person intentionally makes and then there are decisions that are heavily influenced by underlying personality components that originated throughout a person's development. (Busch, Rudden, & Shapiro, 2004) This treatment would address the feelings, thoughts and behaviors that influence a person's current situation.
Psychodynamic therapy often focuses on goals beyond the alleviation of symptoms. It is a long-term therapy plan that deeply explores the personal history of the patient and uses that information to contextualize current situations. In addition to looking for past experiences that shaped the patient's sense of self this type of therapy would also look for defense mechanisms, which are ways that the patient has developed to cope with emotional distress, that have developed because of those particularities. (De jonghe, Kool, Peen, Dekker, & van Aalst, 2001) Psychodynamic therapy sessions are not rigidly structured. The therapist relies heavily on free associations made by the patient. (Messer & Warren, 1998) Through the course of these associations, the psychodynamic therapist would look for themes that would give insight to current predicaments. These patterns may appear subtle or indiscernible to the patient, but through exploration of the patient's ideas and observations of the patients' behavior within the therapeutic relationship, the therapist will be able to see the way the patterns act on the patient's current life circumstances and together they can work to change them in a positive fashion. (Busch, Rudden, & Shapiro, 2004)
In response to Leanne's relationship, the psychodynamic approach would look for difficulties that stem from past relationships. It would also look for recurrent themes in past and present relationships. Her early memories of her parents yelling at her and not listening to her can be seen mirrored in the dynamic within her new relationship with her boyfriend. Since she has asked to stay at his house, as a short term solution to her financial problems, she has entered into a relationship where she perceives a lack of power and control over decision-making. Disagreements within this relationship are common and Leanne reports that after a verbal altercation with her boyfriend that she feels belittled and that deeply saddened that this is her life and that she cannot make changes to it. Through further therapy and the development of the therapeutic relationship, Leanne may begin to have a greater insight for what is actually motivating her to behave in certain ways. She may also gain a deeper insight as to why some situations elicit what may seem like an exaggerated emotional response.
An alternative to the psychodynamic approach for Leanne's treatment could be Interpersonal Psychotherapy. This intervention has a theoretical framework that has roots in the biopsychosocial model and also in attachment theory. Interpersonal Psychotherapy was originally designed as a control in an experiment measuring efficacy of antidepressants alone, psychodynamic therapy alone, or against an non-specific treatment that was referred to as "high contact" due to the relatively high amount of contact the clinicians had with the patients in the therapeutic setting. (About IPT, 2012) This method does not use the patient's past to predict or interpret present behaviors or emotions. Instead it focuses on isolating an area of conflict in the patient's life and then focusing on relieving symptoms by exploring and ideally, resolving, the immediate life problem.
In other words, looking at Leanne's problems with her boyfriend and her job can both be viewed as occurring because she has a heightened emotional response to these situations because her expectations of these relationships are not aligned to the reality of what they truly are. More specifically, her quarreling with her boyfriend is deeply upsetting to her, but the subject of these disputes is continually petty and he does not appear affected by these negative encounters. Looking deeper into this relationship and the causes of Leanne's feelings about this relationship may prove to be the key to eliminating the troubling return of her depressive symptoms. Interpersonal Psychotherapy defines problematic life issues as belonging in one of four categories, complicated bereavement, interpersonal role dispute, role transition or interpersonal deficit. (Klerman, Weissmann, Rounsaville, & Chevron, 1984) Interpersonal Psychotherapy is proven to be effective in relieving the symptoms of depression in patients who have decent insight into their problems, are engaged in the therapeutic process and who are not in a psychotic state. (About IPT, 2012)
Viewed from the perspective of any theory, Leanne is a person who has been dealing with depression for the majority of her life. Despite her current negative self-descriptions, she is a successful and independent woman. She has consistently followed her dreams and overcome adversity that she has encountered in many forms. She follows her psychiatrist's pharmacological plan and takes her medication as prescribed and keeps appointments to follow-up. She has a history of reaching out for psychological guidance when her symptoms intensify or change, showing that she is engaged in the process of managing her mental health. Based on these positive qualities and the patient history, I am choosing to follow the route of providing Interpersonal Psychotherapy to Leanne.
Treatment
After discussing the problems Leanne was facing, I decided to approach her problems by focusing my attention on defining what her problem areas were. She described conflict in her living situation, also known as an interpersonal role dispute. She described unhappiness with her new job, also known as role transition. Upon further reflection, Leanne also described her social situation as isolating and lonely, which can be described as an interpersonal deficit. (Klerman, Weissmann, Rounsaville, & Chevron, 1984) Since Leanne has a long history of depression, I chose to direct my attentions to the present situations that were actively contributing to her depressed mood and anxiety.
