depression

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Key Terms: Cognitive-behavioral therapy, Depression screen.

Description

Everybody feels sad sometimes, but to be clinically depressed is not just a matter of feeling sad. A patient with cancer is diagnosed as having major depression only if certain symptoms, such as loss of pleasure or thoughts of death, are present for at least two weeks. Only a healthcare professional can accurately determine whether a patient is depressed or is simply upset because of the disease.

A Note on Depression and Children With Cancer

Few children with cancer experience depression. For many children survivors of cancer, the experience of having had cancer makes them deeper, more understanding human beings later in adulthood and old age. However, some children with cancer do experience depression, sleep problems, and relationship problems. Depression appearing in a child who has cancer should be treated by a healthcare professional.

The symptoms of depression in children are somewhat different from those in adults. The physician should be notified of a sad mood (or, in children less than six years of age, a facial expression that appears to express sadness) that continues for at least two weeks and is accompanied by at least four of the following: (a) appetite changes, (b) sleep problems or excessive sleep, (c) excessive activity or inactivity, (d) loss of pleasure, (e) not caring about anything, (f) fatigue, (g) being overly critical of himself or herself, (h) feeling worthless or guilty for no apparent reason, (i) inability to concentrate, and (j) thoughts of death.

Are Most People Who Have Cancer Depressed?

Most people who have cancer are not depressed. Depression is found in cancer patients about as frequently as in patients hospitalized for major, noncancer illnesses such as heart disease. However, depression is more often present in people who have cancer than in the general population. Approximately one out of eight people with cancer are depressed. Among hospitalized people with cancer, roughly one in four is depressed.

Depression and Embarrassment

Doctors and nurses can do a great deal to help a depressed person feel better. Being embarrassed can get in the way of the patient's getting help. While depression is a disease that happens to a minority of cancer patients, it does appear in a sizable number of these patients. Doctors and nurses are trained to deal with depression in cancer patients. If one out of eight people with cancer are depressed, it is no surprise to healthcare professionals that some patients require treatment for depression. It is not "bothering" a good health care professional to let them know that the patient is experiencing some symptoms that may signal depression. Competent doctors and nurses will not think less of a patient who is depressed. Rather, they will respect the patient who acknowledges the willingness to seek and accept treatment for depression. Cooperative patients are not those who hide depression but those who deal with depression when it appears. Dealing honestly and with the aid of doctors and allied healthcare professionals is the right way to address any cancer-related symptom.

How Does Depression Affect Someone Who Has Cancer?

Depression is not something that can be pointed to, as one would point to a runny nose or an earache. That does not mean it is not real, nor does it mean the depression does not have a major effect on the cancer patient. The fact is that depression may not only affect what patients can do and how they feel, depression may also affect how well they function and how long they live.

A study of patients with acute leukemia who were receiving bone marrow transplantation found that those who were not depressed lived longer. A study of breast cancer patients showed that depression can be treated successfully and life extended. In this study, women with metastatic breast cancer who joined a support group lived twice as long as matched patients who did not join a support group. In light of these types of studies it would be incorrect to assume that depressed cancer patients who work with their doctors and nurses to treat their depression do not live as long as patients without depression.

Untreated depression or inadequately treated depression may slow recovery time. A study of depressed colorectal cancer patients found they were not able to function as well six months after surgery as patients who were not depressed. Another study found that breast cancer patients who were more anxious and depressed felt more pain than those who were not. Other studies have also shown that depression affects how people function and cope with illness.

Causes

It is certainly understandable that someone with a serious illness feels sad. Many cancer patients are confronted with difficulties. These may include having to take medications, dealing with the side effects of these medications, undergoing operations, submitting to other medical procedures, and generally taking time away from other things they would prefer to do. In addition, many patients feel a sense of loss. They may feel a loss of good health; there may be a loss of part of the body, such as a segment of a breast; there may be a loss of the ability to do certain tasks. There may also be financial strains. Any such things are difficult for most people to deal with. It takes time and effort, and sometimes medical intervention, for people to deal with such loss and gradually get their lives back on track.

If patients are in pain it is extremely important that the pain be adequately treated. Pain is often under-treated. When pain is not treated appropriately, patients may be more likely to develop depression.

Patients with cancer of the pancreas are particularly likely to become depressed. In addition, patients with breast, colon, gynecologic, oropharyngeal, and stomach cancer are more likely to experience depression than patients with other types of cancers. No one knows why depression is more likely to be associated with these cancers.

