A Guide to Depression
This is a guide that will talk about the symptoms of different types of unipolar depression, as outlined by the most recent version of the Diagnostic and Statistical Manual of Mental Disorders, otherwise known as the DSM. The version referenced in this guide is the DSM-IV-TR. The DSM-5 is set to come out May 2013, and some of the stuff in this guide will reflect some of the rumored changes, but most of them will be based on the DSM-IV-TR.
Warning: There is mention of suicide and suicidal ideation under the cut.
There are several different diagnoses of depression, as well as different subtypes and specifiers. This guide will cover the differences between them, and how they might manifest in different cases. There are a lot of criticisms with the DSM, much of them stemming from the vagueness and unreliability of the diagnoses, but this is the standard, at least for the United States. I have not read the DSM, so there are probably several other diagnoses of depression, but these are the most commonly found. Depressive episodes are rarely ever the same with different people, and can even sometimes change with the same person.
Diagnosing a Major Depressive Episode (MDE)
In order to be diagnosed with a major depressive episode, five (or more) of the following symptoms have been present during the same 2-week period, at least one of the symptoms is either (1) or (2).
- Depressed mood for most of the day, nearly every day
- Markedly diminished interest or pleasure in all, or almost all, activities that used to give pleasure most of the day, nearly every day (commonly called anhedonia).
- Significant weight/appetite changes
- Insomnia or hypersomnia nearly every day
- Psychomotor agitation or retardation nearly every day, to the point where it is noticeable to others
- Fatigue or loss of energy nearly every day
- Feelings of worthlessness and/or excessive guilt, sometimes to the point where it’s delusional, nearly every day
- Diminished ability to think/concentrate, or indecisiveness nearly every day
- Recurrent thoughts of death (not necessarily suicidal), recurrent suicidal ideation, or suicidal attemptsJust by reading these criteria, you can tell how easy it is for two people with depression to act completely differently. This is a very broad net of symptoms. One person could have anhedonia, severe weight loss, fatigue, insomnia, psychomotor retardation, and suicidal ideation while another diagnosed with depression can be characterized by anhedonia, sudden increase in appetite, hypersomnia, psychomotor agitation, the inability to concentrate, and thoughts of death. There’s no “right” way to act with depression, and as long as a person falls within the guidelines of the DSM-IV-TR, a licensed psychiatrist/psychologist may diagnose them with depression.Other than the appearance of these symptoms, a clinician must also check for other things, especially before prescribing treatment. Some of things that will be covered in the diagnostic interview would be family/personal medical history, history of substance abuse, comorbidity with other disorders, other psychiatric/physical diagnoses, and psychosocial environment. One of the most important questions that must be asked is whether a patient has ever had a manic episode in their life, which automatically gives them a diagnosis of bipolar disorder. This is especially important because some anti-depressants can actually trigger manic episodes.
Major Depressive Disorder (MDD) - Single Episode
- Characterized by a single major depressive episode, that is not accounted for by another disorder, such as substance abuse or other physical ailments. The patient has never had a manic or depressive episode before this.
- Under the DSM-IV-TR, there is a caveat for the diagnosis of depression. Any patient experiencing bereavement after the death of a loved one is allowed two months before they can be considered diagnosable with depression. There are rumors that this caveat will be removed for the DSM-5, and that this two month period will not be necessary before diagnosis. The only time this caveat is revoked is if the patient expresses desire to harm themselves or others, or if it is necessary for the patient to be hospitalized.Major Depressive Disorder (MDD) - Recurrent
- The symptoms are the same for major depressive episodes, only the episodes must be separated by at least a period of two months. Again, if a person experiences a manic or hypomanic episode at any point, their diagnosis becomes one of bipolar disorder.Dysthymia
- Dysthymia is a more chronic form of depression, but the symptoms are not quite as severe as major depressive episodes. In order to be diagnosed with dysthymia, a person must have depressed affect for a majority of the day, for most days, for two years or more. The symptoms cannot have receded for more than two months, and for people with dysthymic disorder, it is often observed that just have a “depressed personality”. These are the people that we tend to think of as the “Eeyores” of the world. They might not necessarily exhibit all the symptoms of depression, but you can usually tell that they are not as happy as the norm seems to be. The patient needs to exhibit depressed mood and at least two other symptoms of an MDE (other than suicidal ideation and thoughts of death). One of the main differences of dysthymia and MDD is that dysthymia does not interfere with everyday life as much as MDD. Patients are still able to function, go to work, have relationships, etc. Both the patients and their friends and family get used to this sort of affect, and it becomes something that is incorporated into their lives.
