Depression Diagnosis

  • Diagnosis

    Depression is an illness that can affect thoughts, mood, and physical health. It is characterized by overwhelming feelings of sadness, emptiness, and worthlessness. With depression, these feelings are severe enough that they interfere with work and relationships Table 01.

    Depression is a long-term condition involving several symptoms that can negatively affect work, relationships, and the quality of life of those that suffer from it. About 17% of the U.S. population experiences depression at some time in their lives. Depression is more common in women but can happen to anyone, regardless of race, income, or education.

    Depression is classified as a psychiatric illness. The term “psychiatric illness” is a general term that covers a wide range of disorders. In the past, ignorance and fear contributed to a social stigma regarding psychiatric illness. It is becoming more widely known that psychiatric problems such as depression are common.

    Many people misunderstand depressive disorders. Depression is not just “feeling blue.” It is not a sign of weakness or lack of character. A person cannot “just snap out of” being depressed. These misinformed attitudes can harm depressed people by causing them to avoid acknowledging their illness and seeking treatment. Without treatment, depression can last for months, or even years.

    Depression is an illness that causes more disability than diabetes, coronary artery disease, or arthritis. The World Health Organization estimates that depression will be the second-leading cause of disability by the year 2020 Table 01.

    Table 1.  The Effects of Depression in the U.S.

    How depression impacts society
    Problems with relationships (family, friends, coworkers, spouses).
    More sick days from work.
    Decreased productivity.
    Job-related injuries.
    Poorer-quality work.
    Lost jobs.
    Failure to advance in school or career.
    Health problems resulting from depression
    Suicide attempts that result in injury or disability.
    Accidents due to depression-caused difficulty in concentrating.
    Illnesses worsened or triggered by the stress of depression.
    Illnesses caused by drug or alcohol abuse.
    Deaths resulting from depression
    There are 30,000 to 35,000 suicides per year in the U.S.
    Depression can cause deaths from accidents related to impaired concentration and attention.
    Depression can contribute to other conditions that may result in death, such as alcohol abuse.
    Depression may play a part in premature death due to other causes, such as heart disease.

    Depression is likely caused by a combination of biological, genetic, and psychological factors.

    The cause of depression for most people is likely a combination of biological (brain chemistry), psychosocial (life stressors), and genetic (inherited) factors. Much about depression is not yet known, and researchers continue to investigate more specific causes.

    Depression runs in families.

    If you have a close relative with a history of depression, you are 1.5 to 3 times more likely to become depressed than someone with no family history of depression. This is likely due at least in part to heredity. For example, adopted children whose biological parents have a history of depression have an increased risk for depression, even if the children's adoptive family has no history of depression. However, nongenetic factors within the environment of some families may also increase the risk of depression. Learned behavior, social environment, and economic conditions may contribute to the development of depression.

    Disturbances in brain chemistry often occur with depression. The brain requires certain chemicals to function. These chemicals are called neurotransmitters. Antidepressant drugs that increase levels of certain neurotransmitters, especially serotonin and norepinephrine, are most effective in treating depression.

    Hormones can influence depression.

    Some women regularly experience depression associated with their menstrual cycle, with symptoms improving after their period begins (when estrogen levels drop). The phenomenon of sadness following birth (postpartum depression) is also well known, and seems to be at least partly hormonally triggered.

    While much more common for women, hormonally driven episodes of depression can occur in men as well. For example, teenagers (both male and female) can become moody as a result of the hormonal fluctuations of adolescence. In addition, men who take testosterone for bodybuilding can become depressed when they stop taking the hormone. Adrenal, thyroid, and growth hormone dysfunction have also been cited as causes for depression in both men and women.

    Physical damage to the brain can trigger depression.

    Injury to the brain (such as head injury or stroke) can cause changes in mood and personality, including depression. Tests such as magnetic resonance imaging (MRI), positron emission tomography (PET), and single photon emission computed tomography (SPECT) can be useful in detecting abnormalities of the brain that may cause depression.

