DEPRESSIVE EPISODE
Clinical features
Characteristic features of a depressive episode include depression of mood, anhedonia, reduced attention and concentration, ideas of guilt and worthlessness, lowered self-esteem and reduced energy, which in turn causes tiredness and reduced activity. In turn, these can lead to hopelessness and a belief that life is not worth living, which can cause suicidal thoughts. Biological symptoms occur frequently (Table 6.1); the types of sleep disturbance that may occur in depressive episodes are shown diagrammatically in Figure 6.1.
| ↓ Appetite |
| ↓ Weight |
| Constipation |
| Sleep disturbance, such as: Early morning wakening Initial insomnia Broken sleep |
| Diurnal variation of mood |
| ↓ Libido |
| Amenorrhoea |
 |
| Figure 6.1 (With permission from Puri BK, Laking PJ, Treasaden IH 2002 Textbook of psychiatry. Churchill Livingstone, Edinburgh.) |
Mental state examination
Appearance
Depressive facies include downturned eyes, sagging of the corners of the mouth and a vertical furrow between the eyebrows. There is typically poor eye contact. There may be direct evidence of weight loss, with the patient appearing emaciated and dehydrated. Indirect evidence of recent weight loss may be indicated by the clothing appearing to be too large. Evidence of poor self-care and general neglect may include an unkempt appearance, poor personal hygiene and dirty clothing.
Behaviour
Psychomotor retardation typically occurs.
Speech
The patient’s speech is typically slow, with long delays before questions are answered.
Mood
The mood is low and sad, with feelings of hopelessness. The future seems bleak. Anxiety, irritability and agitation may also occur. The patient may complain of reduced energy and drive, and an inability to feel enjoyment (anhedonia). There is a loss of interest in normal activities and hobbies.
Thought content
Pessimistic thoughts occur concerning the past, present and future. Suicidal and homicidal thoughts may occur and should be checked for. Obsessions may occur secondary to depression.
Abnormal beliefs and interpretation of events
Ideas or delusions of a hypochondriacal or nihilistic nature may be present.
Abnormal experiences
In severe depressive episodes auditory hallucinations may occur which are typically in the second person and derogatory in content.
DSM-IV-TR criteria for major depressive episode
A. At least five of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) or (2):
(1) Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g. feels sad or empty) or observation by others (e.g. appears tearful). In children and adolescents this can be irritable mood
(2) Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day
(3) Significant weight loss when not dieting or weight gain (e.g. a change of > 5% body weight in a month), or a decrease or increase in appetite nearly every day. In children consider failure to make expected weight gains
(4) Insomnia or hypersomnia nearly every day
(5) Psychomotor agitation or retardation (observable by others) nearly every day
(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
(8) Diminished ability to think or concentrate, or indecisiveness, nearly every day
(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. Exclude a mixed episode (in which a manic episode also occurs).
C. The symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning.
E. The symptoms are not better accounted for by bereavement.
Differentiation from bereavement
The duration of a normal grief reaction varies in different cultures. In DSM-IV-TR a diagnosis of major depressive episode/disorder is generally not given unless the symptoms are still present 2 months after the loss. In differentiating a depressive episode (major depressive episode in DSM-IV-TR) from a normal grief reaction, the following DSM-IV-TR criteria are also held to be more likely to point to a diagnosis of a (major) depressive episode:
• Guilt about things other than actions taken or not taken by the survivor at the time of death
• Thoughts of death other than the survivor feeling that s/he would be better off dead or should have died with the deceased
• Morbid preoccupation with worthlessness
• Marked psychomotor retardation
• Prolonged and marked functional impairment
• Hallucinations other than thinking that one hears the voice of, or transiently sees the image of, the deceased.
Atypical types of depression
Depressive stupor
This is rare these days because of effective treatment.
Masked depression
Depressed patients may present with somatic or other complaints instead of a depressed mood. They may somatize their depressed mood because of cultural factors, or they may not be able to articulate their emotions, as in the case of patients with severe learning disability and elderly patients with dementia. In such cases the presence of biological symptoms of depression is particularly helpful in making the diagnosis. In the case of patients with learning disability diurnal variations in abnormal behaviour may be observed and may mirror diurnal variations in mood.
Seasonal affective disorder
The onset of depressive episodes is related to a particular time or season. For example, untreated depressive episodes may regularly start in autumn or winter and end in spring or summer. The onset of bipolar disorders may also be seasonal. During depressive episodes patients with seasonal affective disorder (SAD) often exhibit carbohydrate craving, hypersomnia and weight gain. Excluded from this category are cases in which there is a clearly distinguished seasonal psychosocial stressor, e.g. becoming depressed each winter because of regular winter unemployment.
Agitated depression
This occurs in the elderly.
Investigations
In addition to routine investigations (Ch. 1), in the case of first presentation with auditory hallucinations in the elderly tests of hearing and vision should be carried out, as sensory deprivation is an important cause of these symptoms in this age group.
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