29 Major Depression

Clinical Vignette

A 69-year-old man was brought to the emergency room by his daughter for evaluation of weight loss, seeming inability to sleep, frequent periods of overwhelming anhedonism, and crying. The patient admitted that his appetite was poor, but was convinced he was losing weight because his bowels were being “eaten away” by cancer. He described himself as a useless individual whose productive life was over; he had become a burden to his family. Additionally he was experiencing intense anxiety, poorly localized back pain, difficulty concentrating, and insomnia. Ten years earlier he had been hospitalized for a depressive episode following a suicide attempt by overdose.

This vignette provides a classic picture of severe depression (Fig. 29-1). This is the most common serious psychiatric disorder; practicing physicians encounter it very frequently in many different guises. Depression is a very significant illness; it ranks second only to cardiovascular disease in overall morbidity and economic loss. Up to 20% of individuals within a general population will have at least one major depressive episode during their lifetime. Women have a higher incidence of depression between menarche and menopause, with an especially high risk postpartum. When depression affects men, the long-term risk of suicide is more common.

Figure 29-1 Major Depression in Seniors.

Depression usually begins in adolescence or early adulthood. It is a chronic illness with a propensity for recurrence. One common clinical pattern, called “double depression,” is characterized by repeated episodes of depression (Fig. 29-2) with eventual remission to a milder “dysthymic” state (Chapter 28). Familial clustering is apparent, although specific genes have not been identified. Depression beginning after age 60 years is probably a different disorder. It is less often associated with a significant family history but is associated with cerebrovascular disease and periventricular white matter abnormalities.

Figure 29-2 Severe Pathologic Depression in Otherwise Healthy, Vigorous Patient.

Clinical Presentation

Major depression predominantly presents with a 2-plus-week history of a sad or anxious mood; impaired energy and concentration; anhedonia (loss of pleasure from normally enjoyable experiences); insomnia, often with early morning wakening; loss of appetite; feelings of worthlessness or guilt; and recurrent thoughts of death or suicide. The presence of predominant diurnal mood fluctuation—feeling worse in the morning—is almost pathognomonic of depression. It is not uncommon to find disturbed sleep architecture with shortened rapid eye movement latency. Many patients have subtle endocrine disturbances, especially hypercortisolism that is not clinically apparent.

One of the major medical concerns vis-à-vis any severely depressed patient is that suicide ideation and very definite attempts of the same are a common occurrence (Fig. 29-3). Although overt suicide attempts are notoriously difficult to predict, physicians must maintain a heightened sense of alertness to assessing suicide risk. One must always stand by to offer help and intervention per se when necessary, especially with the patient having significant suicidal risk factors. These include being a male, intense anxiety or agitation, social isolation, advanced age, history of previous suicide attempts, psychosis, and known alcohol abuse.