Mental features of depression

The cardinal symptom of a depressive illness is of course a pervasive depression of mood. This must go beyond the everyday experience of, for example, 'I'm really depressed about the gas bill.' The mood must be low, flat, and empty, and not able to be cheered up by things that the patient formerly enjoyed.

There are those in psychiatry who feel that depression can be diagnosed without depression of mood being obvious to the patient or readily apparent to the psychiatrist. It is just conceivable that this may apply to prodromal or very mild cases of depression, or to patients with a mixture of anxiety and depression symptoms. However, generally speaking, it is necessary to do violence to the idea of clinical depression to consider that any significant case of depressive illness can exist without depression of mood.

Hence, if depression is diagnosed, there does need to be a proper description of the mood in the clinical notes. The essential feature is that there must be a pervasive depression of mood; that is, the mood must be low in respect of all aspects of the person's life, though not necessarily to the same extent throughout. There must also be loss of enjoyment of things the patient used to take pleasure in - the so-called anhedonia.

If these features are not present, the proponent of a diagnosis of depression would be in a difficult position, although he might be able to establish the diagnosis, at least to the extent of a mild depressive condition, with the aid of associated symptoms.

In a true depressive illness, the patient has a negative view of himself, so that he feels guilty, and that he is a failure or a bad person. This will tend to be coupled with pessimism or hopelessness.

Accordingly, a diagnosis of depression cannot generally be based solely on anger, irritability, or hostility. Depression of mood, and negative view of self, should generally be present.

In any clinically significant depressive illness, the patient's intellectual function will seem to them to be affected. Perhaps because of lack of drive or preoccupation with negative ideas or both, the ability to concentrate will be reduced. This means that work becomes harder and takes longer; not infrequently, patients believe that they are losing their memory, whereas, in fact, they are not remembering things in the first place because they are not able to concentrate properly.

As with other mental disorders, the risk of suicide must be assessed. Patients often feel that 'it would be better if I was not around', or they think, 'I wish I was dead'. It is important to gauge whether the patient has gone beyond this, and has an active plan to kill himself. Thoughts of how they might do it are not uncommon as their subject of depressive rumination; patients can have prominent thoughts about methods of suicide, yet nevertheless give realistic, and apparently reliable assurances that they would not do this because of, for example, family responsibilities.

In severe depressive states, the patient may become psychotic. That is, he may develop delusions and hallucinations (psychotic symptoms). Typical depressive delusions include an unshakeable conviction that he is guilty of some dreadful crime, that his bowels have turned to stone, or some other hypochondriacal preoccupation. Typical hallucinations in psychotic depression include a voice addressing the patient (second person), saying, for example, 'You are a bad person, you deserve to die.'

What are sometimes referred to as 'biological' symptoms of depression are important because, in clinical practice in psychiatry, they are taken as one of the markers of a clinically significant depressive illness. Disturbance of sleep and appetite are the most frequent.

Sleep disturbances include difficulty in getting to sleep, so-called 'initial insomnia'; disturbed sleep with frequent wakening; and early-morning wakening. This last is a classic symptom of a depressive illness, and is often coupled with diurnal mood variation: that is, the patient wakes up early in the morning in a very depressed mood, which is then at its lowest point of the 24 hours. During the day, the mood gradually brightens as the patient gets going.

Traditional teaching has this pattern as indicative of an endogenous depressive illness, that is, one coming from within the patient, in contrast to an exogenous or reactive depression due to external causes, where the sleep disturbances were said to be more in the nature of initial insomnia. Perhaps unfortunately, research has not borne out these intuitively attractive patterns, and the endogenous/reactive classification of depressive illnesses is no longer regarded as useful for therapeutic or prognostic purposes, although, obviously, it remains an important aspect of assessment in respect of causation.

Classically, a depressive illness is accompanied by loss of appetite and loss of weight. Sometimes, however, especially in milder state of depression, there may just be a loss of interest in food with little change in weight; 'comfort eating' of junk and other food, with weight increase, is common also.

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