Approximately one out of every four patients with depression associated with cancer already was depressed at the time of diagnosis. In contrast, approximately three out of four develop the depression after the diagnosis has been made.

Risk Factors for Depression Among Cancer Patients

Anyone can become depressed, and this includes people with cancer and people who are perfectly healthy. Often, there is no way of predicting who will develop major depression. However, some groups of cancer patients are more likely to develop depression than are others. This include patients who:

• are younger
• have a personal or family history of depression or other mental health problems
• have a personal or family history of substance abuse
• have body image problems
• are hospitalized
• are experiencing unrelieved cancer-related symptoms, such as pain
• have advanced or relapsed cancer, or have experienced a treatment failure
• have been diagnosed with stroke or with Parkinson's disease

In addition, some patients are receiving medicines that may cause depression as a side effect. Among these medicines are certain anticancer drugs, antihistamines, blood pressure medicines, anti-Parkinson's disease medicines, medications for convulsions, sedatives, steroids, stimulants, and tranquilizers.

Signs and Symptoms

A patient with cancer is diagnosed as having major depression only if certain symptoms are present for at least two weeks. Among these symptoms are:(a) loss of pleasure or interest in activities, (b) major weight loss or weight gain not associated with dieting, (c) serious sleep problems, (d) loss of energy, (e) fatigue, (f) feeling worthless, (g) feeling guilty without adequate reason, (h) problems concentrating, (i) indecisiveness, (j) thoughts of death or suicide. Symptoms such as sleep problems, fatigue, and weight loss may, however, affect cancer patients who are not depressed in the slightest. So, the diagnosis must be made by a healthcare professional.

Often depression appears gradually. At first, the patient seems no more than sad. At times, the person who is in a very early stage of depression brightens up. For many people things never get worse than this and true depression never touches them. However, other people progress to where negative thoughts have a grip upon them.

Gradually, some of the neurotransmitters in the nervous system may stop working in the most healthy way. Neurotransmitters are the chemicals released by nerves to communicate with other nerves. Once a patient's neurotransmitters are affected, the depression is definitely not simply happening in the patient's mind. The way the body uses actual chemicals is being altered by the depressive disease.

Precisely how the depression shows itself may differ from patient to patient. For example, some patients start to respond to little setbacks as though these are catastrophes. Other patients start making big assumptions, usually in negative directions; for example, they may assume their current therapy will not help them, even although there is good medical evidence that it probably will. For yet another example, they may blame themselves for having cancer, or irrationally see the cancer as a punishment visited upon them for something they have done. Patients may try to be too perfect and repeatedly fail. They may think other people have negative feelings about them, or they may focus upon the negative portions of situations. One danger is that the looming depression may encourage patients to push away and alienate those health professionals, friends, and family members who are trying to be helpful. For a final example, a depressed patient may deny the seriousness of the cancer, saying something like, "The tumor is small so I don't really need to be careful about taking my medicines."

Some patients experience a milder form of depression, called dysthymia. Symptoms of dysthymia include annoyance, feelings of sadness, irritability, loss of pleasure, and self-criticism. The patient with dysthymia may develop aches and pains, express excessive guilt, and distance themselves from loved ones. Dysthymia may be almost unnoticeable; however, many patients with dysthymia are unable to function quite as well as they can when they are healthy.

Depression Screens

The attending doctor or nurse may request that the patient complete a depression screen. This screen is nothing more than a page or two of questions about how the patient is feeling. The patient's responses give healthcare professionals a picture of whether or not depression may be present.

Prevention

It is important for patients to have an idea of the psychological and social stressors they may have to address because of the cancer. Knowing in advance that something may be a problem is a good way of making sure that it is not quite as stressful once it does appear as it otherwise would be. Patients, their families, and close friends should be able to recognize the most important signs and symptoms of depression and should know which healthcare professional to call should depression appear. However, no one except a professional is capable of accurately diagnosing depression. It is a good idea to try to develop an honest relationship with a healthcare professional you trust. Parents of a child who has cancer may find a parent support group helpful, as there is a great deal to learn from other parents who have been through a similar situation.