    Psychological causes can trigger depression.

    In the past, psychiatrists theorized that depression was caused by unconscious anger toward oneself, feelings of childhood loss, or frustration about reality not measuring up to one's aspirations. Current theories state that depression results from persistent negative thoughts about oneself or from stress caused by interpersonal conflicts.

    Psychotherapy that focuses on changing persistent negative thoughts about oneself and others (cognitive-behavioral therapy), improving relationships (interpersonal therapy), and stress reduction techniques can be effective in treating mild to moderate depression. Such psychotherapy can both relieve depression and prevent it from recurring. Psychotherapy may be used alone, or with antidepressant medication.

    Life stresses may trigger episodes of depression.

    Both men and women are particularly at risk for depression after the death of a spouse. Many remain depressed for a year after their loss. Unemployment, divorce, and serious health crises can also trigger depressive episodes. Once someone has experienced an initial episode of depression, they are at higher risk of having depression again in the future.

    Depression is characterized by at least two consecutive weeks of a depressed mood or a markedly reduced interest in previously enjoyed activities. Other symptoms include poor appetite, sleeplessness, and poor concentration Table 02Table 03.

    Depression often involves a sense of overwhelming sadness. Sometimes a depressed person may instead experience a profound loss of interest and pleasure in normal activities such as eating, sex, work, hobbies, and being with family and friends. Other typical symptoms include changes in basic body functions such as appetite (with accompanying weight loss or gain) and sleep patterns (either too much sleep or insomnia, often with early morning wakening). Depressed people may feel restless, irritable, or agitated. At the other extreme, some depressed individuals feel overwhelming fatigue. Depressed people often feel worthless, hopeless, or excessively guilty. If untreated, depressive episodes commonly last from six months to two years.

    Table 2.  Common Emotional Symptoms of Depression

    Feeling "down in the dumps," sad, or discouraged.
    Feeling "blah" or anxious, or having no feelings.
    Apathy (loss of interest or pleasure in usual activities)
    Decreased interest in hobbies, "not caring anymore," or not enjoying activities that were previously enjoyable to the person.
    Anxiety (feeling apprehensive or uneasy for no reason)
    Continual tension, apprehension, or foreboding (feeling that ?something bad? is going to happen).
    Inappropriate guilt
    Feeling that "it is their fault" that they are depressed, and that they would feel better if they tried harder.
    Guilty feelings have been reported by 75% of depressed patients.
    Shame (worthlessness and loss of self-esteem)
    From feelings of inadequacy to a completely unrealistic negative self-image.
    Loss of confidence in the ability to perform well at work or school.
    Hopelessness or despair (inability to see a brighter future)
    Thoughts that no one and nothing can help now or is likely to help in the future.
    Suicidal feelings or attempts
    Recurrent suicidal thoughts occur in up to 40% of depressed patients.
    Specific plans to commit suicide occur in many depressed patients, particularly the severely ill.
    Successful suicide attempts occur in about 4%-15% of severely depressed patients.
    Other symptoms
    Tearfulness (crying spells), irritability, excessive concern with physical health, panic attacks, and phobias.

    Depression can cause physical symptoms.

    Many people who are diagnosed with depression complain to their clinician of vague physical symptoms rather than sadness or depression. This is especially common in the elderly population.

    The most common physical symptoms of depression include fatigue, unexplained pain, cramping, bloating, heartburn, and headache. Other possible physical symptoms related to depression include heart palpitations, premenstrual syndrome, dizziness, or numbness.

