Everybody\'s mood varies according to events in the world around them. People
are happy when they achieve something or saddened when they fail a test or lose
something. When they are sad, some people say they are \'depressed\', but the
clinical depressions that are seen by doctors differ from the low mood brought
on by everyday setbacks. Psychiatrists see a range of more severe mood
disturbances and so find it easier to distinguish these from the normal
variations of mood seen in the community. General practitioners (GP\'s) need to
be sensitive enough to distinguish emotional reactions to setbacks in life from
anxiety syndromes, somatisation and clinical depressions. The general idea is
that anxiety disorders, depressive episodes, somatisation and adjustment
reactions are all different entities, but in practice it is not always that
clear-cut. Major depression, as defined by psychiatrists, is unfortunately
relatively common.

What is depression?

The term "affect" refers to one\'s mood or "spirits." "Affective disorder" refers
to changes in mood that occur during an episode of illness marked by extreme
sadness (depression) or excitement (mania) or both. Depression is a disorder of
affect. Affective disorders are predominantly disturbances of mood that are
severe in nature and persistent despite the influence of external events.
Depression is characterized by severe and persistent low mood, which is often
unresponsive to the efforts of friends and family to cheer the sufferer up.
Patients who suffer with repeated episodes of depression have a Recurrent
Depressive Disorder. Depressive episodes can be classified into mild, moderate,
and severe types, with or without psychotic symptoms. To be classified as
depression, an episode must last more than two weeks. A condition where the
mood is persistently low, but does not quite fulfill all the criteria for a
depressive episode, is sometimes called "dysthymia."

Community studies have found that depression is prevalent between 5 and 20% of
all people. About 10% of people over age 65 will have a major depressive
episode. The incidence of depression is higher in women and in urban settings
rather than rural settings.

Clinical features of depression

Mild depressive episodes typically include features such as:

·Sadness and crying,
·Loss of interest in and loss of enjoyment of life (anhedonia),
·Poor attention and concentration,
·Low self-esteem and ideas of unworthiness,
·A bleak view of the future and the world in general,
·Poor sleep and appetite.

People with mild depressive episodes find it difficult to continue with their
work and social lives, but usually continue to function, although less than
normal. Moderate depressive episodes have a wider range of symptoms, which are
present usually to a greater degree. Sufferers find it very difficult to
function normally at work or home.

Severe depressive episodes typically may also include features such as:

·Great distress and agitation,
·Slowed thought and movement (psychomotor retardation),
·Ideas of guilt,
·Suicidal fantasies or plans which may be acted upon,
·Pronounced somatic symptoms,
·Psychotic symptoms.

People with severe depressive episodes find it impossible to continue with their
work, domestic and social lives, and usually cease to function in these areas.
Depression is often accompanied by slowing of thought processes and biological
features of everyday life which differ from a normal sense of sadness. Crying
is a frequent symptom, although some individuals are reluctant to admit this,
and others feel so depressed it that is as if they have \'gone beyond crying\'.
Suicidal ideas occur in most depressed people, and asking about these is a
crucial aspect of their assessment. Depressed patients often find it a relief to
talk about these ideas with their doctor. Asking about suicidal ideas is a
sequential process, beginning with questions about the severity of the low mood.
The doctor can then ask if the patient has ever felt that life is not worth
living. A \'yes\' could be followed by inquiring whether the patient has ever felt
like ending their own life. Finally the doctor needs to assess if the patient
has any particular plans in mind.

Case History: Janet

Janet Gordon was aged 35 when she lost her job as a manager of a department
store. At first she looked on her period of unemployment as an opportunity to
try out activities she had previously no time for. She went hill-walking and
painting every day. Two months later she had lost interest in these things and
was despairing that she would never work again, although she had an exemplary
work record. Her sleep at night was poor and she had started going to bed
during the day. Janet cried almost daily and had lost interest in the food she
cooked. All food tasted bland, she said to her mother (who was