Treatments

Most important is that study after study has shown that depression in cancer patients can be successfully treated. It is important to understand that this problem probably can get better. Several different approaches to treatment can be taken, and several of these approaches can be effectively combined with one another

If the patient has a doctor or nurse capable of providing sustained emotional support, that can be helpful. On the other hand, it is important for patients to realize that doctors and nurses are usually extremely busy and that it may be necessary to find someone else to provide sustained emotional support. This other person may be a trained professional, such as a social worker, a psychiatric nurse, a psychologist, or a psychiatrist. The persons who provide support may also be family members or friends. A support group may be helpful. During periods of crisis, it is beneficial to have several people who can provide support. The family member or friend who is trying to provide such support should try to listen well and sympathetically.

Cognitive Interventions

Cognitive interventions are also known as cognitive-behavioral treatment (CBT). CBT helps patients' view in a realistic way what is happening to them, where they are, and what they should or should not be doing. This type of intervention can be useful in helping patients give up negative perspectives and replace them with views that rely more upon the facts about what is going on. CBT may be practiced with a healthcare provider, or in a group with other patients and one or more providers.

Among the techniques CBT makes use of are:

• Cognitive distraction: This is the phrase used for techniques that shift the mind-frame of the patient from negative things to more positive thoughts. Music is one of the basic tools of cognitive distraction. Patients should be encouraged to listen to the type of music they like best. Headphones may be helpful if brought to diagnostic and treatment sessions and occasions when waiting is necessary. Imagery is another technique important for cognitive distraction. Imagery can help the mind shift from negative thoughts and difficult situations to helpful images. Each patient should select those images that feel right and good. For one patient this may be swimming at the beach; for another, visiting special friends; for another, walking through the forest.
• Psychoeducation: This CBT technique involves providing information to patients so patients can feel that what is going on is not entirely beyond their control. People often find it difficult to deal with the unknown, and psychoeducation attempts to remove some of what is unknown. Another important psychoeducation technique is having patients make lists of questions to ask their nurse or doctor.
• Image rehearsal: This CBT technique involves working with a healthcare professional. The patient may use image rehearsal to rehearse some activity she or he finds to be stressful. For example, image rehearsal may be used if the patient finds MRI scans or radiation treatments to be stressful.

Other CBT techniques involve relaxation techniques and the conscious decision to participate in activities the patient likes doing.

Psychotherapy

Talking to a psychologist, social worker, psychiatric nurse, psychiatrist, or other health care professional can be helpful. In addition to the cancer and problems associated with therapy, this talk therapy can help the patient address unresolved matters that were already bothersome before cancer was diagnosed.

Group Therapy

Studies have shown group therapy to be an effective approach for patients with cancer-related depression. Various approaches to group therapy may be taken. In all, however, it involves communication not only between patient and healthcare professional, but also among and between patients. Group therapy can also be helpful for loved ones of cancer patients.

Important to note is that studies have shown that cancer patients may tend to isolate themselves from friends and family. In other words, the amount of contact and communication between friends and family may be less than it had been before cancer was diagnosed. This is not a helpful trend. Research suggests that social support can have beneficial effects on a person's physical health. Group therapy can provide this type of social support to patients. In addition, group therapy may furnish a place where patients are able to learn about how to maintain contact with family and friends. It can also provide a way for patients to identify which family members and friends are not supportive.

Medication

A variety of antidepressant medications are available. Among those most frequently prescribed are psychostimulants, tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), and monoamine oxidase inhibitors (MAOIs). These medications help return the neurotransmitters to a normal, balanced function. There are at least three different psychostimulants, six different TCAs, three different SSRIs, and three different MAOIs that doctors may choose among. In addition, there are various other medications that have proven to be effective as treatment for depression. All of these drugs have been shown to work well in general; however, while one specific type of drug may be appropriate for one patient, another patient may require a completely different type of drug. Use of some of these drugs may be accompanied by side effects. Just as there are different antidepressant drugs, so are there different side effects that may appear. However, many patients have no side effects from antidepressant medications or, at most, exhibit only minor side effects. Other patients find that, although they had side effects from one drug, they experienced no side effects after they switched to another medication. Many patients find they are able to successfully combine medications and other treatment approaches, but honest communication with the physician is essestial.

The Suicidal Patient

If a patient is suicidal it is extremely important to immediately contact a healthcare professional capable of dealing with such a crisis.

Resources

Books

Spiegel, David, and Catherine Classen. Group Therapy for Cancer Patients: A Research-Based Handbook of Psychosocial Care. New York: Basic Books, 2000.

Waller, Alexander, and Nancy L. Caroline. Handbook of Palliative Care in Cancer. 2nd ed. Boston: Butterworth Heinemann, 2000.

