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
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,
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 concerned when
she saw how much weight Janet had lost). At her mother’s suggestion Janet went
to her family doctor where she complained about how tired she always felt. She
asked for some sleeping tablets to help her sleep at night.
Case History: Alan
Alan Benson was brought to the accident and emergency department by his son.
Alan had tried to hang himself from the banisters at the family home.
Fortunately the clothes’ line that he had chosen to hang himself with had broken
under his weight. When he was seen by the psychiatrist Alan had a red weal mark
around his throat from the noose. He was staring at a fixed point on the floor.
Now and then he would groan deeply and whisper to himself. He kept repeating the
words ‘I’m for it..I’m for it now.’ He would not make eye contact with the
doctor and initially refused to answer questions.
His son said that the previous week his father had stopped going to work as a
bailiff after he found out that his wife was having an affair. He had watched
her obsessively for two days, not letting her out of his sight. Then a few days
ago he had taken to his bed, and lain there for hours and hours not moving, not
speaking, not eating and not drinking. He had talked about how everything was
his fault and had at times been pleading with an unseen person to forgive him.
He felt that he had committed some unpardonable crime and that he should now be
Armed with this information the psychiatrist talked to Mr. Benson again. This
time Mr. Benson replied, even if only briefly. He said that God was telling him
that his wife had to find another man because her husband had been so evil. He
confessed that he had once had an affair himself many years before, and that God
had told him in the last week that He had punished Mr. Benson with syphilis. His
wife could be spared from the syphilis only if he killed himself. Once he was
dead, he thought, his wife could begin a clean life with another man.
Many physical disorders can be present with depressive illness. They include:
hypothyroidism, hyperthyroidism, Addison’s disease, Cushing’s disease,
electrolyte disturbances, alcoholism, drug abuse, carcinoma and dietary
deficiencies (B12, B1, and folic acid). Various drugs can cause depression.
Psychological disorders that may mimic depression include adjustment reactions,
anorexia nervosa, bulimia nervosa, anxiety disorders, substance abuse,
obsessive-compulsive disorder, dysthymia, seasonal affective disorder, and
abnormal bereavement reactions. Panic disorder commonly co-exists with or pre-
dates depression, (Andrade et al, 1994). Diagnosing and treating underlying
physical causes must be attempted and are key factors in the correct prognosis
of the actual cause of a persons depression.
Risk factors for depression:
In Young Adults:
Previous affective illness,
Family history of depression,
Loss of mother before age 11,
Looking after several young children,
In Older People:
Bereavement of a close figure in last six months,
Loneliness (but not living alone),
Lack of Satisfaction with Life,
The risk factors for older people identified above have some predictive value in
identifying people at risk of depression three years later. Life satisfaction
and bereavement help predict recurrences of depressive illness. The higher
prevalence of depression amongst women could be because women are more prone to
depressive illness biologically or because of their social roles, or could be
because male depression is under-recognized, or incorrectly labeled. However,
suicide is more common among men than women. It is worth remembering that only
50% of depressed patients who present to their GP are correctly diagnosed as
suffering with depression. Most depressed people in the community do not
receive treatment. Over 90% of depressed elderly people in the community suffer
Armed with knowledge of its prevalence, causes and common features, one might
assume that it is a simple task to diagnose depression in general practice
settings. Unfortunately it isn’t. Certainly having a high index of suspicion
and a professional willingness to consider the possibility of depression are
important factors in our ability to diagnose depression.Additionally patients
also have a significant part to play in enabling – or preventing us – from
arriving at a diagnosis of depression.
It is rare to find depression as a simple, unitary diagnosis in general practice.
It is much more common for patients to show a combination of problems – some
physical, others social – within which depression can all to easily be either
unnoticed, or assumed to be inevitable and therefore untreatable. Freeling et
al 1985 and Tylee et al 1993 have shown that severe depression is much more
likely to be missed if associated with significant physical illness. Moreover,
many patients have strong reservations about disclosing depression to their GPs.
Depression itself often contains feelings of hopelessness and despair. Patients
may therefore feel that there is no point in talking to the doctor about it
since there is nothing that they or anybody else can do about it. These
negative perspectives can be compounded by GPs – often unwittingly – if they
give the impression of rushing through their consultations and being unable or
unwilling to sit and listen to our patients’ concerns.
There is still a considerable stigma attached to mental illness. Many people
have a great fear of the consequences of acknowledging their depression to a
professional person: they may be ‘carted off to a loony bin’, or written off as
‘mad’. If the word ‘depression’ appears in medical notes they fear – often
correctly – that this will be prejudicial to future employment or insurance
Fear of antidepressant medication is also a very important obstacle to
disclosure of depression. A study undertaken by the Defeat Depression campaign
showed that many people confuse antidepressants with benzodiazepines, and are
genuinely worried about becoming dependent – ‘getting hooked’ on them, and about
unpleasant effects of withdrawal. There is considerable public skepticism about
the effectiveness of antidepressants. Most patients would prefer to be offered
counseling rather than drugs, but doubt if they will be given such a choice by
their GP. Faced with this complex barrage of obstacles, it is perhaps surprising
that we ever do manage to make a diagnosis of depression! However, there are
many things that can be done to increase the chances of detection. We need to
help some patients to reattribute physical symptoms to psychological causes. If
a patient is feeling tired all the time, has no energy or interest in life and
is sleeping very badly, these chances of their being depressed are very high.
