Understanding Depression

Depression is a common response to health problems and is an often underdiagnosed problem in the patient population. People may become depressed as a result of injury or illness; may be suffering from an earlier loss that is compounded by a new health problem; or they may seek health care for somatic complaints that are bodily manifestations of depression.


Depression is a common response to health problems and is an often underdiagnosed problem in the patient population

Clinical depression is distinguished from everyday feelings of sadness by its duration and severity. Most people occasionally feel down or depressed, but these feelings are short-lived and do not result in impaired functioning. Clinically depressed people usually have had signs of a depressed mood or a decreased interest in pleasurable activities for at least a 2-week period.

An obvious impairment in social, occupational, and overall daily functioning occurs in some people. Others function appropriately in their interactions with the outside world by exerting great effort and forcing themselves to mask their distress. Sometimes they are successful at camouflaging their depression for months or years and astonish family members and others when they finally succumb to the problem.


Many people experience depression but seek treatment for somatic complaints. The leading somatic complaints of patients struggling with depression are headache, backache, abdominal pain, fatigue, malaise, anxiety, and decreased desire or problems with sexual functioning (Stuart and Laraia, 2000).

These sensations are frequently manifestations of depression. The depression is undiagnosed about half of the time and masquerades as physical health problems (Carson, 1999). People with depression also exhibit poor functioning and high rates of absenteeism from work and school.

Specific symptoms of clinical depression include feelings of sadness, worthlessness, fatigue, and guilt and difficulty concentrating or making decisions. Changes in appetite, weight gain or loss, sleep disturbances, and psychomotor retardation or agitation are also common. Often, patients have recurrent thoughts about death or suicide or have made
suicide attempts (American Psychiatric Association, 2000).

A diagnosis of clinical depression is made when a person presents with at least five of nine diagnostic criteria for depression. Unfortunately, only one of three depressed people is properly diagnosed and appropriately treated. In the United States, about 15% of severely depressed people commit suicide, and two-thirds of patients who have committed suicide had been seen by health care practitioners during the month before their death
(National Institute of Mental Health, 1999).

Diagnostic criteria (American Psychiatric Association, 2000)

1. Depressed mood

2. Loss of pleasure or interest

3. Weight gain or loss

4. Sleeping difficulties

5. Psychomotor agitation or retardation

6. Fatigue

7. Feeling worthless

8. Inability to concentrate

9. Thoughts of suicide or death

When patients make statements that are self-deprecating, express feelings of failure, or are convinced that things are hopeless and will not improve, they may be at risk for suicide.

Risk factors for suicide include the following:

• Age younger than 20 or older than 45 years, especially older than 65 years

• Gender—women make more attempts, men are more successful

• Dysfunctional family—members have experienced cumulative multiple losses and possess limited coping skills

• Family history of suicide

• Severe depression

• Severe, intractable pain

• Chronic, debilitating medical problems

• Substance abuse

• Severe anxiety

• Overwhelming problems

• Severe alteration in self-esteem or body image

• Lethal suicide plan

Risk Factors for Depression

• Family history

• Stressful situations

• Female gender

• Prior episodes of depression

• Onset before age 40 years

• Medical comorbidity

• Past suicide attempts

• Lack of support systems

• History of physical or sexual abuse

• Current substance abuse


For all patients, talking about their fears, frustration, anger, and despair can help alleviate a sense of helplessness and facilitate the process of obtaining the necessary treatment. Helping patients learn to cope effectively with conflict, interpersonal problems, and grief, and encouraging patients to discuss actual and potential losses may hasten their
recovery from depression. Patients can also be helped to identify and decrease negative self-talk and unrealistic expectations and shown how negative thinking contributes to depression. All patients with depression should be evaluated to determine whether they would benefit from antidepressant therapy.


In addition to the measures cited previously for helping patients manage depression, research studies indicate a reduction in distress when anxiety and depression are treated with psychoeducational programs, the establishment of support systems, and counseling (Devine and Westlake, 1995). Referrals to psychoeducational programs can be instrumental in helping patients and their families understand depression, treatment options, and coping strategies. (In crisis situations, it is better to refer the patient
to a psychiatrist, psychiatric nurse specialist, or crisis center.) Explaining to patients that depression is a medical illness and not a sign of personal weakness, and that effective treatment will allow them to feel better and stay emotionally healthy, is an important aspect of care (Stuart and Laraia, 2000)


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