Abstract In the last few years a number of researchers have pointed out that the seriousness of mood disorders among preschool and primary school children is still underestimated when compared to the seriousness of the same illness during adolescence and adulthood (Luby, 2009). In spite of that, many pupils are still not diagnosed and treated. Without any treatment, this illness can lead to severe psychiatric problems in future adolescents and adults who suffered from it during their childhood (Carretti et al., 2009; Muratori, 2008; Muratori & Apicella, 2008). The objective of this work is threefold: firstly, to describe the principal symptoms of mood disorders in order to help preschool and primary school teachers to clearly recognise them; secondly, to describe the treatments which psychologists and psychiatrists are using nowadays to treat young children affected by this illness. Finally, as educators, we would like to suggest two programmes which include a close cooperation between clinicians and teachers themselves. The former is a three-step prevention programme to be held during the last two years of primary school, whilst the latter is a programme to be held during the last two years of preschool. It is understood that educators are not asked to become clinicians, but they might closely collaborate with clinicians by supporting children which are coping with mood disorders.

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2. 223MOOD DISORDERS IN PRESCHOOL AND PRIMARY SCHOOL CHILDREN
Preliminary notes
UDK: 616.895.3-053.4/.5
MOOD DISORDERS IN PRESCHOOL AND PRIMARY
SCHOOL CHILDREN
Catina Feresin
Department of Medicine, University of Padua (Italy)
Abstract
In the last few years a number of researchers have pointed out that the
seriousness of mood disorders among preschool and primary school children is
still underestimated when compared to the seriousness of the same illness
during adolescence and adulthood (Luby, 2009). In spite of that, many pupils are
still not diagnosed and treated. Without any treatment, this illness can lead to
severe psychiatric problems in future adolescents and adults who suffered from
it during their childhood (Carretti et al., 2009; Muratori, 2008; Muratori &
Apicella, 2008).
The objective of this work is threefold: firstly, to describe the principal
symptoms of mood disorders in order to help preschool and primary school
teachers to clearly recognise them; secondly, to describe the treatments which
psychologists and psychiatrists are using nowadays to treat young children
affected by this illness. Finally, as educators, we would like to suggest two
programmes which include a close cooperation between clinicians and teachers
themselves. The former is a three-step prevention programme to be held during
the last two years of primary school, whilst the latter is a programme to be held
during the last two years of preschool. It is understood that educators are not
asked to become clinicians, but they might closely collaborate with clinicians by
supporting children which are coping with mood disorders.
Keywords: mood disorders in preschool and primary school children,
collaboration programmes between teachers and clinicians.

3. 224 Catina Feresin
Introduction
In the last thirty years the experimental interest in depressive disorders
among children has gradually increased among researchers. Although a historical
observational study by Spitz had already documented the presence of depression
during childhood (Spitz, 1946), it was only in 1980 that the authors of DSM III
(A.P.A., 1980) pointed out the importance of a systematic study of mood
disorders during childhood. In fact, during the 1980’s and 1990’s the results of
numerous studies, based on the use of accurate tests, confirmed the likelihood
of identifying clinical mood disorders during this early period of human life
(Birmaher et al. 1996 a, 1996 b; Keller et al., 1984; Kovacs et al., 1984a, 1984b,
1994).
More recently, a number of researchers have observed that the
seriousness of mood disorders among preschool and primary school children is
still underestimated when compared to the seriousness of the same illness
during adolescence and adulthood. This means that many children are still not
diagnosed and treated, and without any treatment, this illness can lead to severe
psychiatric problems for the future adolescent who felt depression during
childhood (Carollo et al., 2004). Mood disorders are particularly dangerous if
they strike children at an early age: according to Shuchter (Shuchter et al., 1997),
when adults suffer from depression, they do not lose the ability to recognise that
the odd mental phenomena they experience are a logical product of a
pathological condition, so they try to cope with their illness by starting
psychotherapy and, eventually, taking antidepressants. Children, on the contrary,
may get lost in their depression: they do not have sufficient life experience and
appropriate cognitive skills to make a proper distinction between illness and
health; what they are experiencing is reality, so they are often emotionally
paralysed.
In 1984, Kashani and collaborators identified 4% of preschoolers in a child
development unit who met the DSM III criteria for depression (Kashani et al.,
1984; A.P.A., 1980). In a 1997 study by the same author, 2.7% of 300 preschool
children met the DSM-IV criteria for dysthymia (Kashani et al., 1997; A.P.A.,
2000). Nevertheless, although Kashani identified depression in preschool
children already in 1984, the study of depression which occurs during the
preschool period is relatively new.
Luckily, as Luby had pointed out, “...over the past decade, empirical data
have become available that refute traditional developmental theory suggesting
that preschool children would be developmentally too immature to experience
depressive affects (Stalets & Luby, 2006). Basic developmental studies, serving as
a framework and catalyst for these clinical investigations, have also shown that
preschool children are far more emotionally sophisticated than previously
recognized. While some of these emotion developmental findings are new,
others have been available for some time but never previously applied to clinical

