Clinical classification of depression

The authors of the above classifications emphasize that they have to be interpreted by the experienced clinician. Their inherent problems in respect of depression have been alluded to briefly above. I therefore now proceed to give a clinical guide to depressive illness.

Severe depression is characterized by a pervasive depression of mood, which has a different quality from ordinary sadness, cannot be expressed by tears even if the patient wants to cry, and is unrelated to external circumstances. Somatic symptoms (early morning waking, diurnal variation of mood, anorexia, and weight loss) are often prominent, and psychotic features (delusions and/or hallucinations) may be present. Severe episodes usually respond best to physical methods of treatment (see below) rather than psychological therapies alone.

Case example

A 22-year-old man was brought to the GP by his girlfriend, who complained that over the previous few weeks he had become increasingly 'moody and withdrawn', and had been drinking too much. The GP, who had known him for years, was struck by his gaunt and miserable appearance, but was nevertheless surprised when, after his partner left the consulting room, the patient broke down in tears. There was a clear history of depressed mood, loss of interest in things which he usually found pleasurable, poor sleep with terminal insomnia, poor appetite with weight loss, and inability to concentrate, leading to problems at work.

The GP, noting a positive family history of bipolar affective disorder in the father, made a diagnosis of depressive illness. He prescribed lofepra-mine, and, with the patient's consent, involved the girlfriend in discussing the nature and prognosis of the illness.

After the consultation, the GP realized that he had not yet assessed suicidal risk, and decided to call on the patient on the way home.

Mild depression is more common, and the symptoms are more like an exaggeration of ordinary unhappiness. Somatic symptoms are not prominent, and delusions and hallucinations do not occur. There may be marked tearfulness, anxiety, irritability, and difficulty getting to sleep.

It is, however, probably an over-diagnosed condition these days, especially in general practice. This is not to criticize our colleagues in primary care. Patients have been encouraged to take their emotional difficulties to doctors; in previous eras, they might have been seen as tired and given a tonic, and in later times as anxious, and given benzodiazepines. Currently, the social and medical culture guides doctors and patients toward a diagnosis of depression and the prescription of an antidepressant.

Hence, it is a frequent experience for the psychiatrist to be referred patients who have been diagnosed and treated for depression, but who have truly never had the condition. Some are probably not best regarded as having had a mental illness at all; most of the rest have had adjustment reactions to changes in life circumstances.

The key point is the mood; the patient has to have a true depression of mood; that is, persistent low mood unrelieved by circumstances. If this is not present, depression is not present either. A natural reaction, an adjustment disorder, or dysthymia, is more likely.

Case example

A 22-year-old single mother was referred urgently to the community mental health team for treatment of what was described in the referral letter as 'severe refractory depression'. The patient was seen within a couple of days. It quickly emerged that the patient's 3-year-old daughter had had a convulsion, and had been admitted to hospital for investigation.

The patient had visited the GP to discuss this and had been tearful, upon which depression had been diagnosed and antidepressant medication prescribed. She was no better a month later and was referred by fax.

When the patient was seen, it emerged that she had been upset by her daughter's illness, but that she herself did not believe she was mentally ill. She did not have a truly depressed mood. She was under increasing stress because of accommodation problems, but had been improving.

She was reassured by the information that her feelings were an understandable reaction. When seen in follow-up 2 weeks later, she had been allocated a new flat, and had gone back to normal, and she was discharged.

Dysthymia is a chronic mild depression or unhappiness that may overlap with personality disorder. Recognizing this often helps to make a realistic prognosis.

Case example

A 44-year-old married man came to the attention of a junior hospital psychiatrist after taking an overdose in the context of marital breakdown. He described depressed mood, anhedonia, and continuing suicidal ideation. Although he made a fairly rapid improvement sufficient to return to work, his symptoms only partially resolved. The psychiatrist tried a number of antidepressants and some cognitive therapy to little avail, and, determined to explore all treatment options, he was thinking of suggesting ECT or referral for dynamic psychotherapy.

His consultant suggested discussing the patient with his GP, who turned out to know him well. The GP felt that, although the patient had benefited from treatment to get over the acute episode of distress, he had been 'back to normal' for some time. The patient had 'always had rather a gloomy outlook, just like the rest of his family'.

The patient was eventually discharged back to the care of the GP with a diagnosis of dysthymic personality.

Endogenous and reactive depression is another rather outdated distinction based on whether or not a precipitating life stress predating the depressive episode can be identified. Most depressive episodes are at least in part 'reactive'; therefore, resolving the external stress and/or helping the patient cope with it more constructively should certainly be part of management. But it is important to consider biological treatments if symptoms of severe depression are present, however understandable the cause. For example, drug treatment can be helpful for some patients with depressive illness following life events such as bereavement (see Chapter 6), or in medically ill patients (see Chapter 11), including those with terminal disease. It is impossible to predict which patients will respond to drug treatment.

The term 'psychotic depression', which is self-explanatory, is sometimes used, but the matching term 'neurotic depression' has largely been dropped because of the pejorative overtones of the word 'neurotic'.

Seasonal affective disorder (SAD) is a condition in which depressed mood accompanied by lethargy, excessive sleep, increased appetite, and irritability recurs each winter. It was believed to respond exclusively to light treatment; however, recent studies indicate it can be just as effectively managed with standard methods of treatment, such as medication. It is probably not distinct from depression, and should be managed in the usual way. The best way of increasing light exposure is probably daily walks.

Masked depression describes presentation with somatic symptoms when the patient denies depressed mood and may even appear cheerful and smiling. Self-evidently, this would be an unusual clinical situation requiring careful assessment; the term 'masked depression' is not unanimously accepted or commonly used, however.

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