Depression

August 22, 2011

This widely used term Depression may be referred to as a symptom, a syndrome, an illness, or a disorder. A depressive symptom refers to a temporary, subjective sense of sadness that everyone does experience at one time or another and it may be related to any condition. A depressive syndrome is defined as a collection of signs and symptoms, objective and subjective, that taken together is recognized as a condition that is less severe than a clear illness or disorder. A mood is a sustained emotion that one experiences subjectively but can be observed by others, while an affect is an emotion seen and noted by others only. Disturbances of mood and affect are very common and much of psychiatry is concerned with trying to define when a syndrome reaches a threshold for becoming an illness and requires treatment. Depressive illnesses require a certain severity and duration of the symptoms in order to qualify for a diagnosis. Many persons suffer a great deal from conditions that have not met formal diagnostic criteria. This situation is often referred to as “sub-syndromal” depression. Depressive illnesses are among the most underdiagnosed and unrecognized conditions yet are the most treatable of major health conditions.

Depressive disorders are the most common mental illnesses and are the second leading cause of disability in the Western world after heart disease. The diagnosis of major depressive disorder requires a certain severity and duration of the symptoms for more than 2 weeks including mood changes, which are defined in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) as “a depressed mood most of the day nearly every day as indicated by subjective (e.g., feels sad or empty) or observations made by others (e.g., appears tearful).” Other disturbances include signs of biological (somatic) dysfunctions such as appetite changes, increased or decreased sleep, diurnal variation, and diminished interest in sex; also other symptoms such as problems with concentration and memory, anhedonia that is a lack of pleasure in one’s usual activities, fatigue, increased or decreased physical activity, and often suicidal or homicidal ideation. The latter is of special concern since suicidal persons are often depressed and have visited a health care provider prior to their attempt to act on those thoughts. Other subtypes of depression include bipolar (presence of mania or hypermania), atypical (unusual features such as increased sleepiness and hyperphagia), delusional (presence of psychosis), dysthymia (less severe and chronic for more than 2 years), geriatric (older ages), and comorbid (presence of other psychiatric illnesses). In making these diagnoses one must exclude those that may be caused by other medical conditions and substance or alcohol use.

The causes of mood disturbances are the subject of considerable research with yet much still to be done. It is known that mood disturbances are associated dysregulation of biogenic amines, the best studied of which are the neurotransmitters, norepinephrine, serotonin, and dopamine. There are neuroendocrine factors (hormones), neurotransmitters, genetic factors, and psychosocial factors, all of which interact in vulnerable individuals to produce disease. Treatments have been based on the newer knowledge about causes, especially in the area of development of new medications as well as the refinement of many psychotherapies.

Mental disorders affect both men and women equally, but the patterns and presentations are often different between men and women. Much of what we know and much of the current research are not yet sufficient to completely understand why these differences exist nor to fully understand the variations in incidence, prevalence, etiology, clinical presentation, treatment responses, and prevention strategies.

Starting in adolescence and extending through menopause, women experience twice the rates of depressive disorders (major depressive disorder, dysthymia, rapid cycling bipolar disease, and seasonal affective disorder) compared to men. Women also experience a higher incidence of anxiety disorders such as phobias, agoraphobia, panic disorder, generalized anxiety disorders, and posttraumatic stress disorder. Women often have other mental disorders that accompany the depressive ones, such as anxiety problems or alcohol and substance abuse. Men tend to have higher rates of alcohol and drug abuse. While schizophrenia, obsessive-compulsive disorder, and bipolar disorders occur at similar rates in men and women, there are different patterns that characterize the onset, course, and treatment responses.

The fact that women experience twice the rate of depressive disorders as men do, does not in any way suggest that they are weaker or have a greater susceptibility to mental illnesses. While the causes for gender differences remain unclear some theories have been suggested, such as, these variations may be a mistake in sampling and/or women may recall past episodes of depression better than men. However, the most likely explanation is that biological and psychological factors may be involved. Since differences appear between men and women in the likelihood of developing depression at puberty in women and not in men, there are probably hormonal and genetic influences. Women are most likely to experience mood changes during their reproductive years, especially at times related to menses, pregnancy, after pregnancy, or weaning a baby. Ten to fifteen percent of women experience major depression in the postpartum period and these figures may be even higher during the pregnancy.

Psychological and cultural factors may also contribute to the gender differences in the rates of depression between men and women. Women may face more social and economic difficulties, more physical and sexual abuse, different role expectations, and responsibilities for balancing child care and careers. In crosscultural research women’s social status contributes to their well-being. Women with young children at home have an increased risk for depressive disorders. Some of the best predictors for depressive disorders are a past personal history of depression, a family history of depression, a lack of social supports, loss of close family or friends, and other major life stressors.

Diagnosis of major depression includes a history of mood change lasting for more than 2 weeks with accompanying signs and symptoms of changes in sleep, appetite, weight, concentration, memory, sexual interest, anhedonia, fatigue, and possibly ideas of self-harm or harming others. The latter is characterized by feelings of helplessness, hopelessness, and being “trapped” in some situation. Dysthymia is a more minor mood change lasting for 2 years or more. Seasonal affective disorder is a mood change that occurs during times of the year when there is less light. Rapid cycling bipolar disorder refers to a manic depressive illness where there are four or more episodes of mania or depression in a given year.

Menstrual-related depressive and anxiety symptoms are quite common. Premenstrual syndrome (PMS) occurs in about 70% of normal women and is characterized by a collection of physical and psychological symptoms that may include depression, irritability, lability, or less often elation that starts a few days to a week or more before the onset of menses and are usually relieved with bleeding. The physical symptoms include breast tenderness, water retention, edema and bloating, and occasional headaches. Many women can function throughout these periodic times. However, about 4-5% of women experience much more severe symptoms that can interfere with their functioning at school, work, or with interpersonal relationships. This condition is called premenstrual dysphoric disorder (PMDD). It is important to note that about half of the women who experience PMS or PMDD may be experiencing the worsening of another condition such as depressive illnesses, anxiety disorders, substance abuse, alcoholism, or psychosis. It is helpful to keep a prospective diary in order to find out if the woman does have PMS or PMDD. The causes of PMS and PMDD are not clearly known except for their relation to sex hormones. Research is under way to clarify the relationship of ovarian hormones to brain neurotransmitters, adrenal hormones, thyroid function, and psychosocial variables. Mild PMS does not require treatments, while more severe reactions have been managed with diet, vitamins, exercise, relaxation training, group support, use of antidepressants especially the selective serotonin reuptake inhibitors or antianxiety medications. There has not been good support for the use of ovarian hormones.

SEE ALSO: Bipolar disorder, Dysthymia, Postpartum disorders, Pregnancy

Suggested Reading

Sadock, J. B., & Sadock, V. S. (2000). Comprehensive textbook of psychiatry (7th ed.). Philadelphia: Lippincott, Williams & Wilkins.

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Category: D, Depression