Depression is a prevalent psychiatric disorder. Unawareness about depressive symptoms and missing the diagnosis might delay the treatment and the person might lose on their productive time. Also introversion in a person might hide the symptoms and lingering depression might predispose them to suicidal tendency. Early recognition and timely management of the symptoms would help not only the patient but his / her entire family.
It is important to understand what common symptoms might help us in recognition of Depression:
Core symptoms of depression:
Depressed mood most part of the day as reported by the individual (e.g. feels empty, sad, irritable) or observed by others (appears tearful); children and adolescents present with irritable mood.
Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day [subjective/objective observation]
Weight loss or weight gain [change of more than 5 percent of body weight in a month
Sleeping less with early morning wakening 2-3 hr sooner than the usual or sleeping more than usual
Psychomotor agitation or retardation - usually observable by others
Fatigue or loss of energy nearly everyday
Feeling of worthlessness or excessive or inappropriate guilt
Diminished ability to think or concentrate or indecisiveness
Recurrent thoughts of death
As per DSM-5 (Diagnostic and Statistical Manual of Mental Disorders), five or more of the symptoms of the above symptoms should have been there during the same 2 week period to diagnose depression.
At least one of the symptoms is either :
1) depressed mood
2) loss of interest or pleasure.
Also, there should be significant impairment in social, occupational and other important areas of functioning. The episode should not be attributable to any substance or any other mental condition. For example in the case of former, it will be classified as substance related disorder.
Different presentations of the core symptoms
Mood is often described as the person as sad, empty, discouraged or “down in the gumps”. Some people deny having low mood at first and in subsequent interviews it may be elicited. At times it is inferred from the demeanour and facial expression. Some individuals emphasise somatic complaints (for e.g. bodily aches and pains) rather than feeling sad. Many individuals report irritable mood (persistent anger, tendency to respond to events with angry outbursts or blaming others, an exaggerated frustration over minor matters) rather than sad mood. Children and adolescents as well present with irritable mood.
Markedly diminished interest may be observed in form of less interest in hobbies, not caring anymore or not finding pleasure in activities which were previously pleasurable. Family members often notice social withdrawal and avoidance of pleasurable activities (for example an individual who enjoys painting finds excuses not to paint). Significant reduction in sexual desire or interest may be there.
Weight changes may occur - in either direction. Some depressed individuals eat more and in some there is reduction in appetite.
Sleep disturbances may present as difficulty sleeping or sleeping excessively. Difficulty sleeping may be present in the form of initial insomnia (difficulty falling asleep), middle insomnia(waking up in the middle of the night and then having difficulty returning to sleep) or terminal insomnia(waking too early and being unable to return to sleep). Some individuals who present with the complaints of oversleeping may experience prolonged sleep episodes at night or excessive day time sleepiness. Many a times, disturbed sleep is the only complaint and when we dig deeper, its depression.
Psychomotor changes may present in form of agitation (e.g. inability to sit still, pacing, hand wringing) or retardation (e.g. slowed speech, thinking and body movements).
Substantial fatiguability may be reported by individuals even without physical exertion. Some individuals may report putting in substantial effort for small tasks. Efficiency may be reduced.
Negative evaluation of one’s worth or guilty feeling may preoccupy one’s mind. At times, this may be of delusional proportion.
Inability to concentrate or indecisiveness may be there. Those engaged in cognitively demanding situations are unable to function. This may present in children as drop in grades and in elderly as memory difficulties.
Thoughts of death may range from a passive wish not to awaken in the morning, to recurrent thoughts of committing suicide, to a specific suicide plan.
There are few variants of Depression that might actually warrant slightly approach medically. Let us discuss few of them :
Evaluation of depression in medically ill
Evaluation of depression may be difficult in an individual who also has a general medical condition (e.g. cancer, diabetes, myocardial infarction). Some of the criterion signs and symptoms of a depressive episode are identical to those of general medical conditions (e.g. weight loss with untreated diabetes, fatigue with cancer). Non-vegetative symptoms of dysphoria, anhedonia, guilt or worthlessness, impaired concentration or indecision and suicidal thoughts should be assessed with particular care in such cases.
Endicott’s substitution criteria is used to diagnose depression in the medically ill with higher accuracy. In this approach, the physical/somatic symptoms of depression are replaced by the psychological symptoms.
Endicott Substitution Criteria for Depression
Clinical features of Atypical depression are:
Mood reactivity is there. The individual has the capacity to be cheered up when presented with positive events.
Prolonged period of nighttime sleep or daytime napping that totals at least 10 hours of sleep
Excessive eating leading to significant weight gain
Feeling of heaviness in the limbs (leaden paralysis)
Oversensitivity to perceived rejection[person's fear of being rejected causes them to struggle to form new connections and to undermine their existing relationships]
Along with core symptoms of depression, delusions and hallucinations are present.
When to seek Medical Help?
Any patient or person whose Depression is affecting personal daily activities and hampering personal, social and professional responsibilities is in need of professional medical help. Remember Depression can be wonderfully managed with social support and medicines. Either in reaction to a situation or endogenous depression the person needs help and with proper help he or she can come back and resume normal life.
American Psychiatric AssociationDiagnostic and statistical manual of mental disorders: 5th Edn. Washington, DC: (2013)
Dr Nikita Rajpal
MD - Psychiatry ( PGI - Chandigarh )