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Depression has been described as a combination of misery and malaise. It may present in a variety of ways, from a vague sense of loss of well-being through to a severe life-threatening disorder.
Major depression is characterised by a general slowing down of physical and mental activity, including a lowering of mood. This may manifest as irritability, sadness, dejection, tearfulness, and a sense of hopelessness, anguish and despair. Psychosomatic symptoms such as fatigue, loss of appetite, weight loss, sleep disturbance, and multiple forms of bodily discomfort may be present. Feelings of self-reproach, worthlessness and guilt may be extreme.
Thought processes may also be affected. There may occur a diminished ability to think, to concentrate, to make decisions, as well as agitation (which can be extreme). Memory will be impaired. There may be diminished interest or pleasure in day-to-day activities, and also morbid ruminations on death, or suicidal ideas.
A depressive psychosis is a very severe depression with a schizophrenia-like picture, with persecutory beliefs, 'voices' and other strange experiences. Commonly, in depression, these experiences would again be in keeping with a low mood. For example, sufferers may believe they are guilty of great crimes, that they've caused the world to end, that they should die to save others. Sometimes they may believe that the world is such a terrible place that they should kill their friends or relatives to save them from living. People with schizophrenia can also be depressed, and with certain cases it requires time before a clear diagnosis of either schizophrenia or depression is made.
Major depression carries a risk of suicide and occasionally of homicide (for example the killing of infants by mothers). Because of the complications of the accompanying physical problems (such as malnutrition or immobility), referral and hospitalisation are often necessary for proper management.
A variety of drugs are available to treat depression. These can be highly effective therapeutically but they may take some weeks to begin to work. Many have unpleasant side effects and some are lethal in overdosage, but they are life saving medications when used appropriately. These are listed in the 'Depression' table.
Fred is 45 years old and has been keeping a low profile for days. He now presents with tears in his eyes and smells strongly of alcohol. He repeats his gloomy declaration that he 'can't see the point of it all'.
This situation may have arisen because of:
Enquire if Fred's low mood has been with him for days. If so, ask what brought it on. Ask him how much alcohol he has been drinking. Initiation of contact with medical and psychiatric authorities is essential due to the risk of self-harm or a suicide attempt.
If there is no precipitating factor (for example, the death of a friend) and you can establish that alcohol seemed to bring on the melancholia, detoxification from the alcohol is needed.
A situational crisis triggering a depressed mood may be alleviated by addressing the cause. First, help Fred to clearly identify the associated problems, and to understand what resolving the problems would mean. Identify all possible solutions, helping Fred to go through the implications of each 'solution' and to choose the most helpful and achievable response. Break this solution down into small practical steps and support Fred in carrying these out.
If there is no clear cause and no clear solution, if the mood has been pervasively low for some weeks, or if Fred has suicidal ideas, then regard this as urgent and refer to a doctor or psychiatrist. This may be clinical depression.