Yarboro, Connie H., Margaret H. Frogge, and Michelle Goodman. Cancer Symptom Management. 2nd ed. Boston: Jones and Bartlett Publishers, 1999.

Periodicals

Lovejoy, Nancy C., Derek Tabor, Margherite Matteis, and Patricia Lillis. "Cancer-related Depression: Part I—Neurologic Alterations and Cognitive-Behavioral Therapy." Oncology Nursing Forum 27 (2000): 667-677.

Sheard, T., and P. Maguire. "The Effect of Psychological Interventions on Anxiety and Depression in Cancer Patients: Results of Two Meta-Analyses." British Journal of Cancer 80 (1999): 1770-1780.

—Bob Kirsch

A melancholy mood; a feeling of hopelessness or an attitude of dejection. Depression varies from mild forms, which most people experience, to very severe clinical forms that require expert medical treatment. Although depression can affect the motivation to exercise, it is generally agreed that aerobic activity can protect against and relieve depression. Aerobic exercise sustained for at least 30 minutes, five times a week, can have remarkable anti-depressant effects. The reason is unclear, but may be linked to the production of endorphins during exercise, or increased self-esteem and control.

noun

1. An area sunk below its surroundings: basin, concavity, dip, hollow, pit, sag, sink, sinkhole. See convex/concave.
2. A feeling or spell of dismally low spirits: blues, dejection, despondence, despondency, doldrums, dolefulness, downheartedness, dumps, dysphoria, funk, gloom, glumness, heavy-heartedness, melancholy, mope (used in plural), mournfulness, sadness, unhappiness. See feelings, happy/unhappy.
3. A period of decreased business activity and high unemployment: recession, slump. See rich/poor.

Definition: concavity, cavity
Antonyms: bulge, convexity, protuberance

n

Definition: low spirits; despair
Antonyms: cheerfulness, encouragement, happiness, hope, hopefulness

Depression is sometimes referred to as the common cold of mental illness. It is a debilitating disease with significant societal costs. It is, however, one of the most clearly defined and treatable of mental illnesses. Technically, the term "depression" is used to cover a variety of symptomatic conditions, all characterized by negative mood and a loss of pleasure. Together these conditions comprise a spectrum ranging from major depression to dysthymia to adjustment reactions to normal grief and sadness. At one extreme of this continuum lies major depressive disorder, a syndrome characterized by severe episodes of depressed mood accompanied by loss of sleep, appetite, concentration, energy, and hope. The depressed mood must persist for greater than two weeks in order to warrant this diagnosis. At the other end of the continuum lies the diagnosis of dysthymia, which is characterized by a lower level of mood disturbance that persists chronically; that is, involving more days than not for a period of two years or greater. Many patients complain of depressed mood but do not fit neatly into either of these two categories. These patients' symptoms are frequently best accounted for as a reaction to an acute life stressor. These reactions are typically nonpathological and resolve with time, but they may constitute an adjustment reaction if normal functioning is sufficiently disturbed.

Depression is both common and costly. It has a lifetime prevalence of 5 to 10 percent of women and 2 to 5 percent of men. It is an expensive disorder in both direct and indirect terms, as depression causes a higher degree of functional disability than many medical illnesses including diabetes, chronic lung disease, and arthritis. Additional costs to society result from the effect of untreated depression on the treatment of medical illnesses, where it contributes to longer hospital stays and morbidity. This has been particularly well demonstrated in the treatment of myocardial infarction (heart attack), where the presence of major depression has consistently been found to increase mortality.

Depressive illness is thought to result from a combination of biological and psychological factors. The biological component is strongly suggested by the high genetic concordance of depressive disorders. In the twenty-first century, there are various competing theories about the nature of this genetic/biological contribution, but the available data do not yet indicate the specific nature of the illness. The psychological component is similarly suggested by the correlation of onset of major depression with negative life events and with the increased risk of depression in individuals who experienced abuse in childhood. A variety of psychological theories exist and are linked to models of psychotherapeutic treatment. Interpersonal psychotherapists, for example, emphasize the role of grieving due to the loss of an important relationship or a transition in social roles (e.g., transition from working to retirement, marriage to divorce). Cognitive therapists emphasize a mind-set of construing life events in a way that leads to depression. Alternately, psychodynamic therapists search for the ways that unconscious coping processes and repetitive relational patterns result in negative effects. A commonly postulated mechanism would include the turning of anger in on the self. For example, a depressed woman may feel critical of herself rather than direct her anger toward an abusive spouse.

