Major depressive disorder (MDD) constitutes a major public health problem worldwide and affects women twice as frequently as men. Previous linkage studies have identified a 451 kb region of 2q33-35 that exhibited significant evidence of linkage to Mood Disorders among women (but not men) from families with recurrent, early-onset MDD (RE-MDD), a severe and strongly familial subtype of MDD. This 451 kb region includes CREB1, an attractive susceptibility gene for MDD and related disorders. Sequence variations in the CREB1 promoter and intron 8 have been detected that cosegregate with Mood Disorders, or their absence, in women from these families, identifying CREB1 as a sex-limited susceptibility gene for unipolar Mood Disorders. These findings implicate the cAMP signaling pathway in the pathophysiology of Mood Disorders and related conditions. Molecular Psychiatry (2003) 8, 611-618. doi:10.1038/sj.mp.4001354Keywords: genetics; CREB1; depression; sex-specific; women Major depressive disorder (MDD) is characterized by two or more weeks of depressed mood or impaired enjoyment, accompanied by disturbances of sleep and appetite, psychomotor changes, impaired concentration, inappropriate guilt, and suicidal thoughts or actions. 1 Most epidemiologic and family studies indicate that the lifetime prevalence of MDD is between 5 and 10%, with women twice as likely to be affected as men. 1-3 Suicide, a tragic consequence of MDD, has been reported to occur in 10-15% of patients who were previously hospitalized for depression, 4 a rate of death that is three orders of magnitude greater than that reported for the American population as a whole. 5 In addition to suicide, an even greater absolute increase in age-specific mortality from natural causes has been reported for individuals who suffer from MDD and their family members. 6 The significance of these public health problems has been highlighted by two recent reports from the Surgeon General. 3,5 In a study conducted by the World Health Organization, MDD ranked second only to ischemic heart disease as a source of disability worldwide. 7 Twin studies have demonstrated that genetic factors typically account for 40-70% of the risk for developing MDD, and adoption studies have confirmed the important role played by genetic risk factors in the development of MDD (for reviews, see US Department of Health and Human Services 3 ; Zubenko et al 6 ). Early age at onset of the first major depressive episode, as well as recurrence, are independent factors that increase the morbid risk of MDD among family members. In a recent study of 81 extended families (407 first-degree relatives and 835 extended relatives) ascertained through adult probands with recurrent (X2 episodes), early-onset (onset p25 years) MDD (RE-MDD), 6 over one-third of first-degree relatives and nearly one-fifth of extended relatives suffered from MDD, prevalence rates that were 7.7 and 3.8 times greater than the corresponding population rates reported by the Epidemiologic Catchment Area Study. 2 The results of a genetic se...