At the end of the first session, I counseled Leanne establishing a therapeutic relationship that would evolve in line with the theories of interpersonal psychotherapy, "We have spoken about your life and your previous diagnosis of major depressive disorder. All of the negative feelings you are having are part of an illness that is treatable. They are not happening because you did something wrong. Over the last year, your life has changed dramatically. You are now in a new relationship, with new struggles and complications. These changes in your life have resulted in new role disputes. By resolving your struggle at home and helping you accept your current job as a temporary situation, I believe that you will see your mood improve. I would like to spend the next 16 weeks looking at your current situation and helping you toward enhancing your life." Before leaving, we drafted a treatment contract that set the duration of the therapy at 16 weeks, with once weekly meetings, lasting one hour each. We agreed that the foci of the sessions would be her interpersonal relationships with her boyfriend and her boss. We agreed that the goal of the therapy would be to eliminate the severity of her symptom's impact on her ability to function productively at work and at school. Part of the contract specifically addressed Leanne's preoccupation with death and an agreement to not harm herself. I asked Leanne to think about what she wanted to achieve at home and at work. I asked her to think about her relationship with her boyfriend and her job situation and determine the best possible outcome, the probable outcome and the worst possible outcome of each situation. I told her that we would discuss her ideas in the next couple of sessions.
During the second session I asked Leanne to talk about her living situation. From her previous statements I concluded that her symptoms became particularly troublesome after she moved into her boyfriend's house. I asked her to describe a typical dispute between them. She stated that "there are different rules for me and him. If I leave a dish unwashed, he will tell me that I need to do better, but I often come home after work and find the kitchen is a complete mess. If I bring this up to him, then we have an argument and he tells me that it is "his" house and that I am a guest there." She followed up by further explaining her living situation. She is, in fact, only staying there on a temporary basis. She plans to move out next summer when she has completed her master's degree. She mentions that when she is done with her commitment to school that she will be able to resume her side-work grooming dogs on a part-time basis to supplement her income while she finds a better paying job utilizing her new degree. This would allow her to return to living alone, which is currently not financially possible with her present salary, financial commitments and school schedule. I asked her to describe her relationship with her boyfriend before she began staying with him after she sold her house. She detailed a relationship that was monogamous, but not overly involved. She said that they used to talk on the phone briefly each evening and would usually go out together on Saturday and Sunday. She said that they would take turns staying at each other's houses on the weekends and that they very rarely saw each other during the week; only for special social occasions. She said that they met 8 years ago at work and that their relationship became romantic after she separated from her husband.
In the third (and final introductory) session, I guided Leanne to discuss the relationship that she has with her boss at work. She described her as continually seeking input on business decisions, but never following through on them. Leanne feels that she is overqualified for this position because she normally performs the duties of a secretary. She stated that she frequently finishes her work early and asks for additional tasks, but none are given. She finds the work to not be challenging and she feels that she has too much down time on the job. She contributes her lack of motivation at work to these factors. These initial sessions have served the purpose of providing me with a thorough history, have established the therapeutic relationship, allowed me to assess the symptoms and set the stage to shift Leanne's internal blame from herself to the illness.
Now that the information gathering sessions are over, the goal of the next eight weeks will be to help Leanne focus on her problem relationships. We agree that her relationship with her boyfriend and the resulting tension at their home is the primary area in her life that needs to be reconciled. My role in these sessions will not be neutral; I will instead be an active member of Leanne's support system, giving her guidance and positive reinforcement. (van Ijzendoorn, 1995) Leanne will be responsible for making the changes in her life and also for choosing topics of discussion that are significant to her. Additionally, the conversation will shift at this point from focusing on the illness (symptoms) to focusing on the interpersonal interactions of the patient. I will continue to monitor the symptoms of depression to ensure there is no dramatic shift in severity.