- If a patient has had an MDE within the first two years of the disorder, this diagnosis cannot be given. However, after the initial two years, an MDE may occur on top of the dysthymia, and both diagnoses can be given concurrently.
Depression Subtypes and Specifiers
Depression can have different subtypes and accompanying symptoms, and it is important for a clinician to note these before prescribing treatment. If no such symptoms are present, the clinician will prescribe a diagnosis of (disorder name)-NOS, which stands for “not otherwise specified”.
Mild, Moderate, and Severe
- Mild: Necessary symptoms to have a diagnosis; normal everyday function can be achieved with extra effort; no severe impairments
- Moderate: Symptoms fall between mild and severe (I know this is super arbitrary, but so are a lot of things in the DSM)
- Severe: Most symptoms present and little to no ability to function without the aid of others; at risk of harming self or others
With Melancholic Features
With Psychotic Features
- Some characteristic symptoms in addition to meeting the symptoms of an MDE: Early morning awakening, depression markedly worse in the morning, psychomotor agitation/retardation, loss of appetite/weight, excessive guilt
- This is marked by severe anhedonia, where the patient has lost interest/pleasure in nearly all activities and/or does not react to pleasurable stimuli/events.
- Often associated with childhood trauma
With Atypical Features
- Some characteristic symptoms in addition to meeting the symptoms of an MDE: Delusions or hallucinations, feelings of guilt/worthlessness, break from reality
- These hallucinations/delusions are mood congruent, often very depressive in nature. These are not the ideas of grandiosity often exhibited during manic episodes. These are ideas such as causing a major natural disaster with their thoughts, or feeling like their body is disintegrating from the inside out.
- Some characteristic symptoms in addition to meeting the symptoms of an MDE: Increase in appetite/weight, hypersomnia, leaden paralysis, acute sensitivity to rejection
- The defining characteristic of atypical depression is mood reactivity, where the patient’s mood brightens in response to positive events. As such, there is some evidence to link atypical depression with a milder form of bipolar disorder with hypomanic episodes. Because of this, treatment for this subtype of depression often includes MAOIs rather than other types of antidepressants.
With Catatonic Features
- Some characteristic symptoms in addition to meeting the symptoms of an MDE: Psychomotor symptoms such as motoric immobility or extensive psychomotor activity, mutism, and rigidity
With Seasonal Pattern (Commonly known as seasonal affective disorder or SADS)
- At least two or more episodes in the past two years, that have occurred at the same time of year (usually fall or winter) and must fully remit at the same time every year (usually during the spring).
- This type of depression must be connected to the seasonal patterns
With Postpartum Onset
- The post-baby blues are relatively common among women. The body is going through massive hormonal changes, sleep cycles are disrupted, and women are undergoing a lot of stress at this time. This is not the same thing as postpartum depression. Only 10% of women fit the criteria for postpartum depression, and an even smaller percentage fits the criteria for postpartum psychosis, which is what we read about in the news, about women who kill their children during a psychotic break.
Comorbidity is the fancy way to say that there are two or more disorder affecting one person simultaneously. Depression is a highly-comorbid disorder. Anxiety/panic disorders, eating disorders, and substance abuse are among the most comorbid with depression. Some personality disorders such as borderline personality disorder may also have depressive episodes.
Cultural/Age Differences/Causal Factors
It is important to note where the prevalence of depression diagnoses, and how these diagnoses might reflect on different cultural backgrounds. Depression is most common in more-developed, industrialized areas, such as Western Europe, the US, Canada, and Eastern Asia. A theory behind this data is that people in these countries expect to be happy. They see happiness as something that is integral to their life, and when they can’t achieve it, their bodies have a difficult time coping. In essence, people in these countries feel bad for feeling bad.
An important distinction to make, however, is that non-Western cultures often exhibit depression in more somatic symptoms, focusing more on fatigue, psychomotor movement, and appetite changes. On the other hand, Western cultures tend to focus more on emotional/mood symptoms such as depressed affect, sensitivity to rejection, and feelings of guilt/worthlessness. An interesting case is the Old Order Amish, who have a tenth of the rate of depression diagnoses in comparison to mainstream culture. Many theorize that this may have to do with the tight-knit sense of community that is prevalent in this culture, and people have less of an opportunity to socially isolate themselves from others, which often makes depression symptoms worse.
