Clinical Review

ABC of mental health: Depression

BMJ 1997; 315 doi: (Published 05 July 1997) Cite this as: BMJ 1997;315:43
  1. Anthony S Hale


    Depression has a range of meaning—from a description of normal unhappiness, through persistent and pervasive ways of feeling and thinking, to psychosis. Textbook descriptions of depression seen in hospitals are often very different from presentations in primary care.

    In recent community surveys, 2% of the population suffered from pure depression (evenly distributed between mild, moderate, and severe), but another 8% suffered from a mixture of anxiety and depression. Even patients with symptoms not severe enough to qualify for a diagnosis of either anxiety or depression alone have impaired working and social lives and many unexplained physical symptoms, leading to greater use of medical services.

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    Key practical questions relate to treatment. Is any required at all and, if so, what sort and for how long?

    Forms of depression

    Most depressions have triggering life events, especially in a first episode. Many patients present initially with physical symptoms (somatisation), and some may show multiple symptoms of depression in the apparent absence of low mood (“masked” depression).

    Features of depression

    Core features
    • Pervasive low mood

    • Loss of interest and enjoyment (anhedonia)

    • Reduced energy, diminished activity

    Other features
    • Poor concentration and attention

    • Poor self esteem and self confidence

    • Ideas of guilt and unworthiness

    • Bleak, pessimistic views of the future

    • Ideas or acts of self harm or suicide

    • Disturbed sleep

    • Diminished appetite

    Less severe depression has been awarded many labels, including neurotic depression, minor depression, and reactive depression (not depression as a reaction to circumstances but when reactivity to events in the surroundings is preserved). It is now termed dysthymia, a persistent low grade condition. This may be complicated by episodes of more severe depression, resulting in “double” depression in which resolution of the more severe syndrome is difficult to judge.

    Somatic syndrome

    Present if more than four of the following features are present

    • Anhedonia

    • Loss of reactivity (loss of emotional reactivity to normally pleasurable surroundings and events) …

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