Treatment of depression parallels theories of etiology in that both biological and psychological treatments exist and have been efficacious. A number of different antidepressant medications have been developed, including monoamine oxidase (MAO) inhibitors, tricyclic antidepressants, and selective serotonin reuptake inhibitors (SSRI). These medicines have demonstrated efficacy in both the treatment of acute depressive episodes and in the prevention of relapses. A variety of psychological therapies are also employed in the treatment of depression. Interpersonal psychotherapy and cognitive behavioral psychotherapy are psychotherapeutic models for which depression-specific therapeutic techniques have been developed. These tend to be delivered in the form of brief semi-structured treatments, lasting less than a year in duration. One advantage of these approaches is that they have been well tested in research settings and have an established record of effectiveness in appropriately selected patients. There is also some clinical consensus that long-term psychodynamic (emphasizing unconscious mental processes) therapies are also helpful, especially when the mood disorder exists in the context of a long-standing personality disorder.

(SEE ALSO: Mental Health)

Bibliography

Eisendrath, S. J., and Lichtmacher, J. E. (1999). "Psychiatric Disorders." In Current Medical Diagnosis and Treatment 1999, eds. L. M. Tierney, S. J. Mcphee, and M. A. Papadakis. Stamford, CT: Appleton & Lange.

Gabbard, G. O. (1994). Psychodynamic Psychiatry in Clinical Practice: The DSM-IV Edition. Washington, DC: American Psychiatric Press.

Panzarino, P. J. (1998). "The Costs of Depression: Direct and Indirect: Treatment versus Nontreatment." Journal of Clinical Psychiatry 59(20):11–14.

— JAMES POWERS; STUART J. EISENDRATH

1. Movement of the shoulder girdle or another body part downwards (i.e. in an inferior direction). Compare elevation.

2. A melancholy mood; a feeling of hopelessness, or an attitude of dejection. Depression can adversely affect the motivation to train and compete. In serious cases, depression is a symptom of mental illness. Exercise is often used in the treatment of mild depression and anxiety. Research has shown that aerobic exercise sustained for at least 30 min, five times a week can have anti-depressant effects, and the exercise produces physiological benefits that extend the range of activities that the patient can undertake with ease. Some of the psychological benefits are probably linked to an improved general feeling of well-being. In contrast, severe overtraining has been found to produce signs of depression in some athletes.

Depression is a mood disorder, understood from the psychoanalytical viewpoint as resulting from an intrapsychic conflict that stems from the ego's difficulties in integrating aggressive drives that are experienced as too dangerous for the preservation of libidinally cathected objects. These aggressive drives turn against the subject via the superego, which becomes too strict and demanding. Depressive manifestations are frequent in other clinical entities where the conflicts are essentially intrapsychic, such as the psychoneuroses.

Karl Abraham (1912/1989) was one of the first psychoanalytical authors to concern himself with depressed patients and to describe the extent of the ambivalence of their drives. Narcissism is another characteristic of the depressive personality, which that Freud emphasized in "Mourning and Melancholia" (1916-17g [1915]). Subsequently, Abraham (1924/1927) described the pregenital underpinning of this ambivalence, given the importance of oral fixations in these patients.

Freud compared the psychological mechanisms of melancholia with those of mourning, which constitutes a depressive state in the normal person. The essential difference is the narcissism of the melancholic, whose intolerance of experiences of loss lead him to the oral incorporation of the lost object into the ego, where it is attacked by the superego. Conversely, the person in mourning finds himself faced with the painful difficulty of detaching the libido cathected onto the lost object so as to recathect it onto objects in the external world. However, the major problem raised by Freud's descriptions of the dynamics of melancholia is that he does not specify the variations in the psychological mechanisms corresponding to the different degrees of depressive states.

Melanie Klein (1940) developed the comparison with mourning in her description of the depressive position. For her, the capacity to work through one's mourning will depend on the possibility of resolving the reactivation of the conflict proper to the depressive position that the conflict causes, i.e., the feeling of losing good internal objects. Klein, like Freud, is imprecise when it comes to the different problematics of depression. However, clinical analysis shows a whole series of levels of severity in this problematic between the working through of the mourning process (or during the integration of the depressive position) and the peak of this process, which Klein described as "a melancholia in statu nascendi" (Palacio Espasa). These depressive forms of conflict can be defined by reference to the predominant form of the fantasies expressing the experiences of the loss of the object of libidinal cathexis, and by the quality of the types of anxiety experienced by the ego.