Often a direct question – ‘do you think you may be depressed?’ – is all that is
needed to move the consultation onto a psychological agenda. Sometimes it is
better to take a more indirect route. The word ‘stress’ is a very useful bridge,
since it intrinsically has both physical and mental components: ‘Are under any
extra or unusual stress at the moment?’, or ‘Do you think these symptoms might
be due to stress?’ are effective open ended questions. For those few patients
who appear reluctant to consider any diagnosis of depression it may initially be
most profitable to concentrate on its more physical manifestations – sleep and
appetite disturbance, or energy loss – without forcing the issue of their
We must also accept patients’ genuine anxieties about the shame attached to
depression, and acknowledge their concerns about the harmful effects of drug
therapies. Good basic consultation skills include inquiry into patients’
expectations and fears about the nature and consequences of their problems. This
will take us a long way towards understanding not only whether our patients are
depressed, but the context and meaning that their depression has for them. Many
people experience enormous relief when their problems are explored in this way.
To a large extent, therefore, effective diagnosis is also the most crucial
aspect of effective treatment.
There are two important dimensions to be considered in deciding how best to
manage depression in general practice. First, mild depression may often be
managed effectively through sympathetic exploration of the factors precipitating
it – whether physical illness, a recent personal crisis in work or relationships
– and encouragement of the patient’s own coping mechanisms and supportive
informal social networks. Moderate and severe depression have been shown to
respond to antidepressant drug therapy. As we have seen it is essential to
discuss patients’ anxieties and expectations of drug treatment before starting
it. Also, drugs should be viewed as complementary rather than alternative to
talking about depression. Problem-solving is a useful and simple skill to
develop. The first stage is the creation of a problem list. This is something
usually best done by the patient between sessions, although they may need some
help initially. The patient writes down a list of problems which he is
experiencing at present, either in terms of how he feels – miserable, tired,
bored etc. – or in terms of things he is unable to do – go to work, enjoy
hobbies, etc. He can then rank these problems in order of importance, and set
goals for overcoming them. These goals should be staged and not too ambitious.
For instance, if feeling bored is a central concern, it might be useful to
discuss which aspects of life give the most pleasure and interest – watching TV
soaps, walking the dog, having a bath, and agreeing that the patient will spend
a set amount of time each day doing just that.
Problem-solving works well in conjunction with drug therapy, and directly
addresses the sense of hopelessness that is central to depression. It enables
both doctor and patient to achieve a sense of purpose and direction, and
provides a practical means ofmonitoring and demonstrating progress. The second
dimension to the management of depression in general practice concerns the views
and experience of the doctor and the patient. GPs vary considerably in their
skills, experience and confidence in dealing with depression. Some of us will
prefer to refer early to other professional colleagues, whether counselors,
psychologists or psychiatrists, while others are more comfortable about managing
even acute and severe problems. Patients, as we have seen, may also have strong
views about the causes, effects and treatment of depression. If we are to manage
it effectively we must take these into account. When people feel they are being
listened to, and have genuine choices about what happens to them – whether they
receive counseling or drug therapy or both, whether they are referred for
psychiatric opinion or not – they are more likely to be committed to the
management plan that emerges. Many patients, even when expressing suicidal
thoughts, may prefer to be managed at home by their GP than be admitted to a
psychiatric ward: the problem then becomes one for us, in assessing the degree
of risk and responsibility that we feel able to sustain. It is worth
remembering that, involving our patients in genuine decision-making about the
management of their illness is intrinsically therapeutic. Studies of treatments
versus placebo have endorsed the value of physical therapies such as ECT
(electric-convulsive treatment or “shock therapy”) in severe depression and
antidepressants in mild, moderate and severe depression. Most depressive
illnesses respond to such treatments. Tricyclic antidepressants need to be
taken regularly in adequate doses for an adequate length of time. Inadequate
doses of Tricyclic antidepressant are linked to suicidal behavior in some
studies. Newer antidepressants (SSRIs and RIMAs) offer a relative safety in
overdose. Some psychological treatments have proven efficacy, notably cognitive-
behavioral therapy and interpersonal psychotherapy for mild and moderate
depression. Their drawbacks are that they take longer to have an effect and are
not well-standardized. There is evidence that cognitive behavioral therapy and
interpersonal psychotherapy may help maintain health when combined with
antidepressant medication, but there is as yet little evidence to suggest that
counseling alone is a suitable treatment for major depression. Where there is
evidence of continued relationship or family difficulties psychotherapy may be
particularly useful. Cases of moderate to severe depression may need vigorous
treatment by a community psychiatric team and close follow-up to help prevent
relapse and improve prognosis. Severely depressed patients with or without
psychotic symptoms require inpatient admission and may respond best to electro-
Who to refer people to:
Counselors, psychotherapists, community psychiatric nurses, occupational
therapists, social workers and psychologists, unless also medically qualified,
are not trained to diagnose depression, recognize its origin, or formulate long-
term management plans. If referring on to one of these agencies as the sole
provider of psychological care, the onus is on the general practitioner to
diagnose the depression correctly, to be certain about its origin and to have a
clear long-term management protocol in mind. The General practitioner must
therefore be sure to have excluded physical illness as a cause of the depression
before referring on to the non-medically trained.
The long-term prognosis for depression is still guarded, however. Up to 15% of
patients who have had depression will go on to kill themselves. Recurrent
episodes of depression are the norm rather than the exception. Long-term studies
of lithium suggest that it may help to reduce the number of episodes and prevent
suicide. Studies of long-term use of antidepressants suggest beneficial effects.
Long-term efficacy of psychotherapy and counseling has not been proven.
Learning points: depression
Depressive illness affects 10-18% of the adult population. Depressive illness
in the community is largely untreated, because patients generally do
not seek medical help, and of those that do seek help only about 60% of
those that see
their family doctor are recognized by them as suffering from depression.
Depressive illness is treatable – over 80% of cases can be resolved with
treatment. Treatment may include antidepressants, (SSRIs, tricyclics, MIRA
drugs, or MAOIs),
ECT (for severe or delusional depression) or psychotherapy for mild to
depression (particularly cognitive therapy).