During sessions 4-8 I will rely on a few different techniques to encourage a free and open discourse with Leanne. Clarification is a common technique in Interpersonal Psychotherapy and is a way for the therapist to give definitive qualities to vague ideas that are presented by the patient. This is achieved through asking direct and open-ended questions, being an empathetic listener and also using the communication technique called reflexive listening, where the listener rephrases and repeats ideas back to the speaker. (Miller & Mount, 2001) Another tool that will be used to provide insight into Leanne's relationship is communication analysis to enhance problem solving for recounted examples of interpersonal incidents. (Klerman, Weissmann, Rounsaville, & Chevron, 1984)
In session 5, Leanne described a confrontation between her and her boyfriend that had occurred during the past week. She stated that she returned home after work and was feeling frustrated. She was anticipating having to take a difficult exam for her class that evening. She said that upon arriving home she found that her boyfriend had a friend over and that they were playing a video game in the room that she does her school work. She said that the kitchen was in disarray and that she had to clean it up so she could make something to eat. She said that she hoped that her boyfriend and his friend would be done with the game by the time she finished, but they weren't. She asked if they could go in the other room, but he suggested that she take her computer and go in the bedroom. She said that she explained that she would rather not have to move her books and her cords and get the laptop desk all back to the bedroom before she took her exam. She said that her boyfriend told her that this was the only room that they could play the game in. Leanne explained to me that at this point she was very upset and that her boyfriend commented that she needed to do something besides stand there and start a fight with him. She reported that she felt like her feelings were never considered, that her needs were not being met, and that her status of a long-term house guest, as opposed to a partner, was causing her to feel anxious. She said that she felt, in that moment, that she would feel miserable forever and that her entire life has been nothing but one painful encounter after another.
After listening to Leanne's recount of this argument, I asked her to think back to the three possible outcomes we discussed when we first met. I asked her to tell me what she thought was the worst, best and most probable outcome of her relationship. She stated that the best outcome would be that her and her boyfriend would stop fighting and she would remain living with him even beyond the end of her graduate studies because she would want to. She stated that the worst outcome would be that they would not be able to stop fighting and that he would ask her to leave which would result in her being homeless and unable to finish her program. She said that the probable outcome would be that they would continue to fight and she would continue to be depressed until she finishes school and is able to move out. I reminded Leanne that she had told me previously that she would prefer to live alone and to resume the dating relationship that they had before she sold her house. I also asked her to consider if her boyfriend was aware that she was already upset about the exam and the kitchen before they had their confrontation. She agreed that she had not told him that she had an upcoming test that was causing her stress. She also said that the kitchen is frequently a mess because her boyfriend tends to cook when he gets home and to clean before bed. I addressed her self-deprecating thoughts that surfaced after the argument by suggesting that she reaffirm her goals for the relationship. If she wanted to continue to develop this union into cohabitation that has marriage as the goal, then she would need to communicate those wishes to her boyfriend. If she wants to just make it through this living arrangement until the beginning of May when she graduates and then move out, then she would need to examine her own affect as she is experiencing it. Through further discussion, it came to light that she does actually want to return to living alone because she was happy when that was her living arrangement before she sold her house. She said that she loves her boyfriend, but acknowledged that they are both independent people who are pretty set in their ways. We proceeded to brainstorm some options for avoiding conflicts like this in the future. She made several suggestions and I augmented her proposals with a few options that she overlooked. I asked her to evaluate these possible solutions and to discuss how they would have changed that confrontation and also how they might be applicable to other disagreements that she has with her boyfriend.
My goal through the aforementioned exercise is to help Leanne examine the communication the way it happened and also to reflect of the possible reasons her emotional response was so intense. Depressed patients are often unable to see alternatives solutions to problems and part of the interpersonal psychotherapy is assisting the patient with this type of decision analysis, but taking precautions to not undermine the self-sufficiency of the patient. (Klerman, Weissmann, Rounsaville, & Chevron, 1984) Some of the suggestions that we explored for Leanne to try for similar situations were to communicate worries about school and work to her boyfriend before they are imminent and also to have a contingency plan for completing school work at another location. We ended the session with me asking Leanne to monitor and appraise her interactions with, not only her boyfriend, but also her boss. I reminded her of the determination that we had made regarding her feelings during a conflict resulting from a reaction to ideations that are not being communicated effectively to the other party. I also instructed her to have the goal of all interactions clearly in mind while the encounters are happening.
Through the next several sessions, Leanne reported using different techniques for dealing with her interactions with her boyfriend. We repeated the affirmations of her goals and worked on improving her communication to be more direct and specific. We engaged in some role playing that allowed her to practice conversations before she actually had to have them. She began to report a decrease in her anxiety levels and depressive symptoms. The effects of improving her relationship with her boyfriend were also spilling over into her job. She began to remind herself that her position with her current employer was temporary and that her goal was to remain employed until her master's degree was finished. By session 13 she reported that she was feeling more motivated to do the best job that she could at work. She also stated that she was having less bickering and hurt feelings in her dealings with her boyfriend. She had chosen on several occasions to take her laptop and books to the library to do her work and she had also done work at a friend's house where she also got some much needed social interaction outside of her typical relationships. She had come to realize that she had not been honest with herself about her expectations of these relationships and that viewing the problematic interpersonal interactions in the context of what her true objectives were helped her to make choices in a more constructive fashion.
