Clinical features of depression

Depression is a common clinical problem. Many of us at sometime or other experience sadness, fed up or down in dumps. It is called as depressive illness when such symptoms become qualitatively different and interfere with normal functioning. It can vary in severity may be mild, moderate or severe. Symptoms can be transient or persistent. Patients usually experience disturbance of mood , speech, energy and ideas. Some patients describe symptoms in physical terms. Two most common physical symptoms are fatigue and headache. If symptoms  are severe patients require hospitalization.

Many patients describe the world looking grey and they are devoid of pleasure and interest in life (anhedonia). Anxiety and phobic disorders are common in these patients. Symptoms usually last for at least 2 weeks. In severe forms of the disease diurnal variation in mood can be seen. Such people feel worse in the morning after awaking. One of the major risk is suicide, risk is 5%in out patients and 15% in those whose symptoms are severe enough to require hospital admission.

The following changes are noted in depression.

Mood - May be depressed, miserable or irritable.

Talk - Slow, monotonous.

Energy - Low energy and lethargic.

Ideas - Feeling of futility, guilt, self unworthiness, hypochondriacal preoccupation, worrying, suicidal thoughts, delusions of guilt and persecution.

Cognition - There can be impaired learning and pseudodementia in elderly patients .

Behavior - Retardation or agitation ,poverty of movements and expression.

Hallucination - Auditory ,often hostile and critical

Physical - Early waking, poor appetite ,constipation, loss of libido, erectile dysfunction, fatigue, bodily aches and pains.

Other psychiatric disorder associated with depression

1. Misuse of alcohol

2. Amphetamine and derivatives misuse and withdrawal

3. Dementia

4. Delerium

5. Schizophrenia

Other medical illness associated with depression

1. Cushing syndrome

2. Thyroid disorders

3. Increased parathyroid hormone

4. Steroid treatment

5. Brain tumours

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Medical disorders associated with Depression

Depressive disorders occurs in 3.7% to 6.7% of general population. In general medical inpatients, the proportion increases to 10% to 14% and 9% to 16% in general medical outpatients. Major depression is an independent risk factor for mortality in patients hospitalized for heart attack at 6 month follow up. About 47% of depressed patients with acute life threatening medical illnesses, either died or had complications compared to 10% of non depressed patients.

Various forms of distress are common in medically ill people. Unless these are recognized and managed appropriately, medical management alone will be less effective. Depression is not the most common distress state, but the most visible one. It is often not diagnosed and insufficiently treated. It will cause the person for decreased survival, marked disability and increased healthcare cost.

In  physically  ill people  depression

• Can  be a coincidental association.
• Can  be a complication of physical illness.
• Cause or make worse somatic symptoms (such as fatigue, malaise, or pain).

Depressed patients with physical illness 

• Consider  themselves as more sick and visit their doctors more frequently than non-depressed physically ill person.
• Have longer hospital stay.
• Poor compliance with medication and  medical advice.
• They  undergo more medical and surgical procedures.
• Depressive illness may be associated with increased mortality (excluding suicide) in patients with physical illness, such as heart attack.

Specific medical conditions with likelihood of developing depression

• Heart attack.
• End stage kidney disease.
• Cancer.
• Chronic pain.
• Neurological disorders such a stroke, Parkinson’s disease,multiple sclerosis.
• Hormonal disorders.
• HIV.

Features to suggest a medical origin of the psychiatric symptoms are the following

• Late onset of initial presentation of symptoms.
• Known underlying medical condition.
• A typical presentation of a specific psychiatric illness.
• Absence of personal or family history.
• Illicit (forbidden by law)  substance use.
• Medication use.
• Treatment resistance or unusual response.
• Sudden onset of mental symptom.
• Abnormal vital signs.
• Waxing and waning mental status.
• Sphincter disturbances in the form of bowel and bladder dysfunction

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Risk factors for depression

Depression is the fourth leading cause of global burden of mental ill health. According to WHO it will be the second most common form of disability by 2020 after ischemic heart disease. Depression is a major cause of suicide. Nearly 1 million people die of suicide, annually. Incidence of major depressive disorder is 1 in 20 people during their entire life time. It is more common in women than men.

Depression affect compliance, immune functioning, quality of life and it will lead to unhealthy behaviours in patients. Due to depression patient experience a variety of somatic illness. Less than one half of depressed patients are identified and adequately treated by primary care physician. It is a common condition and is treatable. Hence identification of this syndrome is important.

Risk factors for depression are

1. Gender-common in females. 
2. Genetic/biological vulnerability. 
3. Stress/environmental/life events especially loss events such as bereavement. 
4. Physical illness especially chronic and painful illness.
5. Drugs.
6. Chronic and excessive alcohol intake.
7. Difficulties in interpersonal relationship.
8. Lack of social support with no confiding relationship. 

Pathways to depression

Broadly depression  can be classified as two major groups.

1. “Major” depression – Pharmacologically treated.
2. “Minor” depression – Treated mainly by psychological approaches.

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How to diagnose depression and what are the criteria for major depression

Five or more of the following symptoms can happen during two week.

Period representing a change from normal functioning. 
At least one of the symptoms is either depressed mood or decreased interest or pleasure. Do not include symptoms due to medical conditions, delusion or hallucination. 

1. Depressed mood*.
2. Substantial weight loss or weight Gain.
3. Insomnia/lack of sleep or hypersomnia.
4. Feelings of worthlessness or inappropriate guilt.
5. Recurrent thoughts of death or suicide or suicide attempt.
6. Decreased interest or pleasure*.
7. Psychomotor retardation or agitation.
8. Fatigue or loss of energy
9. Diminished ability to think or concentrate

*From Diagnostic and Statistical Manual of Mental Disorders, fourth edition

*One of these symptoms must be present 

• Symptom should not meet the criteria for mixed episode.
• There  is  clinically significant distress in social, occupational, or other important areas of functioning.
• These symptoms are not due to the direct physiologic effects of a substance (e.g. drug of abuse, 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 episodes are diagnosed as mild, moderate and severe depending on the number of symptoms and intensity. Minimum duration of the whole episode is expected to be about two weeks.

Screening questions for depression

1. How have you been feeling recently?
2. Have you been low in spirits?
3. Have you been able to enjoy the things you usually enjoy?
4. Have you had your usual level of energy, or have you been feeling tired?
5. How has your sleep been?
6. Have you been able to concentrate on newspaper articles or your favourite television or radio programmers? 

Following are the difficulties for a non psychiatrist in diagnosing depression

1. Making sense of the emotional experience of the patient.
2. Pinning down the predominant mood state.
3. Assumptions /attributions to a physical or external factor.
4. Difficult questions to explore deeply.
5. Either normalising or interpreting any sadness as depression.

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