The most common age group for depression is teenagers and young adults from 15-24. This may have to do with various hormonal changes going on during this point in life, but studies have also shown that as generations pass, younger generations are more prone to have depression than older ones. This may have to do with the lessening of stigma around depression, and that people are more willing to talk about it now, rather than twenty years ago. Another theory is that we are placing too many expectations on the younger generations, to do more in a shorter amount of time, with more stress involved. Some factors include the loss of community, that is fostered by the prominence of social media and technology, or even something as simple as children’s sleep cycles are more disrupted now than ever. There are a great many causal factors for depression, from genetics and physiology to stressful life events and chronic stress. No one case is exactly alike.
Suicide (Warning: This may be triggering for some)
One of the most important things to know about suicide is that all suicides are not the same. There are different categories of people who attempt suicide.
- Death Seekers: These are the people with very clear intentions to die. They have thought about suicide for a long time, very often have plans and backup plans, and they show signs of wanting to die. They might write notes to family members or give their possessions away.
- Death Initiators: These are people who are terminally ill and attempt to end their pain and hasten death. Often called physician-assisted suicide, made famous by Dr. Kevorkian, this type of suicide is legal in Oregon and Washington.
- Death Ignorers: People who see death as a means to a new life, perhaps spurred by religion or a cult, or even just personal beliefs. These are the people who see death in this world as a beginning in another.
- Death darers: These are the people who engage in reckless, potentially deadly behavior. They play Russian Roulette, or drive very recklessly on an empty winding road. They might not necessarily want to die, but put themselves in situations where it could happen.Some Facts:Important Note: Suicidal thoughts and ideation are notpresent in all cases of depression. Some people may be clinically depressed but have never given serious thought to harming themselves.
- Women are 3-4 times more likely to attempt suicide, but men are more likely to complete suicide. This is due to the fact that women often use slower agents such as wrist cutting or ingesting drugs, while men use more lethal means, such as a gunshot or jumping off of a high point.
- East Asia has the highest suicide rates in the world. In these cultures, the idea of “suicide of honor” is highly prevalent. On the other hand, countries where the dominant religion frowns on suicide, such as Catholicism, suicide rates are much lower.
- Suicide is the second leading cause of death in college students.
If you are thinking of hurting yourself, please don’t. One of the things about major depressive episodes is that they are episodes. Eventually, your mood will stabilize and brighten. Seek help if you need it. Talk to your friends, your parents, a close relative or an older figure that you can trust, or even a stranger who won’t judge you. The number for the US National Suicide Prevention Hotline is listed below.
Avoid Romanticizing It
Depression hurts. Unlike in some manic episodes, people don’t enjoy feeling depressed or sad. They don’t enjoy not being able to do things, or enjoy not being able to feel happy at simple pleasures, or enjoy being unable to maintain relationships with their loved ones. Some people are ashamed to even bring it up because sometimes they feel as though they are simply being self-indulgent, or that because there are no physical scars or marks, because they’re not in a wheelchair or permanently disfigured, that somehow their pain is lesser than others. That having to take pills in order to live a “normal” life is something to be frowned upon. This is not the case. Depression affects not only the depressed person, but their friends and family as well. People don’t like it.
What to Do After the Diagnosis
This guide doesn’t go into much detail about what happens after the diagnosis. There are a lot of different types of medication and therapy out there, and there is no cookie cutter response to this question. Sometimes the first anti-depressant a person is put on will work. Other times, it will take three or four attempts. The human body’s physiology differs from person to person, as does the way they interact with different people. Most antidepressants don’t work for up to 3-5 weeks after beginning treatment. It takes time for the body to recognize and adapt, and so it may take time before patients begin to feel any sort of change. Some people do very well in therapy and don’t need medication. Others do.
I’ve never been diagnosed with depression, nor have I experienced an MDE. I don’t know what it’s like to be depressed. This guide is meant to show what a clinician would be looking for in a diagnosis. As stated multiple times above, depression manifests itself in different ways, and different people/personalities will reflect that. This was a lot of information to throw at you, and there is much more literature to be read on the topic. This is a very light skimming of the types of depression that is most often diagnosed, and what that might entail. This is your character. You know them best, from their background to their personality to that nightmare they had when they were seven years old. This is simply the gritty side of it all.