When fantasies of the catastrophic and irreparable destruction of the object predominate, given that the subject has very little confidence in his libidinal capacities, feelings of guilt become intolerable and feelings of sadness are massively denied. The ego can only resort to archaic mechanisms of defense: splitting, denial, projective identification, idealization, etc.—the mechanisms proper to schizo-paranoid functioning or to the dynamics of extreme melancholia, with confusion between the ego and the object attacked (the "parapsychotic" depressive conflict proper to borderline or psychotic structures).

When fantasies of severe and barely reparable damage or death of the objects take the upper hand, the ego will be confronted with intense feelings of guilt and sadness. The significant repression of the aggressive drives towards the object (an aggressiveness that reinforces the severity of the superego) will make it possible for the negative affects to be partially denied. The ego will succeed in keeping the conflict interiorized but at the cost of diverse inhibitions in the functions of the ego. Thus, the symbolic possibilities of the individual are limited, but are not qualitatively affected. This very narrow form of repression is often insufficient, and the ego also has to resort to maniacal defenses or to defenses of a melancholic type, which then determine the clinical manifestations of mood disturbances.

When feelings of abandonment and rejection prevail—i.e., when the experiences of loss are above all fantasies such as the loss of the object's love—depressive conflict will take a "paraneurotic form." The feelings of sadness are often conscious, for guilt is less intense and can equally easily become conscious. The ego's greater confidence in its libidinal capacities gives these subjects a profusion of fantasies of reparation that will counteract the damage done to the object, damage that is fantasized as resulting from their own aggressiveness. These fantasies underlie many of the neurotic mechanisms of defense, especially those of an obsessional kind, for example retroactive cancelling, reaction formation, etc. Under their influence, repression authorizes a greater possibility of symbolic expression, which distinguishes neurotic repression from the massive repression of the depressive type. Such a libidinal predominance changes the nature of what is repressed, for the counter-cathexis does not operate on aggressiveness alone, but also on the libidinal fantasies of an incestuous nature. This contributes to the sexual differentiation of parental objects, bringing into operation the conflict occasioned by triangulation and the Oedipus complex.

Bibliography

Abraham, Karl. (1927). The process of introjection in melancholia: two stages of the oral phase of the libido. In Douglas Bryan and Alix Strachey (Trans.). Selected papers of Karl Abraham, M.D. (pp. 442-452). London: Hogarth. (Original work published 1924) ——. (1927). Notes on the psycho-analytical investigation and treatment of manic-depressive insanity and allied conditions. In Douglas Bryan and Alix Strachey (Trans.), Selected papers of Karl Abraham, M.D. (pp. 137-156). London: Hogarth and the Institute of Psycho-analysis. (Original work published 1911)

Freud, Sigmund. (1916-17g [1915]). Mourning and melancholia. SE, 14: 237-258.

Klein, Melanie. (1940). Mourning and its relation to manic-depressive states. International Journal of Psycho-Analysis, 21, 125-153.

Palacio Espasa, Francisco. (1993). La Pratique psychothérapique avec l'enfant. Paris: Bayard.

—FRANCISCO PALACIO ESPASA

Quotes:

"It's a recession when your neighbor loses his job; it's a depression when you lose your own." - Harry S. Truman

"Depression is melancholy minus its charms -- the animation, the fits." - Susan Sontag

"In addition to my other numerous acquaintances, I have one more intimate confidant. My depression is the most faithful mistress I have known -- no wonder, then, that I return the love." - Soren Kierkegaard

"I am in that temper that if I were under water I would scarcely kick to come to the top." - John Keats

"The world leans on us. When we sag, the whole world seems to droop." - Eric Hoffer

"That terrible mood of depression of whether it's any good or not is what is known as The Artist's Reward." - Ernest Hemingway

See more famous quotes about Depression

1. a hollow or depressed area.
2. a lowering or decrease of functional activity.
3. decreased interest in surroundings, decreased response to external stimuli. The least degree in a range of depressive mental states. See also somnolence, lassitude, narcolepsy, catalepsy, syncope, coma.

• d. fracture — important in the skull where they may penetrate brain tissue, introduce infection, or cause pressure on the brain because of hemorrhage or hematoma formation.