4. 225MOOD DISORDERS IN PRESCHOOL AND PRIMARY SCHOOL CHILDREN
models of childhood affective disorders. These findings on early emotion
development, obtained using narrative and observational methods, provide a key
framework for studies of early childhood depression, as they establish that very
young children are able to experience complex affects seen in depression, such
as guilt and shame. Indeed, guilt and shame have been observed to occur more
frequently in depressed than in healthy preschoolers.” (Luby, 2009).
Children may exhibit depression in different ways: bad school performance
(both at preschool and at primary school), an increased irritability, constant
sadness, low self-esteem, a difficult social integration with friends. The main
consequence of this way of feeling is a different way of behaving in comparison
with their classmates: in fact, such children do not explore the world around
them as much or play with their friends as much, they do not develop significant
interpersonal skills with adults, which can be a disadvantage as it influences the
correct development of personality. Moreover, in the context of a class (often
very large), these pupils are generally quiet: they usually do not disturb the work
of the teacher or attract his/her attention (except for bipolar children during
manic or hypomanic episodes). It is therefore imperative for the teacher to be
able to recognise the principal symptoms of this illness. In order to accomplish
this task with more competence and to provide the most effective help, teachers
must further train themselves by attending specific courses and reading scientific
papers and books about mood disorders (Lo Piccolo, 2005; Stark, 1995; V.A.,
2001).
Main types of mood disorders among preschool and primary school children
According to Caretti et al. (2009), to Ismond (1996) and to the DSM IV-TR
criteria (A.P.A., 2000); there are basically two types of mood disorders: 1)
depressive disorder and 2) bipolar disorder (Actually, there are more than two
types of mood disorders which clinicians use to make different diagnoses among
children, but the ones we have just mentioned remain the principal two).
1) Depressive disorder can be divided into a) major depressive disorder
and b) dysthymic disorder; the first is a severe condition characterised
by one or more major depressive episodes lasting at least two weeks;
the second is a mild disorder, but is more persistent: children are
depressed for most of the day on most days and symptoms may
continue for about one year (several years among adults). Children
affected by major depressive disorder sometimes show another mental
disorder, such as conduct disorder, anxiety, phobias, and attention
deficit hyperactivity disorder. This phenomenon is called comorbidity
(Rietveld et al., 2002).
2) Bipolar disorder can be further classified into bipolar I and bipolar II
disorders. Bipolar I disorder is considered as the classic form of manic
depression, with full manic episodes followed by major depressive
episodes; bipolar II disorder also involves major depressive episodes

5. 226 Catina Feresin
which are, however, followed by hypomanic instead of full manic
episodes (Kovacs et al, 1994; Kovacs et al., 2005).
We are aware of the fact that recognising mood disorders among children
is a complex task; however, we firmly believe that, after an appropriate training,
preschool and primary school teachers should be able to recognise the presence
and duration of depressive and bipolar disorders, observing the
emotional/cognitive and physical symptoms of this illness, as explained in the
following paragraph.
Main symptoms of mood disorders among preschool and primary school
children
In a recent review by Mocinić and Feresin (2012), the symptoms of
depressive disorders are precisely defined for primary school children. However,
as Luby pointed out in 2009, symptoms of depression in pre-school children are
quite similar to those already found in school children and, sometimes, in adults
(Luby, 2009; Luby et al., 2003; States & Luby, 2006). The following is the list of
symptoms mentioned by Mocinić and Feresin:
Sadness / Irritability
Sadness is one of the most significant emotional/cognitive symptoms
among depressed children (usually, bipolar children show more irritability than
sadness). During a major depressive episode, pupils experience a deep sadness
or start crying without being able to understand why they are behaving this way.
Teachers can observe this crucial symptom for a few weeks (at least two weeks
according to the DSM IV-TR criteria, 2000); if it disappears in less than two
weeks, it is not connected with depression (e.g. the pupil may have lost a good
friend or may have changed school).
Loss of pleasure (anhedonia)
Generally, children lose interest in things they once loved very much; this
is normal behavior. On the contrary, during depressive episodes, depressed or
bipolar children show a clear emotional/cognitive symptom: they do not feel
pleasure in anything and they lose their normal desire to play with classmates
(i.e. they stop participating in games and activities). Teachers must also observe a
potential decline in these children’s grades, because these pupils do not
complete their homework and sometimes they even miss school.
Difficulty in concentrating
Difficulty in concentrating is another emotional/cognitive symptom. It is a
simple task for a trained teacher to notice if students cannot concentrate well; in
fact, during both depressive and manic episodes, depressed or bipolar children
keep their minds busy all day long, focusing their attention on themselves, which
has a negative influence on their ability to concentrate on regular school
activities.

