Indian Write-Ups

Diagnosis

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

The introduction of antidepressant drugs iproniazid and imipramine in 1957 gave a fresh impetus to research in depressive disorders, particularly regarding their etiology. Earlier, electroconvulsive therapy (ECT) or shock treatment enjoyed great popularity as a treatment modality, although its mechanism of action remained obscure. Since the 1950’s, the subject of depression has become more complex because of new theories, newer treatment methods and wider clinical experiences with mild and atypical cases. These complexities have led to further refinements in the classification of mood disorders. As a result, the American Psychiatric Association periodically publishes newer and updated versions of its diagnostic and Statistical Manual of Mental Disorders (DSM).

Table 2

Diagnostic Criteria for Manic Episode

A) A distant period of abnormally and persistently elevated, expansive or irritable mood.

B) During the period of mood disturbance, at least three of the following symptoms have persisted and have been present to a significant degree.

Inflated self-esteem on grandiosity
Decreased need for sleep
More talkative than usual or pressure to keep talking
Flight of ideas or subjective experience that thoughts are racing
Distractability
Increase in goal directed activity (either socially, at work or school, or sexually) or psychomotor agitation
Excessive involvement in pleasurable activities which have a high potential for painful consequences (e.g. unrestrained buying spres, sexual indiscretions or foolish business investments)

C) Mood disturbance is sufficiently severed to cause marked impairment in occupational functioning or in usual social activities, or to necessitate hospitalization to prevent harm to self or others.

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

E) Not superimposed or schizophrenia or any other psychotic disorder

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

Note : A manic synodrome is defined as including criteria A,B and C of the above list of A to F. A hypomanic syndrome is defined as including criteria A and B, but not C, of the above list of A to F.

Table 3

Diagnostic Criteria for Melancholic Type of Depression

The presence of at least five of the following :

Loss of interest or pleasure in all, or almost all, activities
Lack of reactivity to usual pleasurable stimuli
Depression regularly worse in the morning
Early morning awakening (at least two hours before usual time of awakening).
Psychomotor retardation or agitation
Significant anorexia or weight loss (more than 5% of body weight in a month)
No significant personality disturbance before first major depressive episode
One or more previous major depressive episode followed by complete, or nearly complete, recovery
Previous good response to specific and adequate somatic antidepressant therapy (e.g. tricyclic drugs, lithium carbonates, etc)

Table 4

Diagnostic Criteria for Dysthymia

A)Depressed mood for most of the day, more days than not, as indicated either by subjective account or observation by others , for at lest two years.

B) Presence while depressed, of at least two of the following:

Poor appetite or overeating
Insomnia or hypersomnia
Low energy or fatigue
Low self-esteem
Poor concentration or difficulty making decisions
Feelings of hopelessness

C) During the two year period of the disturbance, never without the symptoms in A for more than two months at a time

D) No evidence of an unequivocal major depressive episode during the first two years

E) Has never had a manic episode or unequivocal hypomanic episode

F) Not superimposed or a chronic psychotic disorder (e.g. schizophrenia )

G) It can not be established that an organic factor initiated and maintained the disturbance

Type of Depressive Disorders

The DSM-III R (DSM III – 3rd revised edition ) lists four main types of depressive disorders. These are :

Major Depression
Bipolar Disorder
Dysthymia
Cyclothymia

1. Major Depression

For the diagnosis of major depression, a patient must fulfill the diagnostic criteria for Major Depressive Episode (Table 1). In addition, the patient should not have suffered from a manic episode (Table 2) in the past. Major depression is further classified into the following two types according to the number of previous depressive episodes:

Major Depression, single episode
Major Depression, recurrent

The recurrent pattern of depressive episodes and the absence of any manic episodes is the reason why this type of depression is sometimes referred to as “unipolar depression”. DSM – III R distinguishes another sub-type of major depression based on the occurrence of a particular set of vegetative symptoms. This is called a melancholic type of major depression (Table 3)

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