• Hills, Hollows, and Valleys - depression: any hollow place or low point in earth’s surface
• Forecasting and Meteorology - depression: area in which atmospheric pressure is lower than surrounding areas, causing unsettled weather; low pressure
• Economics and Economic Theory - depression: severe, prolonged decline in business activity
• Syndromes, Disorders, and Conditions - depression: depressive neurosis or psychosis
• Agitation, Abnormality, and Instability - depression: condition of general despondency, dejection, and withdrawel

"Despair" redirects here. For other uses, see Despair (disambiguation).

Albrecht Dürer's engraving Melencolia I, ca. 1514

Depression is a state of low mood and aversion to activity that can affect a person's thoughts, behavior, feelings and physical well-being.^[1] Depressed people may feel sad, anxious, empty, hopeless, worried, helpless, worthless, guilty, irritable, or restless. They may lose interest in activities that once were pleasurable; experience loss of appetite or overeating, have problems concentrating, remembering details, or making decisions; and may contemplate or attempt suicide. Insomnia, excessive sleeping, fatigue, loss of energy, or aches, pains or digestive problems that are resistant to treatment may be present.^[2]

Depressed mood is not necessarily a psychiatric disorder. It is a normal reaction to certain life events, a symptom of some medical conditions, and a side effect of some medical treatments. Depressed mood is also a primary or associated feature of certain psychiatric syndromes such as clinical depression.

Contents 1 Causes 1.1 Life events 1.2 Medical treatments 1.3 Non-psychiatric illnesses 1.4 Psychiatric syndromes 2 Assessment 3 References 3.1 Selected cited works

Causes

Life events

Life events that may precipitate depressed mood include personal conflicts or disputes with family members or friends, bereavement, moving, losing a job or income, divorce, retirement, menopause,^[3] social isolation, and social rejection.

Medical treatments

Certain medications are known to cause depressed mood in a significant number of patients. These include Hepatitis C drug therapy and some drugs used to treat high blood pressure, such as beta-blockers or reserpine.

Non-psychiatric illnesses

Depressed mood can be the result of a number of infectious diseases and physiological problems including hypogonadism (in men), Addison's disease, Lyme disease, multiple sclerosis, sleep apnea and disturbed circadian rhythm. It is often one of the early symptoms of hypothyroidism (reduced activity of the thyroid gland). For a discussion of non-psychiatric conditions that can cause depressed mood, see Depression (differential diagnoses).

Psychiatric syndromes

A number of psychiatric syndromes feature depressed mood as a main symptom. The mood disorders are a group of disorders considered to be primary disturbances of mood. These include major depressive disorder (MDD), commonly called major depression or clinical depression, where a person has at least two weeks of depressed mood or a loss of interest or pleasure in nearly all activities; and dysthymia, a state of chronic depressed mood, the symptoms of which do not meet the severity of a major depressive episode. Another mood disorder, bipolar disorder, features one or more episodes of abnormally elevated energy levels, cognition and mood, but may also involve one or more depressive episodes.

Outside the mood disorders: borderline personality disorder commonly features depressed mood; adjustment disorder with depressed mood is a mood disturbance appearing as a psychological response to an identifiable event or stressor, in which the resulting emotional or behavioral symptoms are significant but do not meet the criteria for a major depressive episode,^[4] and posttraumatic stress disorder, an anxiety disorder that sometimes follows trauma, is commonly accompanied by depressed mood.^[5]

Assessment

Main article: Rating scales for depression

A full patient medical history, physical assessment, and thorough evaluation of symptoms helps determine the cause of the depression. Standardized questionnaires can be helpful such as the Hamilton Rating Scale for Depression,^[6] and the Beck Depression Inventory.^[7]

A doctor generally performs a medical examination and selected investigations to rule out other causes of symptoms. These include blood tests measuring TSH and thyroxine to exclude hypothyroidism; basic electrolytes and serum calcium to rule out a metabolic disturbance; and a full blood count including ESR to rule out a systemic infection or chronic disease.^[8] Adverse affective reactions to medications or alcohol misuse are often ruled out, as well. Testosterone levels may be evaluated to diagnose hypogonadism, a cause of depression in men.^[9] Subjective cognitive complaints appear in older depressed people, but they can also be indicative of the onset of a dementing disorder, such as Alzheimer's disease.^[10][11] Cognitive testing and brain imaging can help distinguish depression from dementia.^[12] A CT scan can exclude brain pathology in those with psychotic, rapid-onset or otherwise unusual symptoms.^[13] No biological tests confirm major depression.^[14] Investigations are not generally repeated for a subsequent episode unless there is a medical indication.