6. 227MOOD DISORDERS IN PRESCHOOL AND PRIMARY SCHOOL CHILDREN
Negative self-evaluation / Guilt / Grandiose self-image
Negative self-evaluation is a cognitive/emotional symptom which occurs
among children suffering from depression or bipolar disorder during depressive
episodes. Teachers are generally required to observe whether negative self-
evaluation affects school performance, but also if it influences the pupil's
physical aspect and his/her social ability to integrate with friends. Guilt is also an
emotional/cognitive symptom: depressed children feel guilty more frequently
than children who do not suffer from depression. In this case, teachers are
required to notice whether these pupils blame themselves for facts they are not
responsible for (i.e. separation of their parents). During manic or hypomanic
episodes, bipolar children often suffer from grandiose self-image, accompanied
with an increased level of talking and feeling euphoric. Teachers are able to
clearly observe this cognitive and emotional symptom, especially when it follows
a period of negative self-evaluation.
Recurrent thoughts of death, suicidal ideation and suicide attempts
Recurrent thoughts of death and the idea of committing suicide without a
specific plan is an emotional/cognitive symptom among primary school children
suffering from depression or bipolar disorder which occurs during depressive
episodes, whilst actual suicide attempts or ideations of a specific plan for
committing suicide are more frequently encountered among adolescents than
among primary school children (Cheung et al., 2007).
Fatigue/Hyperactivity
Teachers can easily observe if pupils are tired during classes. Fatigue is a
rare condition among healthy children, but it is a very common physical symptom
among children suffering from depression or bipolar disorder which occurs
during depressive episodes. It can occur in a mild form without changing the
child's habits, or it can influence daily activities by obstructing the normal rhythm
of life. On the contrary, hyperactivity with an increased level of energy is a
frequent symptom during manic and hypomanic episodes in bipolar children.
Changes in appetite
A decrease in appetite may cause an unbalanced growth of a child's body:
he/she increases in height but remains equal in weight, with possible serious
physical disorders. Abnormal decrease in appetite is considered to be a physical
symptom and is usually associated with depressive disorder or bipolar disorder
(during depressive episodes). The opposite case, an increase in appetite, should
not be confused with the normal growth process: it is considered abnormal if it is
accompanied by obesity, when the child eats at all times and when the thought
of eating interferes with his/her daily activities. Abnormal increase in appetite is
another physical symptom which is generally associated with bipolar disorder
during manic or hypomanic episodes.

