From the patient and the family it is learned that the patient has been “feeling unwell,” “low in spirits,” “blue,” “down,” “unhappy,” or “morbid.” There has been a change in his emotional reactions of which the patient may not be fully aware. Activities that were formerly found pleasurable are no longer so. Often, however, change in mood is less conspicuous than reduction in psychic and physical energy, and it is in this type of patient that diagnosis is most difficult. A complaint of fatigue is almost invariable; not uncommonly, it is worse in the morning after a night of restless sleep. The patient complains of a “loss of energy,” “weakness,” “tiredness,” “having no energy,” that his job has become more difficult. His outlook is pessimistic. The patient is irritable and preoccupied with uncontrollable worry over trivialities. With excessive worry, the ability to think with accustomed efficiency is reduced; the patient complains that his mind is not functioning properly, and he is forgetful and unable to concentrate. If the patient is naturally of suspicious nature, paranoid tendencies may assert themselves.
Particularly troublesome may be the patient’s tendency to hypochondriasis. Indeed, most cases formerly diagnosed as hypochondriasis are now regarded by some writers as depression with superimposed anxiety. The patient passes from doctor to doctor, seeking relief from symptoms that would not trouble the normal person, and no amount of reassurance relieves his state of mind. The anxiety and depressed mood of these persons may be obscured by their preoccupation with visceral functions.
When the patient is examined, the facial expression is often plaintive, troubled, pained, or anguished. The patient’s attitude and manner betray a prevailing mood of depression, hopelessness, and despondency. In other words, the affect, which is the outward expression of feeling, is consistent with the depressed mood. During the interview, the patient may be tearful and may cry openly. In some, there is a kind of immobility of the face that mimics parkinsonism, though others are restless and agitated (pacing, wringing their hands, etc.). Occasionally the patient will smile, but the smile impresses one as more a social gesture than a genuine expression of feeling.
The stream of speech is slow. Sighing is frequent. There may be long pauses between questions and answers. The latter are brief and may be monosyllabic. There is a paucity of ideas. The impediment extends to all topics of conversation and affects movement of the limbs as well. The most extreme forms of decreased motor activity, rarely seen in the office or clinic, border on muteness and stupor (“anergic depression”). Conversation is replete with pessimistic thoughts, fears, and expressions of unworthiness, inadequacy, inferiority, hopelessness, and sometimes guilt. In severe depressions, bizarre ideas and bodily delusions may be expressed (“blood drying up,” “bowels are blocked with cement,” “I am half dead”).
Several theories have emerged concerning the cause of the pathologic depressive state, but none can be confirmed with confidence except for a heritable aspect. These views are elaborated on in Chap. 48.
It is the authors’ belief that depressive states are among the most commonly overlooked diagnoses in clinical medicine. Part of the trouble is with the word itself, which implies being unhappy about some specific aspect of life, whereas most depressions are endogenous and instead are the agents of negativity and discouragement about almost all life events. Endogenous depression may be suspected in states of chronic ill health without explanation, hypochondriasis, disability that exceeds the manifest signs of a medical disease, asthenia and ongoing fatigue, and chronic pain syndromes. Inasmuch as recovery is the rule, suicide is a tragedy for which the medical profession must sometimes share responsibility. In extreme circumstances, however, the patient is impelled to suicide and efforts on the part of the physician cannot be considered as a failure.
Depressive illnesses and theories of their causation and management are considered extensively in Chap. 48.