According to DSM, an abstract of the essential diagnostic criteria of endogenous depression (“major depressive syndrome”) consist of a dysphoric mood or loss of interest or pleasure in all usual activities (including sexual activity) in combination with at several of the following symptoms: (1) disturbance of appetite and change in weight; (2) sleep disorder; (3) psychomotor retardation or agitation; (4) decreased energy and fatigue; (5) self-reproach, feelings of worthlessness or guilt; (6) indecisiveness, complaints of memory loss and difficulty in concentrating; and (7) thoughts of death or suicide or actual suicide attempts. In this diagnostic scheme, each of the 4 diagnostic symptoms should have been present for at least 2 weeks and the state should represent a departure from previous functioning. This is a useful listing but simply recapitulates the well-described emotional, conative, and physical aspects of endogenous depression. Several formalized diagnostic criteria have been devised for both screening and diagnosis of major depression (Table 48-2). These codify the clinical features discussed in previous paragraphs but separate major depression from bipolar disorder by requiring the absence of elements that suggest a manic or hypomanic episode and further exclude depression that is plausibly connected to personal distress or grieving due to a loss, or the effects of a drug or toxic substance.
The depressed patient tends to move slowly, sighing is frequent, and speech is reduced. The mental life of such an individual may narrow to a single-minded concern about physical or mental health. In dialogue, the patient’s responses become so stereotyped that the listener can soon predict exactly what is going to be said. There is a poverty of ideation and sometimes a notable absence of insight. Consciousness is clear, and although there is no evidence of a schizophrenic type of thought disorder, delusional ideas, and less often hallucinations, may be prominent in some patients, justifying the term depressive psychosis. The delusions are generally congruent with the patient’s mood and are not as fixed or bizarre as those of schizophrenia or paranoia. In our experience, delusions are more common in older patients and tend to appear only after weeks or months of more typical symptoms of depression. Common ones in experience with our patients have been gas poisoning in the house, unaccustomed suspiciousness, alleged home break ins, having inadequate money, or being stolen from or cheated. (Some of these arise in early dementia as well.) Hallucinations, when they occur, are usually transitory, vocal, and only vaguely accusatory; their presence should always raise the possibility of an associated structural brain disease, drug intoxication, or alcoholic auditory hallucinosis.
Frequently, agitation or irritability rather than physical inactivity and mental slowness are the principal behavioral abnormalities. The source of the agitation appears usually to be related to an underlying anxiety state. Pacing the floor and wringing the hands, particularly in the early morning hours, are characteristic. Such patients tend to be overly talkative and vexed in their manner of expression, irritable, short-tempered, impatient, and intolerant of minor problems—changes noted mainly by family members. Attempts at reassurance may meet with initial success, only to be dispelled in the next rush of doubts. These patients remain impervious to reason and logic with respect to their symptoms, even though they are reasonable and logical in other areas of their lives. At its worst, the illness takes the form of a depressive stupor; the patient becomes mute, indifferent to nutritional needs, and neglectful even of bowel and bladder functions (anergic depression). The condition in this extreme form is a catatonic depression. Such patients must be fed and their other needs attended to until therapy (usually electroconvulsive therapy [ECT]) brings about improvement.