Depression is the single most common reason for psychiatric hospitalization in the United States.
As many as 15% of individuals with severe depressive disorders eventually commit suicide (37). Depression is a significant risk factor for cardiovascular disease and for noncompliance with essential treatments for other diseases, including diabetes. Depression is a recurrent disorder; of those who experience a major depressive episode, 50% have a second one. Of these, 70% have a third, and the incidence continues to increase with each subsequent episode. In the past diagnostic criteria were not standardized, so it is difficult to know whether the incidence of depression has increased over recent years, as has been asserted in the popular press.
Because women’s roles in society changed a great deal over the past few decades, there is a temptation to postulate a higher rate of depression attributable to women’s work outside the home.
There is no evidence that employment outside the home increases women’s vulnerability to depression. Multiple life roles actually contribute to life satisfaction, although the need to carry out multiple roles in the absence of adequate social support, as is all too common in women’s lives, is stressful (38–40).
Depression is characterized by the following (9,19): 1.
2.
3.
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Decreased ability to concentrate 5.
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Interference with sleep, generally with early awakening, inability to return to sleep, and failure to feel rested; atypically, with increased sleep 7.
Decreased appetite and weight; atypically, increased food intake 8.
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Inability to enjoy previously gratifying activities 10.
Loss of libido 11.
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Thoughts of death or suicide
The patient who has five or more of the signs and symptoms of depression for most of each day for 2 weeks or more fulfills the criteria for the diagnosis of clinical depression (36–38). Depression may be acute or chronic (dysthymic disorder). Like many diseases, it is caused by genetic, neurophysiologic, and environmental factors. Trauma in early life plays a role. Serotonin is a major mediator of mood. Treatment, whether pharmacologic or psychotherapeutic, is effective for depression. The average duration of a major depressive episode is approximately 9 months (36). Patients must be cautioned to continue treatment at least that long, even if symptoms remit; relapse is common.
Depression may be precipitated by an adverse life event such as an interpersonal loss, economic reversal, or serious illness (41,42). When there is an identifiable precipitant, there is a danger that the depression will be written off as the inevitable reaction to the event rather than considered properly as a complication that requires active treatment, similar to infection or pneumonia complicating a surgical procedure. When a patient’s symptoms meet criteria for the diagnosis, treating the depression will relieve symptoms and will enable her to cope more successfully with the precipitating situation (43).
Paradoxically, patients in happy life situations, and their loved ones, may have resistance to the idea that they are depressed. They need to understand that depression is not a sign of ingratitude or lack of appreciation for their life advantages, but a disease, like any other, that can strike even otherwise fortunate people.
Concomitant gynecologic or other medical illness can cause signs and symptoms similar to those of depression—loss of energy, sleep, and appetite—but does not cause guilt, hopelessness, or helplessness (44). These observations are helpful in differentiating depression from the malaise associated with other disease states.