Depression Primer
(from Cornell University)
- What is depression
- What is major depression?
- What is dysthymia?
- What is bipolar depression (manic-depressive illness)?
- What is Seasonal Affective Disorder (SAD)?
- What is Post Partum Depression
- How is bereavement different from depression?
- What is Endogenous Depression
- What is atypical depression? **Symptoms**
- What are the typical symptoms of depression?
- What are the diagnostic criteria for depression?
**Causes**
- What causes depression?
----------------------------------
Q. What is depression?
Being clinically depressed is very different from the down
type of feeling that all people experience from time to time. Occasional
feelings of sadness are a normal part of life, and it is that such
feelings are often colloquially referred to as "depression."
In clinical depression, such feelings are out of proportion to any
external causes. There are things in everyone's life that are possible
causes of sadness, but people who are not depressed manage to cope with
these things without becoming incapacitated.
As one might expect, depression can present itself as feeling
sad or "having the blues". However, sadness may not always be
the dominant feeling of a depressed person. Depression can also be
experienced as a numb or empty feeling, or perhaps no awareness of
feeling at all. A depressed person may experience a noticeable loss in
their ability to feel pleasure about anything. Depression, as viewed by
psychiatrists, is an illness in which a person experiences a marked
change in their mood and in the way they view themselves and the world.
Depression as a significant depressive disorder ranges from short in
duration and mild to long term and very severe, even life threatening.
Depressive disorders come in different forms, just as do other
illnesses such as heart disease. The three most prevalent forms are
major depression, dysthymia, and bipolar disorder.
Q. What is major depression?
Major depression is manifested by a combination of symptoms
(see symptom list below) that interfere with the ability to work, sleep,
eat; and enjoy once-pleasurable activities. These disabling episodes of
depression can occur once, twice, or several times in a lifetime.
Q. What is dysthymia?
A less severe type of depression, dysthymia, involves
long-term, chronic symptoms that do not disable, but keep you from
functioning at "full steam" or from feeling good. Sometimes
people with dysthymia also experience major depressive episodes.
Q. What is bipolar depression (manic-depressive illness)?
Another type of depressive disorder is manic-depressive illness, also
called bipolar depression. Not nearly as prevalent as other forms of
depressive disorders, manic depressive illness involves cycles of
depression and elation or mania. Sometimes the mood switches are
dramatic and rapid, but most often they are gradual. When in the
depressed cycle, you can have any or all of the symptoms of a depressive
disorder. When in the manic cycle, any or all symptoms listed under
mania may be experienced. Mania often affects thinking, judgment, and
social behavior in ways that cause serious problems and embarrassment.
For example, unwise business or financial decisions may be made when in
a manic phase.
Q. What is Seasonal Affective Disorder (SAD)?
SAD is a pattern of depressive illness in which symptoms recur every
winter. This form of depressive illness often is accompanied by such
symptoms as marked decrease in energy, increased need for sleep, and
carbohydrate craving. Photo therapy - morning exposure to bright, full
spectrum light - can often be dramatically helpful.
Q. What is Post Partum Depression?
Mild moodiness and "blues" are very common after
having a baby, but when symptoms are more than mild or last more than a
few days, help should be sought. Post part depression can be extremely
serious for both mother and baby.
Q. How is bereavement different from depression?
A full depressive syndrome frequently is a normal reaction to
the death of a loved one (bereavement), with feelings of depression and
such associated symptoms as poor appetite, weight loss, and insomnia.
However, morbid preoccupation with worthlessness, prolonged and marked
functional impairment, and marked psychomotor retardation are uncommon
and suggest that the bereavement is complicated by the development of a
Major Depression. The duration of "normal" bereavement varies
considerably among different cultural groups.
Q. What is Endogenous Depression?
A depression is said to be endogenous if it occurs without a
particular bad event, stressful situation or other definite, outside
cause being present in the person's life. Endogenous depression usually
responds well to medication. Some authorities do not consider this to be
a useful diagnostic category.
Q. What is atypical depression?
"Atypical depression" is not an official diagnostic
category, but it is often discussed informally. A person suffering from
atypical depression generally has increased appetite and sleeps more
than usual. An atypical depressive may also be able to enjoy pleasurable
circumstances despite being unable to seek out such circumstances. This
contrasts with the "typical" depressive, who generally has
reduced appetite and insomnia, and who is often unable to find pleasure
in anything. Despite its name, atypical depression may in fact be more
common than the other kind.