I introduced the impending termination of therapy in the next session, stressing the positive results of treatment, but crediting the results to Leanne's own work and dedication. (About IPT, 2012) We continued to use the techniques that were introduced in earlier sessions to evaluate issues as they continued to arise over the next few weeks, but we also focused on the fact that new issues would certainly occur after the end of the therapy agreement and how Leanne might deal with those things. I discussed the possibility of her symptoms returning and the need for her to remain vigilant in using the skills that she had learned to tackle problems as they come. In the final session I made arrangements with her to check in with me in May when she completes her degree.
There are other types of therapies and treatments that can be used to combat depression. The other most common therapy type is cognitive behavior therapy. This type of therapy focuses on changing the thought patterns of the patient and also on teaching new behaviors that will hopefully become part of normal functioning. There is substantial evidence that suggests that the use of anti-depressant medications, such as SSRI's, MAO Inhibitors and Tricyclic antidepressants, in conjunction with therapy is the most effective treatment for depression. (De jonghe, Kool, Peen, Dekker, & van Aalst, 2001) The type of therapy used depends on the severity of the depression in the patient, the personality of the patient and the counselor, plus additional constraints based on finances and schedules.
Etiological Considerations
There is no single factor that determines the onset of depression. Some factors that may contribute are biological, genetic and environmental/social. Biological considerations are the basis of pharmacology in psychiatric treatment. These drugs work on the basis of replacing or changing the chemical components that are naturally found in the body. Several neurotransmitters have been connected to depression. The main association between neurotransmitters and depression are in the chemicals serotonin, norepinephrine and dopamine. (Ehlert, Gaab, & Heinrichs, 2001) Other brain areas that have been studied as biologic causes of depression are the limbic system and the hypothalamus. (Ehlert, Gaab, & Heinrichs, 2001) There is some evidence that genetic factors play a role in depression. The heredity of depression has been studied because there has been evidence that suggests that it can run in families, but there was also the question of whether or not it was the familial environment that was really the cause. Several genetic factors with a definitive link to depression were discovered in research funded by the National Institute of Mental Health. This research has shown that there are genetic similarities in depressed patients that lead to functional disruption in the synaptic pathways. (Fields, 2012) Environmental factors such as drug abuse can contribute to depression. Sometimes people with a genetic predisposition to depression are not affected where other people similarly predisposed are. There are many theories that cite traumatic experiences in life as a causal factor to depression. Other social factors such as divorce or chronic stress can contribute to the onset of depression. Conversely, depression can also cause life to be more stressful. (Oltmanns, Martin, Neale, & Davison, 2009) It is interesting to note that depression is more common in women than in men. There are several reasons that can explain this statistic. One factor is that women are more likely to experience hormonal fluctuations than men, especially during their reproductive years. Women are also more likely to seek treatment for depression than men are, so this contributes to the disparity in the rate of diagnosis. (Curran, Ogolsky, Hazen, & Bosch, 2011)
Leanne's depression has been pretty well managed by a daily dose of Lexapro over the past 8 years. She has not had many periods of intensifying symptoms during this time. Lexapro is a selective serotonin reuptake inhibitor (SSRI) and it affects the rate at which the synapse pumps the serotonin, so the serotonin remains active in the synapse for a longer period of time. The last time her symptoms were at this level was when she started taking the Lexapro because her symptoms were returning even with an increased dose of Celexa. She sought therapy before she got married because she noticed her symptoms returning under the stress of work and planning a wedding. She reported that the sessions were helpful in relieving her excessive stress by giving her someone to talk to who was impartial. It is likely that Leanne has a biological cause that her depression is rooted in, but it is also clear that times of extreme stress cause her symptoms to become worse.
The recurrent nature of her depression means that she should maintain a vigilant approach to managing her mental health. Just like the symptoms that brought her in to seek counseling most recently, Leanne should continue to take her prescriptions in accordance with her prescribing psychiatrist and she should be aware of her mood during times of extreme life-changing events. She should seek treatment as soon as she notices her depressive symptoms intensifying, even if there is not a clear social or environmental cause for her depression.
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