29 Major Depression

This vignette provides a classic picture of severe depression (Fig. 29-1). This is the most common serious psychiatric disorder; practicing physicians encounter it very frequently in many different guises. Depression is a very significant illness; it ranks second only to cardiovascular disease in overall morbidity and economic loss. Up to 20% of individuals within a general population will have at least one major depressive episode during their lifetime. Women have a higher incidence of depression between menarche and menopause, with an especially high risk postpartum. When depression affects men, the long-term risk of suicide is more common.

Figure 29-1 Major Depression in Seniors.

Depression usually begins in adolescence or early adulthood. It is a chronic illness with a propensity for recurrence. One common clinical pattern, called “double depression,” is characterized by repeated episodes of depression (Fig. 29-2) with eventual remission to a milder “dysthymic” state (Chapter 28). Familial clustering is apparent, although specific genes have not been identified. Depression beginning after age 60 years is probably a different disorder. It is less often associated with a significant family history but is associated with cerebrovascular disease and periventricular white matter abnormalities.

Figure 29-2 Severe Pathologic Depression in Otherwise Healthy, Vigorous Patient.

Clinical Presentation

Major depression predominantly presents with a 2-plus-week history of a sad or anxious mood; impaired energy and concentration; anhedonia (loss of pleasure from normally enjoyable experiences); insomnia, often with early morning wakening; loss of appetite; feelings of worthlessness or guilt; and recurrent thoughts of death or suicide. The presence of predominant diurnal mood fluctuation—feeling worse in the morning—is almost pathognomonic of depression. It is not uncommon to find disturbed sleep architecture with shortened rapid eye movement latency. Many patients have subtle endocrine disturbances, especially hypercortisolism that is not clinically apparent.

One of the major medical concerns vis-à-vis any severely depressed patient is that suicide ideation and very definite attempts of the same are a common occurrence (Fig. 29-3). Although overt suicide attempts are notoriously difficult to predict, physicians must maintain a heightened sense of alertness to assessing suicide risk. One must always stand by to offer help and intervention per se when necessary, especially with the patient having significant suicidal risk factors. These include being a male, intense anxiety or agitation, social isolation, advanced age, history of previous suicide attempts, psychosis, and known alcohol abuse.

Figure 29-3 Major Depression.

Certain medical conditions may provoke or mimic major depression. These most commonly include hypothyroidism, alcohol abuse, or need for corticosteroid therapy such as in the patient with myasthenia gravis. Depressed alcoholics and drug abusers are very unlikely to maintain a recovery from depression unless they maintain their sobriety.

Psychotic depression may develop in those individuals who are the most severely depressed at presentation. This is typically characterized by delusions that are “affect consonant,” for example, delusions of poverty, moral depravity, or life-threatening illness. Bowel delusions are the most common of the various physical complaints that the depressed patient may express their inappropriate concern. The recognition of psychotic thinking in the depressed patient has very definite therapeutic consequences. This is particularly important because this subgroup of patients with depression fails to respond to standard antidepressant medications. There are two primary therapeutic options for psychotically depressed patients: (1) electroconvulsive therapy or (2) a combination of antidepressant and antipsychotic medication.

A primary bipolar disorder may underlie or be masked per se in at least 10% of individuals presenting with what appears on first pass to be unipolar depression. One single episode of mania will establish the bipolar diagnosis. A heightened level of suspicion for the presence of underlying bipolar disorder is necessary for anyone raised in a family with history of bipolar disorder, having experienced a childhood onset of depressive illness, or a poor therapeutic response. Similarly, if the patient experiences a sudden response to initiation of antidepressant medication, that is, “switching,” rather than following the usual delayed therapeutic response, a bipolar disorder requires further consideration. Efforts should be made to limit the exposure of patients with known or suspected bipolar disorder to the usual antidepressant medications (Chapter 30).