7. 228 Catina Feresin
Pain complaints without medical cause
Sometimes children complain to the teacher about headaches, stomach
aches or other kinds of pain. Pain complaints are considered symptomatic when
there is no objective reason for feeling them. This physical symptom is usually
associated with major depressive disorder and its severity is defined by the
intensity of pain and the frequency with which it occurs.
Sleep disorders
This physical symptom can be divided into insomnia, when the child sleeps
less than he/she needs, and hypersomnia, when the child sleeps longer than
he/she needs (and often has difficulty getting up in the morning). Furthermore,
insomnia can be divided into initial insomnia and intermediate insomnia during
the night. The teacher may notice this symptom if the pupil loses concentration
and takes short naps at his/her desk. Among preschool and primary school
children, nightmares during REM sleep are very common and often disturb the
quality of sleep; on the other hand, night terrors (e.g. restless leg syndrome,
sleepwalking) are commonly encountered in children affected by bipolar disorder
and they occur during deep sleep (Mocinić and Feresin, 2012).
Main therapies to treat mood disorders among preschool and primary
school children
According to Luby, despite the fact that many studies have shown the
existence of depression in preschool children, there is little scientific literature
available to guide treatment once depression has been diagnosed (Luby, 2009).
Play therapy
Play therapy is a common form of therapy for very young children which
uses techniques for engaging children in recreational activities to help them cope
with their problems and fears. During this kind of therapy, a psychologist
observes the child while he/she is playing with a variety of toys, thus expressing
his/her unpleasant feelings which cannot be communicated verbally. According
to many researchers, more experiments are required in order to prove the
effectiveness of this kind of therapy as a means of coping with depression in
preschoolers (see Luby, 2009).
Verbal therapy
Verbal therapy is very helpful for primary school children, but not for very
young children who haven't developed sufficient verbal skills to correctly express
their feelings, lacking the linguistic sophistication to describe any kind of
emotional experience.

8. 229MOOD DISORDERS IN PRESCHOOL AND PRIMARY SCHOOL CHILDREN
Antidepressants
Regarding antidepressants, there is a general concern among mental
health providers about this form of medical treatment, since they tend to avoid
using medication for treating children at such a young age. Researchers have
different opinions about antidepressant for primary school children and
adolescents (Bailly, 2006; Wagner, 2005): some are pro such medicines, while
others are against them. On the other hand, regarding preschoolers there is a
common concern among researchers about the use of this type of medical
treatment (including also the recently developed antidepressants). According to
Luby, “the use of antidepressants is not the first- nor even the second-line
treatment for early childhood depression at this time”(Luby, 2009). A study by
Nulman and collaborators (Nulman et al., 2012) provides relevant information by
distinguishing the effects of maternal depression from the effects of exposure to
antidepressants (e.g. venlafaxina). Indeed, this study included a group of women
with histories of depression who had discontinued antidepressants prior to
conception (mothers' depression was defined according to the DSM-IV criteria).
The preliminary conclusion of this study is that exposure to untreated maternal
depression in utero and during early childhood is associated with worse cognitive
and behavioral outcomes in children.
Parent-Child Interaction Therapy (P.C.I.T.) and Emotion Development
Therapy (E.D.)
Recently, parent-child psychotherapy has been developed for the
treatment of preschool depression. It combines two separate therapies, i.e.
Parent-Child Interaction Therapy (P.C.I.T.) and Emotion Development Therapy
(E.D.). The former (P.C.I.T.), originally developed in the 1970s to treat disruptive
disorders in preschool children, is based on the common knowledge that the
child is not an independent entity at this early age and that the caregiver is a
fundamental part of the child’s psychological world, which is why the caregiver
figure is always involved in this kind of therapy. The latter (E.D.) is designed to
enhance the child’s emotional development capacities through the use of
emotional education. Parent-Child Interaction Therapy/Emotion Development
(P.C.I.T./E.D.) combines the use of emotional education by enhancing the
caregiver’s capacity to serve as an effective external emotion regulator for the
child. The primary goal of this therapy is to enhance the child’s capacity to
identify emotions in oneself and in other people; the second goal is to teach the
child to develop healthy emotions; the third goal is to enhance the child's
capacity of experiencing positive affect as well as the capacity to recover from
negative affect. Those who advocate this type of therapy hope that children will
learn how to handle depressive symptoms and parents will reinforce those
lessons. All this is based on the hypothesis that depressed children are less
reactive to positive stimuli and more reactive to negative stimuli than healthy
children. As Luby explained in one of her articles, “P.C.I.T./E.D. is a treatment

