Ellen is a 55-year-old teacher's assistant who has been a patient of your practice for more than ten years. She is married with two adult children. She presents one Saturday morning with her husband Stan.

You notice a difference in Ellen's appearance as soon as she enters the room. She appears slow, stooped, and does not smile spontaneously.

Stan does most of the talking because "Ellen is too tired". He says Ellen has complained of feeling tired and 'run down' since her adult son left home two months ago, and has gradually lost interest in everything around her. She is unable to sleep at night. When you ask Ellen what is wrong she shrugs and says, hesitantly: "I'm not like I was before."

Stans says that Ellen had an episode of depression after leaving home thirty years ago. She has had no recurrence since. He says there are no problems at home or work, and is at a loss to understand the reason for her problems. He says he thinks Ellen's mother was diagnosed with major depression in her forties.

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