Indian Write-Ups

Diagnosis

Depression – An overview
- Dr Amit Desai,
Consulting Psychiatrist,Mumba

Disorders of mood or the internal emotional state of a person are characterized by predominant disturbances in the mood and are accompanied by a subjective experience of distress and by a loss of control over one’s emotions. Mood disorders are of two types, namely:

Depression – morbidly excessive lowering of mood
Mania – abnormally elevated, elated or irritable mood

The distinction between sad mood and clinical depression is not always clearly defined. A clinician must be able to distinguish clinical depression from “normal" sadness. This distinction is important because clinical depression, if left untreated, is frequently recurrent and is associated with significant morbidity and mortality.

Broadly speaking, three criteria are used to diagnose clinical or pathological depression. These are –

Intensity of depression
Duration of depression
Presence of certain psychopathological features

1. Intensity of Depression

Patients with clinical depression often report a subjective feeling of distress. Depressed patients also feel that they have no control over their mood. The depressed mood persists throughout the day and is accompanied by a loss of interest or pleasure in their surroundings.

2. Duration of Depression

Lowering of mood which occurs in response to the stresses of daily life is normally short lasting. These people can be made to “snap out“ of their lowered mood and they can get along with their daily life. Depressed patients, on the other hand, suffer from a persistent lowering of the mood. The depressed mood often becomes more severe over a period of time, leading to a disruption in interpersonal, occupational or recreational functioning.

3. Presence of certain psychopathological features

Irrespective of the intensity or duration of the depressed mood, the occurrence of certain characteristic symptoms, namely, delusions of guilt, hopelessness, helplessness or worthlessness, disturbances in vegetative functions like sleep, appetite, sexual activity, cognitive disturbances and strong suicidal tendencies indicate the pathological nature of the mood state and the need for therapeutic intervention.

HISTORICAL ASPECTS OF DEPRESSIVE ILLNESS

Description of what are now referred to as mood disorders have been recorded since antiquity. About 400 B.C., Hippocrates used the terms “mania“ and “melancholia“ to describe certain mental disturbances. These theories of Hippocrates influenced medical thinking for many centuries after they were first propounded. In 1621, Robert Burton in England published his famous book “The Anatomy of Melancholia“ Burton’s work was significant because it inspired a host of other books on melancholia and other mental illnesses.

A clinician must be able to distinguish clinical depression from "normal" sadness. This distinction is important because clinical depression, if left untreated, is frequently recurrent and is associated with significant morbidity and mortality.

In 1882, a German psychiatrist, Dr. Khalbaum introduced the term “cyclothymia“ to describe the occurrence of elation and depression as stages of the same illness.

In the early years of the twentieth century, Sigmound Freud founded the psychoanalytical school of theory which sought to understand the psychological basis of human behavior. According to this theory episodes of depression are precipitated by a symbolic loss of loved object. This loss results in a regressive process which a person retreats from a mature state of a mental functioning to an immature state. The depressive symptoms, according to Freud could be ascribed to the latter state of functioning.

Table 1

Diagnostic Criteria for Major Depressive Episode

At least five of the following symptoms have been present during the same two-week period and represent a change from previous functioning; at least one of the symptoms is either depressed mood or loss of interest or pleasure.

Depressed mood most of the day, as indicated by subjective account or observation by others

Markedly diminished interest or pleasure in all, or almost all activities most of the day, nearly every day.

Significant weight loss or weight gain when not dieting, or decrease or increase in appetite nearly every day.Insomnia or hypersomnia nearly every day.

Psychomotor agitation or retardation.

Fatigue or loss of energy.

Feelings of worthlessness or excessive or inappropriate guilt.

Diminished ability to think or concentrate, or indecisiveness.

Recurrent thoughts of death, recurring suicidal ideation without a plan, or a suicidal attempt or a specific plan for committing suicide

It cannot be established that an organic factor initiated and maintained the disturbance.

The disturbance is not a normal reaction to the death of a loved one

Absence of delusions or hallucinations for as long as two weeks in the absence of prominent mood symptoms.

Not superimposed or schizophrenia or any other psychotic disorder.

Question pertaining to the classification of mood disorders received a great deal of attention. In 1952, the American Psychiatric Association published the first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-I) in which four different types of depressive disorders were depressive reaction, psychotic depressive reaction and neurotic depressive reaction. The word “reaction” was used to signify the relationship between environmental stresses and the onset of the depressive disorders.

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