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Diagnosis Biological signs Diurnal variation in temper; may be agitation Sleep disturbance particularly with frequent or early morning waking Psychological signs Persistent, pervasive low mood with lack of pleasure and pleasure Withdrawal from relationships and actions Morbid guilt, feelings of helplessness and worthlessness/low shallowness Persistent unfavorable considering type relating to all elements of life, previous, current and future Excessive rumination Suicidal ideas and intentions Causes/Risk elements Past historical past of despair Need to regulate to many life changes over a short time period Loss of previous roles, loss of deliberate future Poor symptom management Immobility and isolation with poor quality of life and lack of support Uncertainty about illness or prognosis Early dementia Drugs corticosteroids (long term 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 assist or therapies C Drug therapies are really helpful in average or extreme despair impotence at 30 buy cheap malegra fxt 140mg on line. 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