-------Symptoms --------
Q. What are the typical symptoms of depression?
A depressive disorder is a "whole-body" illness,
involving your body, mood, and thoughts. It affects the way you eat and
sleep, the way you feel about yourself, and the way you think about
things. A depressive disorder is not a passing blue mood. It is not a
sign of personal weakness or a condition that can be willed or wished
away. People with a depressive illness cannot merely "pull
themselves together" and get better. Without treatment, symptoms
can last for weeks, months, or years. Appropriate treatment, however,
can help over 80% of those who suffer from depression. Bipolar
depression includes periods of high or mania. Not everyone who is
depressed or manic experiences every symptom. Some people experience a
few symptoms, some many. Also, severity of symptoms varies with
individuals.
Symptoms of Depression:
* Persistent sad, anxious, or "empty" mood
* Feelings of hopelessness, pessimism
* Feelings of guilt, worthlessness, helplessness
* Loss of interest or pleasure in hobbies and activities that
you once enjoyed, including sex
* Insomnia, early-morning awakening, or oversleeping.
* Appetite and/or weight loss or overeating and weight gain
* Decreased energy. fatigue, being "slowed down"
* Thoughts of death or suicide, suicide attempts
* Restlessness, irritability
* Difficulty concentrating, remembering, making decisions
* Persistent physical symptoms that do not respond to
treatment, such as headaches, digestive disorders, and chronic pain
Symptoms of Mania:
* Inappropriate elation
* Inappropriate irritability
* Severe insomnia
* Grandiose notions
* Increased talking
* Disconnected and racing thoughts
* Increased sexual desire
* Markedly increased energy
* Poor judgment
* Inappropriate social behavior
Q. What are the diagnostic criteria for depression?
Depression comes in many forms and in many degrees. Below, you
will find some of the most common depressive types, along with some of
the diagnostic criteria from the DSM-III-R (the official diagnostic and
statistical manual for psychiatric illnesses).
**Major Depression:**
This is a most serious type of depression. Many people with a
major depression can not continue to function normally. The treatments
for this are medication, psychotherapy and, in extreme cases,
electroconvulsive therapy (ECT).
Diagnostic criteria
A. 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 (1)
depressed mood, or (2) loss of interest or pleasure. (Do not include
symptoms that are clearly due to a physical condition, mood- incongruent
delusions or hallucinations, incoherence, or marked loosening of
associations.)
1. depressed mood most of the day, nearly every day, as
indicated either by subjective account or observation by others
2. markedly diminished interest or pleasure in all, or almost
all, activities most of the day, nearly every day (as indicated either
by subjective account or observation by others of apathy most of the
time)
3. significant weight loss or weight gain when not dieting
(e.g. more than 5% of body weight in a month), or decrease or increase
in appetite nearly every day
4. insomnia or hypersomnia nearly every day
5. psychomotor agitation or retardation nearly every day
(observable by others, not merely subjective feelings of restlessness or
being slowed down)
6. fatigue or loss of energy nearly every day
7. feelings of worthlessness or excessive or inappropriate
guilt (which may be delusional) nearly every day (not merely self-
reproach or guilt about being sick)
8. diminished ability to think or concentrate, or
indecisiveness nearly every day (either by subjective account or as
observed by others)
9. recurrent thoughts of death (not just fear of dying),
recurrent suicidal ideation without a specific plan, or a suicide
attempt or a specific plan for committing suicide
B. (1) It cannot be established that an organic factor
initiated and maintained the disturbance (2) The disturbance is not a
normal reaction to the death of a loved one
C. At no time during the disturbance have there been delusions
or hallucinations for as long as two weeks in the absence of prominent
mood symptoms (i.e..- before the mood symptoms developed or after they
have remitted).