9. 230 Catina Feresin
which usually includes fourteen psychotherapeutic weekly sessions. During a
single session, the therapist observes the child and the caregiver interaction
through a one-way mirror. The setting also contains a microphone and an earbud
which allow the therapist to interact more easily with the caregiver and to
intervene more effectively on the child’s behalf. In the case of a depressed young
child, enhancing positive emotion in response to incentive events and reducing
negative emotion in response to frustrating or sad events are targets of
treatment by coaching the parent to respond to the child during contrived (and
spontaneous) in vivo experiences during the therapeutic session” (Luby, 2009).
Conclusion: The importance of a close collaboration between teachers
and school psychologists for helping children to cope with mood disorders.
First proposal: a three-step early prevention programme to be held
at primary schools as a possible way to fight an illness as frequent as
depression:
Primary schools are generally investing limited efforts in the early
identification of children affected by mood disorders. Cash and Cowan (2006)
supposed that the main cause for this lack of early identification is connected
with school psychologists' profession itself. The two authors literally wrote:
“Unfortunately, many people, including some members of the profession, still do
not perceive school psychologists as providers of mental health services. Perhaps
this is, in part, due to the fact that it is common to narrow mental health service
provision down to psychotherapy. Possibly it is a result of the failure to recognise
prevention, assessment, and crisis intervention as mental health services.”
As Mocinić and Feresin recently suggested (Mocinić & Feresin, 2012), we
need a three-step early prevention programme to be held at primary schools as a
possible way of fighting an illness as common as depression:
1) Firstly, a large-scale programme should be developed and applied during the
last two years of primary school, when the knowledge of mother tongue is
comparable to that of adolescents and when pupils can easily follow a written
test. All children should be screened for possible mood disorders, just as they
are screened for visual acuity or other health problems. Many valid and
reliable tests can be used to collect data for identifying children who might
suffer from mood disorders: “The Child Behavior Checklist (CBCL)” and “The
Children's Depression Inventory (CDI)” (Achenbach, 1991; Gregory, 2004;
Rivera et al., 2005). The Australian clinicians designed the other two
questionnaires for assessing mental health of children in primary schools. As
suggested by Dix et al. (2008), “...the first measure is Goodman’s Strength and
Difficulties Questionnaire (SDQ), which needs to be completed by each
participating child’s parent/caregiver and teacher. The second measure, the
Flinders SCS, contains items about school, family and child factors, along with
the outcome measures of student mental health.”

10. 231MOOD DISORDERS IN PRESCHOOL AND PRIMARY SCHOOL CHILDREN
2) Secondly, after the screening is completed, the diagnosis process can start,
carried out by a trained clinician who can interpret the results of the
previously mentioned tests. As Guetzloe (2003) pointed out, “...a precise
diagnosis of depression is a complex task, extremely difficult even for highly
skilled physicians and other clinicians. It requires a careful examination of
physical, mental, emotional, environmental, and cultural factors related to the
child.”
3) Thirdly, a treatment plan is traditionally coordinated by a school psychologist
at the end of the process, and the most frequently used therapies are
cognitive behavioral therapy and interpersonal therapy which help the
depressed child to change his/her distorted view of himself/herself by
improving his/her social skills (Sherril & Kovacs, 2002). Only in severe cases of
depression, medication, such as antidepressants, may be used (Bailly, 2006;
Emislie et al., 1997; Wagner, 2005). In cases of bipolar I disorder, clinicians
prefer to use mood stabilizers instead of antidepressants because some
antidepressants can induce manic episodes (for an accurate review see
Kowatch et al., 2005).
Traditionally, teachers are not expected to diagnose depression in children.
Usually, the major role of educators is to detect symptoms of depression, keep
notes and make appropriate referrals to school psychologists. However, quite
recently, Vulić-Prtorić suggested that there is a need for a closer collaboration
between educators and clinicians (Vulić-Prtorić, 2007). For example, during the
test assignment phase, teachers can help school psychologists to distribute these
tests to the entire class. Also, school psychologists may ask teachers to
collaborate with them during the treatment itself; for instance, educators (and,
of course, parents) can participate in therapy by providing the pupil with a warm
human touch and emotional support. Educators should also understand
depressed pupils and provide them with patience and encouragement, making
them talk, listening to them carefully without underestimating their feelings, and
offering them a real hope of solving depression. Clinicians and teachers can
provide a supportive environment not only during the therapy but also during
classes: teachers can invite school psychologists to join collective activities in the
classroom, thus helping depressed children to develop positive relationships with
peers and to enhance optimistic feelings.
It is understood that many children continue to attend school while being
assessed for depression; therefore, they will benefit from a close collaboration
between their educators and the school psychologist. Mocinić and Feresin (2012)
claim that bringing educators and clinicians together might be a good approach
to fighting depression during childhood, because a multidisciplinary team, which
organises regular meetings, will be able to provide support to the child in solving
mood disorders before he/she becomes an adolescent.