    Table 3.  Other Common Symptoms of Depression

    Pain (vague aches and pains)
    Muscle aches, backaches, and headaches.
    Changes in appetite or weight
    A loss of or increase in appetite.
    Unintentional weight gain or loss.
    Problems with sleep
    Difficulty falling asleep.
    Waking up and then having trouble returning to sleep.
    Waking up too early in the morning.
    Sleeping for longer than usual.
    Excessive daytime sleepiness.
    Fatigue (loss of energy, general tiredness)
    Decreased energy, tiredness, and fatigue.
    Difficulty completing tasks, reduced efficiency, and impaired performance at school or work.
    Gastrointestinal (abdominal) complaints
    Cramping, bloating, or heartburn.
    Constipation or diarrhea.
    Agitation or retardation of actions or movement
    Agitation: the inability to sit still; pacing; hand-wringing; or pulling or rubbing the hair, skin, clothing, or other objects.
    Retardation: slowed speech and thinking, long pauses before speaking, slowed body movements, and/or soft, scant speech.
    Change in desire for or ability to have sex
    Diminished interest in sex.
    In men, the inability to ejaculate, difficulty with erection, or even total impotence.
    In women, a loss of sexual interest or orgasm.
    Other physical symptoms
    Menstrual cycle disturbances, generalized itching, dry mouth, dizziness, numbness, palpitations, or blurred vision.
    Changes in thinking (slowed thinking, indecisiveness)
    Slowness or difficulty thinking, often accompanied by a shortage of ideas.
    Indecisiveness and lack of confidence.
    Changes in concentration
    Difficulty concentrating.
    Difficulty staying focused on tasks or activities.
    Poor memory
    Decreased ability to remember things.

    Depressed people may consider suicide Table 04[Table 6].

    Depressed people often have recurrent thoughts of death. These thoughts may include contemplating taking one's own life (suicide). Suicidal thoughts may or may not include a specific plan to carry it out.

    It is important for the depressed person to know that their feelings of hopelessness and lack of self-worth are a result of their illness. If you are thinking of harming yourself or know someone who is thinking of harming themselves, it is important to get help right away. Call a trusted clinician, or if danger is imminent, call 9-1-1. More information is available from a variety of local sources or by calling 1-800-SUICIDE Table 04[Table 6].

    Table 4.  Risk Factors and Signs of Suicide Risk

    History of suicide attempt(s)
    History of psychiatric illness
    Alcoholism or substance abuse
    Psychotic symptoms (especially hallucinations, severe anxiety, panic attacks, or severe insomnia)
    Previous history of suicide in the family (especially parents)
    Living alone/social isolation
    Physical illness (especially chronic pain or terminal illness)
    Increased age (peak risk in men is at age 75; in women it is at age 55 to 65)
    Gender (females make more suicide attempts, but males are 4 times more likely to die from suicide)
    Marital status (widowed, divorced, separated, married without children, and never married individuals are at greater risk)
    Communication to family, friends, or clinician of intent to harm self, financial plans after death, or specific means of suicide
    Giving away valued possessions

    Those who have family members with mood disorders have an increased risk for depression Table 05.

    Although the genetic pattern cannot be precisely determined, depression runs in families. Those who have family members with a history of depression are more likely to suffer from depression than people from families with no history of depression Table 05.

    Some people are prone to depression during the winter months.

    Seasonal affective disorder (SAD) is a type of depression that occurs during the winter months when hours of daylight are reduced. SAD occurs more often among populations living in more extreme latitudes (where there are unusual fluctuations in hours of sunlight throughout the year) than among other populations. People suffering from SAD typically experience extreme fatigue, sleep excessively, have sugar cravings, and gain weight.

    Many people become depressed after a heart attack or after being diagnosed with a chronic illness or cancer.

    Some people with serious illness become depressed. It is often difficult, however, to determine whether depression is caused by physical changes related to the illness, or if depression is a reaction to an altered lifestyle and concern about one's health. Whatever the cause, depression should be treated along with the accompanying illness.

    People who abuse alcohol or illegal drugs are at high risk for depression.

    It's often hard to know if a drug or alcohol problem causes depression, or if people turn to abuse of these substances in an attempt to alleviate depression. Treatment for depression should be a part of drug- and alcohol-addiction recovery efforts.

    Age can be a risk factor for depression.

    Most people experience their first depressive episode in their mid-20s, with most cases overall occurring between ages 25 and 44. However, in recent years there has been a growing number of cases of depression reported in people under the age of 20.