D. Not superimposed on Schizophrenia, Schizophreniform
Disorder, Delusional Disorder, or Psychotic Disorder
**Dysthymia:**
This is a mild, chronic depression which lasts for two years
or longer. Most people with this disorder continue to function at work
or school but often with the feeling that they are "just going
through the motions." The person may not realize that they are
depressed. Anti-depressants or psychotherapy can help. Diagnostic
criteria:
A. Depressed mood (or can be irritable mood in children and
adolescents) for most of the day, more days than not, as indicated
either by subjective account or observation by others, for at least two
years (one year for children and adolescents)
B. Presence, while depressed, of at least two of the
following: 1. poor appetite or overeating 2. insomnia or hypersomnia 3.
low energy or fatigue 4. low self-esteem 5. poor concentration or
difficult making decisions 6. feelings of hopelessness
C. During a two-year period (one-year for children and
adolescents) 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 (one year for children and adolescents) of
the disturbance.
E. Has never had a Manic Episode or an unequivocal Hypo manic
Episode.
F. Not superimposed on a chronic psychotic disorder, such as
Schizophrenia or Delusional Disorder.
G. It cannot be established that an organic factor initiated
or maintained the disturbance, e.g., prolonged administration of an
antihypertensive medication.
**Adjustment Disorder with Depressed Mood:**
This is the type of depression that results when a person has
something bad happen to them that depresses them. For example, loss of
one's job can cause this type of depression. It generally fades as time
passes and the person gets over what ever it was that happened.
Diagnostic criteria:
A. A reaction to an identifiable psycho social stressor (or
multiple stressors) that occurs within three months of onset of the
stressor(s).
B. The maladaptive nature of the reaction is indicated by
either of the following: 1. impairment in occupational (including
school) functioning or in usual social activities or relationships with
others 2. symptoms that are in excess of a normal and expectable
reaction to the stressor(s)
C. The disturbance is not merely one instance of a pattern of
overreaction to stress or an exacerbation of one of the mental disorders
previously described (in the entire DSM).
D. The maladaptive reaction has persisted for no longer than
six months.
E. The disturbance does not meet criteria for any specific
mental disorder and does nor represent Uncomplicated Bereavement.
Causes ------
Q. What causes depression?
The group of symptoms which doctors and therapists use to
diagnose depression ("depressive symptoms"), which includes
the important proviso that the symptoms have manifested for more than a
few weeks and that they are interfering with normal life, are the result
of an alteration in brain chemistry. This alteration is similar to
temporary, normal variations in brain chemistry which can be triggered
by illness, stress, frustration, or grief, but it differs in that it is
self-sustaining and does not resolve itself upon removal of such
triggering events (if any such trigger can be found at all, which is not
always the case.)
Instead, the alteration continues, producing depressive
symptoms and through those symptoms, enormous new stresses on the
person: unhappiness, sleep disorders, lack of concentration, difficulty
in doing one's job, inability to care for one's physical and emotional
needs, strain on existing relationships with friends and family. These
new stresses may be sufficient to act as triggers for continuing brain
chemistry alteration, or they may simply prevent the resolution of the
difficulties which may have triggered the initial alteration, or both.
The depressive brain chemistry alteration seems to be
self-limiting in most cases: after one to three years, a more normal
chemistry reappears, even without medical treatment. However, if the
alteration is profound enough to cause suicidal impulses, a majority of
untreated depressed people will in fact attempt suicide, and as many as
17% will eventually succeed. Therefore, depression must be thought of as
a potentially fatal illness. Friends and relatives may be deceived by
the casual way that profoundly depressed people speak of suicide or
self-mutilation. They are not casual because they "don't really
mean it"; they are casual because these things seem no worse than
the mental pain they are already suffering. Any comment such as,
"You'd be better off if I were gone," or "I wish I could
just jump out a window," is the equivalent of a sudden high fever;
the depressed person must be taken to a professional who can monitor
their danger. A formulated plan, such as, "I'm going to jump in
front of the next car that comes by," is the equivalent of sudden
unconsciousness: an immediate medical emergency which may require
hospitalization.
Depression can shut down the survival instinct or temporarily
suppress it. Therefore, depressed suicidal thinking is not the same as
the suicidal thinking of normal people who have reached a crisis point
in their lives. Depressive suicides give less warning, need less time to
plan, and are willing to attempt more painful and immediate means, such
as jumping out of a moving car. They may also fight the impulse to
suicide by compromising on self-injury -- cutting themselves with
knives, for example, in an attempt to distract themselves from severe
mental pain. Again, relatives and friends are likely to be astonished by
how quickly such an impulse can appear and be acted upon.