11. 232 Catina Feresin
The three-step programme suggested by the two authors is likely to be
very expensive from an economic point of view, but the cost of depression
among future adolescents and adults in the society is even more expensive than
the provision of this programme during the last two years of primary school.
Second proposal: Parent-child therapy should include teachers when
the caregiver shows affective disorders – a new clinical approach to
treat depressed preschoolers
It is well known that depression runs in families – children affected by
depressive disorders often have a parent affected by the same illness. This is
probably due to the fact that the two predominant causes of depression in
children are the following: 1) living with a depressed parent, 2) inheriting
depressive traits from him or her.
Very recently, Feresin, Mocinić and Tatković (2013) proposed that the
teacher – a person who is affectively very close both to the child and to the
parent/caregiver – be included in the treatment process. The three authors
emphasized that “he/she spends a lot of time with school or preschool children
and their parents; therefore, he/she is in a unique position to provide a strong
emotional support both to caregivers and to children themselves”. Furthermore,
the authors say that “...preschoolers are younger than school children, and for
them the caregiver is more fundamental in terms of affective development than
for primary school children. They therefore suggest that the teacher should
interact with the parent/caregiver to help the caregiver to participate effectively
in the treatment. Instead of the usual triadic relationship (child–caregiver–
psychologist), they proposed a different relationship (child–caregiver–
psychologist–teacher), in which the four people follow a short-term programme
which generally may last up to 14 weeks (similar to Luby's programme). During
the first stage of the programme, teachers are trained by attending specific
courses and classes and reading scientific papers and books about mood
disorders in children. After that, teachers can be trained by psychologists to help
the caregiver to actively participate in the treatment, while the caregiver is
undergoing a personal psychotherapy (e.g. cognitive therapy). During the
treatment itself, the teacher effectively helps the caregiver to encourage his/her
child to achieve a normal emotion regulation, to work on fighting the feeling of
guilt, and to learn how to handle depressive symptoms.”
As Feresin et al. (2013) pointed out, “To develop the project and to have a
direct confirmation of the validity of this kind of psychotherapy which includes
the presence of a teacher, further research is necessary which directly examines
depressed preschoolers' brain function by using f.M.R.I., and uses an experiment
to compare the first situation in which the teacher is present with the second
situation in which the teacher is absent.”

12. 233MOOD DISORDERS IN PRESCHOOL AND PRIMARY SCHOOL CHILDREN
Nowadays researchers are starting to study brain functions in depressed
preschoolers by means of f.M.R.I.; for example, a paper by Gaffrey and
colleagues has indicated that “depressed preschoolers exhibited a significant
positive relationship between depression severity and right amygdala activity
while viewing facial expressions of negative affect… The results suggest that,
similar to older children and adults suffering from depression, the relation
between amygdala responsivity and degree of depression severity exists from as
early as age 3” (Gaffrey et al., 2011). A more recent work by Suzuki and
collaborators (Suzuki et al., 2012) indicated that “smaller bilateral hippocampal
volumes were associated with greater cortico-limbic activation to sad or negative
faces versus neutral faces.” It is a well-established fact that amygdala, hippo-
campus and prefrontal cortex are strongly connected to perception of emotions
in mammals. Further studies are necessary to explore the relationship between
the degree of depression, emotions and activations of cortical and limbic areas.
However, these findings are interesting because they show how developed the
emotions are and how sophisticated their perception is in children who are less
than three years old, even if they do not have the linguistic capacity to verbally
express themselves.
According to Feresin et al. (2013), “a further research is necessary which
directly analyses depressed preschoolers' brain function by f.M.R.I., comparing
the activation of amygdala, hippo-campus and prefrontal cortex and the degree
of depression when children are viewing facial expressions of negative affect”, as
Gaffrey and Suzuki recently did (Gaffrey et al., 2011; Suzuki et al., 2012). If the
idea of involving teachers along with the caregiver is correct, a slight positive
correlation or no correlation at all should be found between the severity of
depression and the activity of cortical and limbic areas, in the case when the
teacher is present. This hypothetical result should mean that the child is learning
how to deal with negative emotions to fight depression.
Of course, modification of P.C.I.T./E.D. therapy and the f.M.R.I. study are
only proposals and they might be the topic of future papers.”

13. 234 Catina Feresin
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