References

1. ^ Sandra Salmans (1997). Depression: questions you have - answers you need. People's Medical Society. ISBN 978-1-882606-14-6. 
2. ^ "Depression". National Institute of Mental Health. 2009-09-23. http://www.nimh.nih.gov/health/publications/depression/complete-index.shtml. Retrieved 2010-05-22. 
3. ^ Schmidt, Peter (2005). "Mood, depression, and reproductive hormones in the menopausal transition". The American Journal of Medicine.
4. ^ American Psychiatric Association 2000a, p. 355
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14. ^ Sadock 2002, p. 260

Selected cited works

• American Psychiatric Association. Diagnostic and statistical manual of mental disorders, Fourth Edition, Text Revision: DSM-IV-TR. Washington, DC: American Psychiatric Publishing, Inc.; 2000a. ISBN 0-89042-025-4.
• Sadock, Virginia A.; Sadock, Benjamin J.; Kaplan, Harold I.. Kaplan & Sadock's synopsis of psychiatry: behavioral sciences/clinical psychiatry. Philadelphia: Lippincott Williams & Wilkins; 2003. ISBN 0-7817-3183-6.

v t e Emotions (list) Emotions Adoration Affection Agony Awe Amusement Anger Anguish Annoyance Anxiety Arousal Attraction Caring Compassion Contempt Contentment Defeat Dejection Depression Desire Despair Disappointment Disgust Ecstasy Embarrassment Empathy Enthrallment Enthusiasm Envy Euphoria Excitement Fear Frustration Grief Guilt Happiness Hatred Homesickness Hope Horror Hostility Humiliation Hysteria Infatuation Insecurity Insult Interest Irritation Isolation Jealousy Loneliness Longing Love Lust Melancholy Neglect Optimism Panic Passion Pity Pleasure Pride Rage Regret Rejection Remorse Resentment Sadness Sentimentality Shame Shock Sorrow Spite Suffering Surprise Sympathy Tenseness Thrill Revenge Wonder Worry Diligence Zest Worldviews Compatibilism Existentialism Fatalism Incompatibilism Metaphysics Nihilism Optimism Pessimism Reclusion Social justice Weltschmerz Source: Parrott, W. (2001), Emotions in Social Psychology, Psychology Press, Philadelphia.

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Dansk (Danish)
n. - depression, nedtrykthed, lavkonjunktur, krise, lavtryk, lavning, sænkning, nedtrykning

Nederlands (Dutch)
depressie (terneergeslagen stemming), depressie (economisch), depressie (lagedrukgebied/ lage luchtdruk), depressiviteit

Français (French)
n. - découragement, (Méd) dépression, état dépressif, (Géog) dépression, dépression (atmosphérique), (Écon) récession, abaissement (d'un levier, etc)

Deutsch (German)
n. - Depression, Senkung, Schwächung, Tiefdruckgebiet

Ελληνική (Greek)
n. - κατάθλιψη, μελαγχολία, γούβα, γούπατο, οικονομική ύφεση, οικονομική κρίση, (μετεωρ.) βαρομετρική ύφεση, (αστρον.) ταπείνωση, χαμήλωμα

Italiano (Italian)
depressione, esaurimento nervoso

Português (Portuguese)
n. - depressão (f)

Русский (Russian)
депрессия, зона низкого давления

Español (Spanish)
n. - bache, hoyo, recesión, depresión, frente de baja presión, inactividad, abatimiento

Svenska (Swedish)
n. - depression, lågkonjunktur

中文（简体）(Chinese (Simplified))
不景气, 沮丧, 消沉

中文（繁體）(Chinese (Traditional))
n. - 不景氣, 沮喪, 消沈

한국어 (Korean)
n. - (땅이) 움푹 꺼짐, 침울, 불황

日本語 (Japanese)
n. - 押し下げること, 下降, くぼみ, 低気圧, 不振, 不景気, 意気消沈, 憂鬱, 鬱病, 俯角, 凹み

العربيه (Arabic)
‏(الاسم) اكتئاب, كساد النشاط الاقتصادي والوظيفي, مكان مجوف في سطح شئ وبخاصه الأرض, حاله جويه ذات ضغط منخفض‏

עברית (Hebrew)
n. - ‮דכאון, שקע, גומה, שקע ברומטרי, תקופת שפל‬

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