    Table 5.  Major Risk Factors for Depression

    Prior episode(s) of depression
    Fifty percent to 85% of persons who experience one episode of depression will eventually have another episode.
    Family history of depressive disorder
    Major depressive disorders are 1.5 to 3 times more common among close biologic relatives of depressed patients than among the general population.
    Prior suicide attempts
    Suicide attempts are frequently associated with depression and other mood disorders.
    Female gender
    Depressive disorders are about twice as common in women as men. Women are particularly prone to depression before each menstrual period, immediately after childbirth, and at menopause. Some women become depressed when they use oral contraceptives.
    Age 25 to 44 years
    The average age of the first episode of depression is the mid-20s. Depression occurs most often between ages 25 and 44 years.
    Older age
    Depression is not a ?normal? part of aging. However, the elderly may be more prone to depression because of life stressors (loss of a loved one or loss of independence). Increased isolation may also make depression more likely in the elderly population. The elderly often take medications that can have depressive side effects.
    Postpartum period
    Twelve percent to 16% of women and up to 26% of adolescent girls have a major depressive episode following the birth of a baby. Postpartum depression usually starts within 1-3 months after giving birth.
    Lack of social support
    Depression occurs more often in individuals who are socially isolated or have no close interpersonal relationships. Being divorced or separated may also increase the risk of having depression.
    Current alcohol or substance abuse
    Alcohol and substance abuse may cause depression or may occur as a result of depression.
    Stressful life events
    Episodes of depression often follow severe emotional stress (e.g., following the death of a loved one, divorce, or job loss). However, depression commonly occurs without being triggered by a stressful life event.
    Chronic, debilitating medical condition
    Chronic pain (backache, headache), two or more chronic diseases, or obesity may contribute to depression.
    Central nervous system (CNS) disorder
    Up to 50% of older persons with Parkinson's or Alzheimer's disease develop a depressive disorder. Their caretakers are also at increased risk for depression.

    Your clinician will take a health history to determine whether you have symptoms of depression.

    Your clinician will ask about the nature, onset, and duration of your symptoms. Your clinician will also ask about family history, physical symptoms that could be related to depression, and pattern of alcohol consumption. Depressed individuals are sometimes not forthcoming about "feeling blue," or they may be unaware of having this feeling. Therefore, it is helpful to have a family member or friend present who can help describe any depressive symptoms they have noticed.

    Your clinician will conduct a physical exam to rule out other medical problems or drug effects that could cause depression.

    Depression can be caused by a variety of diseases, including hormonal problems (such as thyroid disease), some vitamin deficiencies, or cancer. Depression can also occur as a side effect of many common medications, including heart medications and steroids. Alcoholism and use of amphetamines or appetite suppressants can also lead to depression.

    Sleep studies are sometimes performed to help diagnose depression.

    Sleep problems are a common symptom of depression. Clinicians who specialize in sleep disorders may administer sleep studies to determine if sleep patterns that are characteristic of depression are present. These tests involve an overnight visit in a sleep clinic, where sleep patterns will be evaluated.

    There has been an increase in screening programs for depression.

    Many clinicians have started to incorporate questions into their patient exams that help screen for depression. In addition, the general public is becoming more aware that depression is a medical illness, and people are becoming more accepting of seeking treatment.

    Committing to a medication regimen and/or counseling can help prevent recurrent episodes of depression.

  • Prevention and Screening

    There has been an increase in screening programs for depression.

    Many clinicians have started to incorporate questions into their patient exams that help screen for depression. In addition, the general public is becoming more aware that depression is a medical illness, and people are becoming more accepting of seeking treatment.

    Committing to a medication regimen and/or counseling can help prevent recurrent episodes of depression.

Recommended Reading

Meet the Pharmacists

I'm Shereen A. Gharbia, PharmD. Welcome to PDR Health!

Check out my latest blog post on antidepressants

Depression Related Drugs

Depression Related Conditions