Clinical depression or major depressive disorder

Temporary moods of being depressed are a common and often normal reaction to the stress of our everyday lives. With clinical depression or a major depressive disorder (the medical terms for depression) the low mood continues and you may have a number of other symptoms, (listed below under 'Symptoms of depression').

Up to one in four women and one in 10 men can expect to experience depression at some time in their lives. There is some evidence that it is becoming even more common in Western countries. Depression can start at any age - from childhood through to old age. Most often it starts in the mid-20s, and it is more common in the 25 to 45-year-old age group.

Symptoms of depression usually develop over days or weeks, though many people have a period of anxiety or mild depression which lasts for weeks or months beforehand. The duration of an episode can be variable, but without treatment depression typically lasts for six months or more.

How is it diagnosed?

There is no medical test to diagnose depression. A diagnosis is made when the person has some or all of a number of typical symptoms. For this reason it is important that a doctor or other health professional gets a full understanding of the difficulties a person has had, both from the person and their family or whanau or others who know them well.

While depression is the most common cause of these symptoms, the same picture can be seen with the depressed phase of bipolar affective disorder (manic depression). They are also seen in some medical conditions.

Some forms of depression may be seasonal. A person with this kind of depression (called seasonal affective disorder) will be well during summer, but may become depressed during the winter. This is more common the closer to the south or north pole that you live (ie, the shorter the days during winter).

The majority of people with depression are never diagnosed or adequately treated. Depression can be treated effectively, and people will usually recover from it. However, the earlier effective treatment is started, the better their chances of recovery.

Symptoms of depression

Signs or symptoms of depression may vary between individuals and over time in one individual. Not everyone with depression will complain of sadness or a persistent low mood. They may have other signs of depression such as sleep problems. Others will complain of vague physical symptoms.
 
The symptoms of depression are often divided into three categories - mood, physical, and cognitive (related to thoughts and beliefs). Some people will also have anxiety symptoms.
 
Very severe depression can result in symptoms of psychosis (loss of contact with reality). For a diagnosis of depression to be made, mood symptoms and some or all of the other symptoms must have been present for at least two weeks.

Mood symptoms of depression:

• Persistent low, sad or depressed mood can be described in varying ways by people, especially if they are from non-European cultures. The person may describe feeling empty, having no feelings, or may complain of pain.
• Loss of interest and pleasure in usual activities. This is a reduced ability for enjoyment. It includes loss of interest in sex.
• Irritable mood. This may be the main mood change, especially in younger people, and in men (especially from Maori and Pacific nations' ethnic groups).

Physical symptoms of depression:

• Change in sleeping patterns. Most commonly reduced sleep, with difficulty getting to sleep, disturbed sleep, and/or waking early and being unable to go back to sleep. Some people sleep too much. Most people with depression wake feeling unrefreshed by their sleep.
• Change in appetite. Most often people do not feel like eating and as a result will have lost weight. Some people have increased appetite, often without pleasure in eating. This is often seen in those who also sleep more.
• Decreased energy, tiredness and fatigue. These feelings may be so severe that even the smallest task seems too difficult to finish.
• Physical slowing or agitation often comes with severe depression. The person may sit in one place for periods and move, respond and talk very slowly; or they may be unable to sit still, but pace and wring their hands. The same person may experience alternating slowing and agitation.

Cognitive symptoms of depression:

• Thoughts of worthlessness or guilt involve loss of confidence in self and excessive guilt about past minor wrongs. As a result of feeling bad about themselves, people may withdraw from doing things and from contact with others.
• Thoughts of hopelessness and death. The person may feel there is no hope in life, wish they were dead or have thoughts of suicide.
• Difficulty thinking clearly. People may have difficulty in concentrating. They may not be able to read the paper or watch television. They may also have great difficulty making even simple everyday decisions.

Associated symptoms of depression - anxiety

Anxiety symptoms are very common as part of depression but as the depression resolves these symptoms usually stop.

• Excessive worry or fear, with associated physical symptoms such as muscle tension, pounding heart, dry mouth.
• Panic attacks. Sudden episodes of extreme anxiety and panic with physical symptoms of fear.
• Phobias. Specific fears regarding situations, objects or creatures.
• Excessive concern about physical health.

Symptoms of psychosis

 Symptoms of psychosis usually take an exaggerated form of the cognitive symptoms listed above. The person may have unusual or altered beliefs or hear voices when there is nobody there.

These may be about:

• poverty or excessive debts
• extreme guilt, eg, feeling personally responsible for wars or starvation
• physical disease, eg, organs not working or insides rotting
• being killed or struck down by God for perceived sins or bad deeds
• needing to kill themselves for sins or misdeeds
• being dead.

If a person seems to be showing psychotic symptoms it is important to make sure that their experiences are outside of what is considered normal or acceptable within their culture.

Outlook for depression

The course of depression is variable. Without treatment, an episode may last six months or more. With treatment, 70 to 80 percent of people will recover much sooner. In the majority of people, there is complete recovery and return to their usual activities and relationships. Twenty to 30 percent of people will improve but still have some symptoms of depression persisting for months or years later.

In a minority (five to ten percent) there is little improvement and the person remains unwell for two or more years. Some people only ever have a single episode of depression. However, 50 percent or more of those people who have one episode of depression will have one or more further episodes at some time in their life, perhaps with longer periods of wellness in between.

Unfortunately, some may not recover completely between episodes. Early access to treatment increases the chance of a full recovery.

Risks for people with depression

Delays in accessing care may increase the severity of the condition, cause poorer response to treatment, and may result in long-term unwellness and ongoing problems.

Having a good relationship with your doctor or other treatment professional, continuing treatment where this is advised, learning about depression and having a clear plan to maintain wellness are most important.

Alcohol/ drug abuse
Alcohol and/or drug abuse commonly occur with depression, particularly where it is severe. Early recognition and treatment of co-existing alcohol and drug problems are critical to promote recovery.

Suicide
The risk of suicide in people with depression is significant. The lifetime rate of attempted suicide is 30 to 50 percent of people with depression. About ten to 15 percent actually commit suicide. The risks are highest if the person is over 55, and having an episode of depression.

The time of greatest risk may be as the person begins to recover from an episode. It is important that any expressed suicidal thoughts or urges are taken very seriously. Having access to the best possible care can reduce the occurrence of suicide.

Violence
Violent behaviour in people with depression is rare. However, a very small number of people with severe depression may commit murder-suicide involving their loved ones. This is likely to be a result of severe feelings of hopelessness and a belief that the world is a bad place from which their loved ones must be spared. Again, prompt treatment can prevent things reaching a point where such tragedy occurs.

Myths about depression

NOT TRUE Depression is a sign of a weak character.

The fact is that depression can strike anyone. While some particular personality types are more likely to develop depression, the vast majority of people who develop the condition have been previously healthy and led normal lives.

NOT TRUE People with depression can just 'snap out of it' or just choose to 'pull their socks up'.

In reality, one of the most disabling symptoms of depression is the fact that it saps the will and makes doing many things an enormous effort. Depression is an extremely unpleasant experience, and most people would do anything to get well.

See also: Causes of depression, Living with depression, Treatment for depression

Support groups

See the support organisations (which include helplines) under Further information and support below.

Original material provided by the Mental Health Foundation of New Zealand, 2002. Edited by everybody, May 2005.